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The formation of the American hospital before the twentieth century: 1st Place Winner AMT 2007 Feature Writing Contest.

Abstract

When the first settlers came to America, the entire healthcare system consisted of what arrived with them on ship and what they could harvest from the field. The only buildings were those built by the Native Americans. There were no university educated doctors, no medical schools, and no hospitals. As the country evolved and grew, the medical system grew right along side it. As problems cropped up, the citizens dealt with them. This often included medical dilemmas.

The Beginning

When the first settlers arrived in America, there were no hospitals, no public health systems, no doctors, and no medical schools. The only buildings were those that were built by Native Americans. The only healthcare system was a few medicines brought from the old world and a few medical practitioners who were generally barber surgeons, not medical doctors. During the seventeenth century, Europe had a well-developed medical system with guilds of medical professionals similar to our healthcare licensing today. Medical guilds regulated the qualifications and education of each level of practitioner. A physician was the only one with a university education and medical degree and was at the top level. Physicians tended the aristocracy and the very wealthy. Their ambition was to be in the top tiers of society. Physicians did not accompany the first colonists. They were wealthy and had been accustomed to fine accommodations. There was no reason to travel by ship for many months to arrive in a dangerous land without the type of accommodations and civilization that they were used to. (6)

Surgeons of the Long Robe were the second level of medical practitioner in England during the seventeenth century. They had an organized training program at a university and an apprenticeship. They cared for well-off merchants' families and those with money, but not the aristocracy. This guild enjoyed a regular salary and accommodations. The Surgeons of the Long Robe did not accompany the early colonists for the same reasons as the physicians. This guild wore long robes to differentiate themselves from lower level practitioners, Surgeons and Barber-Surgeons. (6)

The first medical people that traveled with the colonists were Surgeons of the Short Robe and Barber Surgeons. These were practitioners with very little medical training. They didn't have a lot to give up in England, so they were the main medical practitioners that arrived with the colonists and started our American medical system. Ship surgeons on English ships were usually of this guild for the same reasons. Physicians and Surgeons of the Long Robe would not give up their lifestyle in England to join the Navy and live onboard ship. Some ship surgeons actually stayed with the colonists for a few months after they landed in America if no medical people accompanied the colonists.

Hospitals had been around Europe for centuries before the first colonists arrived in America. The Alpine Hospice of St. Bernard, adjacent to a monastery, was founded in 962 and provided comfort to the weary. They also rescued and cared for distressed mountain climbers using trained dogs. A group of crusaders organized the Hospitalers of the Order of St. John in 1099 which was capable of caring for up to 2000 wounded military. It is estimated that in Germany alone, 155 towns had hospitals during the early medieval times. (13)

There were no hospitals in America when the ships arrived. Fellow colonists tended each other in their houses and the medical people would visit them there and offer whatever help they could. There were no medical schools to train physicians in the colonies. There was no public health system to look out for the welfare of the citizens.

The First Public Health Initiatives: Inoculation Hospitals & Pest Houses

One of the first public health interventions in Colonial America was inoculation against smallpox. A smallpox epidemic occurred fairly regularly in colonial times with deadly results. In a Boston epidemic of 1720, nearly half the population contracted smallpox. (1) The first American inoculations against small-pox took place in Boston in 1721, when Dr. Boylston inoculated his son and two servants. The first inoculations used live smallpox virus (from an infected person) which caused all the recipients to come down with a mild (and sometimes not so mild) case of smallpox. There were still deaths among the vaccinated but overall, the severity and mortality rates were dramatically decreased when an epidemic occurred in the summer of 1722. Dr. Boylston inoculated 247 people against smallpox. About two percent died compared to twelve percent who died who had not been inoculated. (6)

Local officials were always hesitant to recommend smallpox inoculation until a smallpox epidemic was almost out of control. It was expensive and dangerous to be inoculated. The charge was one pound, five shillings, and four pence per person plus an additional charge of three dollars per week for food, nursing, and other necessities. (1) Physicians and nurses employed in the smallpox hospitals were required to reside there constantly so they wouldn't contaminate the town. (1) If mass inoculation of the poor was to be conducted, this became an expensive proposition for the town. Before the revolution, the attitude was that inoculation was to be used as a last resort. After the Revolutionary War, this attitude changed and if there was any chance of getting natural smallpox, inoculation was considered right away. Since all those who were inoculated became ill with the disease, inoculation hospitals developed in larger cities to care for those receiving the inoculation. As the cow pox vaccination was developed and vaccination became safer, these hospitals were closed or used for some other purpose. (1)

All of the larger seaport towns built some type of facility to isolate those suspected of carrying any infectious disease. Another public health initiative in America's early history was the building of pest houses, isolation hospitals, or quarantine stations. They were not considered general hospitals as the primary purpose was to protect people who were not ill and the secondary purpose was the care for the sick; however, they were health care institutions which did provide care to the sick as well as isolation. These pest houses were staffed with voluntary nurses who were immune to whatever disease was suspected and called "immunes." Apparently, the colonists realized that one attack of small-pox or yellow fever left a person immune for life. These facilities were usually temporary and located outside the general community, receiving donations of food and clothing. Once the epidemic was over, the building, furniture, and bedding were burned to the ground. (1)

In May of 1717, the selectman of Boston authorized an acre of land to be bought on Dere Island to build a pest house. Charlestown, South Carolina, built a pest house on Sullivan's Island prior to 1752 and in 1743 Philadelphia built a pest house on Fisher's Island. In the 1880s, New York built a pest house on Bedloe's Island where the Statue of Liberty would later be located. (6) In Boston Harbor, all vessels that had smallpox on board during the voyage were examined by a selectman or doctor. They removed the sick and their belongings to the isolation hospital. The ship and the remaining passengers were quarantined and the ship was cleaned and aired. (1)

The Almshouse Model

The attitudes of society change over time and the way the poor are treated reflect these attitudes. Before the 1700s in Britain, "outdoor" relief was the custom. Each parish provided for some of the needs of its poor parishioners while they remained in their homes. After the 1700s, Britain was influenced by the Protestant Ethic and poverty was seen as a "voluntary state, a social illness due to lack of application, and moral stamina." (3) Disease among the poor was seen as a "defective constitution or even retribution for sin." (3) The feeling was that if society must take care of the poor, society will make it as difficult for the poor as possible. In 1864, the medical commission was investigating the 82% mortality rate of children at the Children's Asylum and reported that a very large proportion of them die in infancy "by reason of the diseased constitution they have inherited from their parents." (3)

During the 18th century, the poor population was increasing and the parishes were unable to provide resources for them. The changing attitude of society and the inability of small parishes to support a growing number of poor resulted in a series of poor laws being passed during the 1700s (in England) which were reflected in American attitudes. Outdoor relief was replaced by "indoor relief" in which the poor were removed from their homes and placed in workhouses or almshouses. In England by 1732, over fifty almshouses were built and many were built in America in our large cities like Philadelphia in 1732, New York in 1734, and Charlestown in 1735. Using the English Poor Law as a model, New York State in 1788 required each town to establish an almshouse. (3)

The original intent was to confine able-bodied workers, who could provide labor in the workhouse in exchange for food and shelter until they were able to get a job on the outside. It became cheaper for the communities to take care of all the poor, able-bodied or not, in one institution, so the workhouses became the almshouses. (3) The almshouse sheltered "the aged, the orphaned, the insane, the ill, and the debilitated" all mixed together. (18) As the almshouse evolved, a section was generally set aside as an infirmary to care for the ill and a local physician made rounds for a yearly fee. (3)

The almshouse gradually evolved into the general hospital both in England and in America. The New York Almshouse evolved into Bellevue Hospital and the Philadelphia Almshouse evolved into Philadelphia General Hospital (now closed). I will use Philadelphia General Hospital (PGH) to illustrate this process.

The Philadelphia Almshouse, called Green Meadows, was first located between Spruce and Pine and Third and Fourth Street in a brick building erected in 1731. (16) Philadelphia General Hospital can make strong claims to being the first hospital in America. (15) It was the first of its kind to "house the sick, the infirm, the poor and the insane" in one building. (16) Although Pennsylvania Hospital founded in 1753 claims to be the first hospital in America, Agnew argues that in 1742, the Philadelphia Almshouse already had a "hospital for the sick and an asylum for the idiotic, the insane, and the orphan." (2)

The almshouse was under the control of the Guardians of the Poor who were appointed "political hacks" whose only interest was to line their own pockets and keep expenses down. (16) They often obstructed the enlightened members of the professional staff like Dr. DaCosta who said "they had been named Poor Guardians because they did some of the poorest guarding on record." (16) The day to day operation of the almshouse was in the hands of a manager who closely supervised all aspects of the almshouse including the infirmary, even though he knew nothing about medicine. He also made all the decisions as to who was admitted and who was discharged. (2)

The almshouse next moved to an area called Society Grounds which was located between Spruce and Pine and Eleventh and Twelfth Street. The last location, which later became Philadelphia General Hospital and remained there until it closed in the 1970's, was on the west side of the Schuylkill River, far outside the city (then) and was called Blockley. Even during the early days the able-bodied were moved to one section of the workhouse called "The Bettering House" while the non-working poor were housed in the almshouse. The almshouse had an infirmary section which cared for the sick.

Apparently, the first physician appointed to visit the sick in 1738 was Dr. Shippen, Sr. who was paid a fee of 30 pounds, presumably for a one year contract. (3) The institution was compelled out of necessity to care for the sick housed within its walls; however, the primary purpose of the almshouse was to provide food and shelter for the poor. Dr. Evans and Dr. Bond were appointed to the staff sometime before 1769.

In 1771, Dr. Evans proposed to inoculate some inmates against smallpox. Twenty-one children were separated from the others, inoculated, and all recovered. In 1778, another 40 children were inoculated with the same results. (2)

March, 1780, saw an innovation at the almshouse--outdoor medical relief. Drs. Hutchinson and Wilson were requested to attend and prescribe for those who were not inmates living in the community and needing professional services. Dr. Bond visited suspected vessels in Philadelphia harbor and attended to the isolation of suspicious cases as well as supervised fumigation of houses and ships between 1740 and 1754. One of America's most famous physicians, Dr. Physick, visited patients in the "fever hospital" at Bush Hill during a yellow fever epidemic. (2) Another innovation to the almshouse in 1810 was the appointment of an assistant midwife. Mrs. Lavender was the first female resident physician in this country. (2)

During this early period, inmates who had venereal diseases and the violently insane were transferred to Pennsylvania Hospital which was better equipped to handle these cases. The almshouse had to pay a fee to the doctor attending these cases. In the early 1800s, there was much jealousy between the Philadelphia Almshouse and Pennsylvania Hospital. Instead of sharing knowledge, the managers saw their institutions as rivals. A resolution was passed in 1813 that physicians and surgeons who practiced at Pennsylvania Hospital were ineligible for appointment at the Almshouse. In 1835, Drs. Gerhart and Pennock suggested to the board that the name be changed to the Philadelphia Hospital to reflect a sense of hospital. The title Philadelphia Almshouse no longer seemed appropriate. (2)

Any type of nursing care was provided by chronic and convalescing patients who were not nurses by any standard. They were from the very lowest classes and much cruelty and abuse was reported to the managers. Nursing care, if it could be classified by that term, was provided by "inadequately trained persons including residents of the Indigent Home." (5) The Board of Guardians of the Poor decided that the conditions at the almshouse had to be changed and proposed two changes. The first was to separate the almshouse and the infirmary. All those who were able-bodied would be moved into the almshouse section and all those who were unable to work, due to any type of illness, were moved to the infirmary section. The second proposal was to establish a training school for nurses. Both were implemented. (2)

In 1883, there were approximately three thousand patients being cared for within the almshouse infirmary. The Board of Guardians of the Poor's primary duties was to supply shelter, food, and clothing to the inmates. All funding had to be secured through the city and state government. The Board tried to keep expenses down and care of the sick was a second thought. Any care to the sick was provided by convalescent or chronic patients or by the very lowest class of attendants and servants. (2) In newspaper records there was mention of extreme cruelty due to "drunkenness, laxity and corruptness". (2)

In 1883, it was also decided to establish a training school for nurses and an appropriation of one thousand dollars was obtained in 1883. The Board wanted an experienced woman from Philadelphia to be the head of the school and when none could be found, they searched Pennsylvania and then the whole country. When a suitable head still could not be found, the board sought the help of Florence Nightingale. (2) Florence Nightingale's work in nursing became well established and influenced the establishment of the Bellevue Training School (originally the New York Almshouse) in 1873. The Philadelphia Almshouse used the Bellevue Training School as a model for their school which was founded in 1883. (2)

Florence Nightingale recommended Alice Fisher, then a superintendent of a hospital in England, as the first superintendent. Accompanying her was Edith Horner who was to be her assistant. This importation caused a great upheaval among the Board members; in fact, while Miss Fisher was en route to America, her appointment was still not definite. Some of the Board members wanted a Philadelphia or Pennsylvania woman to get the job, or at least a woman from this country; however, there was no one in this country qualified. The Board members made the first few months of Alice Fisher's appointment very difficult. The political resentment was so strong that rotten eggs were tossed at her windows. Influential women of the community paid for Alice Fisher and Edith Horner's passage over to America as this extra expense caused so much upheaval. It was finally decided that Miss Horner was to receive twenty-five dollars per month as the assistant. Alice Fisher was to receive eight hundred dollars per year as chief nurse but she demanded one thousand. The extra two hundred dollars was again made up by influential women in the community. (2)

It seems hard to believe that there was no one in this country qualified for the job. The Nightingale School for Nurses wasn't opened until 1860 in London and formal nursing education did not begin here in the U.S. until 1872 at the New England Hospital Training School. Linda Richards, America's first trained nurse, graduated from there on October 1, 1873. It was fortunate for Blockley that a person with the qualifications of Miss Fisher was sought as the history of Blockley was influenced by her enthusiastic work.

A nursing school opened in January, 1885, offering three different courses. The first two were eventually dropped and the third, a two year program aimed at preparing women for institutional work, continued for many years. At the beginning of the second year, student nurses were in charge of wards. Initially the classes were conducted after eight o'clock at night as it was impossible for students to leave their wards during the day. During this time, there were approximately 3,000 patients on 28 wards. Graduate nurses were to receive sixteen dollars per month and student nurses were to receive five dollars per month the first year and ten dollars the second. The nurses lived in a wing of the men's surgical ward. (2)

To her credit, within six months, Miss Fisher had the whole hospital under her control for the care of the patients as well as the education of nurses. She also took over the care of the insane wards which had been completely controlled by the attendants. The first class of 15 nurses graduated in January, 1886. (2)

Agnew lists a diet table used at Blockley in 1804 which was served to every pauper in the infirmary section. Breakfast was the same every day and consisted of 1/4 pound of bread and a pint of either coffee or chocolate. The noon meal had little variety and usually consisted of 1/4 to 1/2 pound of meat, one pound of potato, 1/4 pound of bread, and one pint of soup. One day a quart of hash was substituted for the meat and soup, while on another day lunch was only mush and molasses. The evening meal was the same every day and consisted of 1/4 pound of bread and a quart of tea. There is no notation of any special diets except one day of the week the menu was 1/4 pound of bread, one pound of potatoes and meat as ordered by the physician. (2)

The almshouse was usually governed by trustees drawn from the community. The trustees of the almshouse were usually of a lower social class than the trustees of the voluntary hospitals. They were less influential politically and ignorant of the health needs of the inmates. Since the costs of the almshouse were paid by taxes, they were more concerned with keeping costs down than with the medical needs of the inmates. (3)

In October, 1776, the almshouse was taken over by Colonel Francis Gurney for the care of sick American soldiers. The poor were transferred to other buildings in town and the soldiers occupied the southwest wing of the House of Employment. In 1777, the British invaded Philadelphia and took over the east wing to take care of sick British soldiers. In 1778, the British left and the original displaced inmates 82 survived to return. (2). In 1779, the almshouse was asked to take in British prisoners who were ill and a monthly rent of one hundred dollars was paid to the almshouse by the American government. During this period there was only one physician under contract for the entire almshouse, Dr. Duffield, who received "two hundred pounds per annum" and had to supply his own medicines. (2)

Gradually, over time, the community hospital evolved from the almshouse. As the population of the almshouse increased, so did the sick population. As medical and nursing science improved, so did the standards at the almshouse. Patients began to be categorized according to their illness and as a result, the medical staff increased and specialized. In 1835, the name was changed to The Philadelphia Hospital and Almshouse and finally to Philadelphia General Hospital in 1903. (3)

The value of the Almshouse as a medical education component was seen early on. Medical students observed the stages of labor and delivery as early as 1770 and this eventually became part of many medical students' clinical experience. The Almshouse established the first obstetrical clinic in the country. The medical community was not interested in helping the individual inmates but was there to observe all types of maladies. This attitude was due to society's attitude toward the poor in general. The board of managers was hostile to student doctors observing patients and although they approved a motion by the doctors to allow students to observe, students were discouraged. In protest, all the physicians withdrew their services from the Almshouse. (2)

In 1803, Dr. Caldwell was allowed to instruct a class of 20 students as long as he took full responsibility for their behavior. In 1806, the managers further conceded to allow clinical lectures twice a week in the winter. Student participation continued to increase as the board saw the contribution they made. In 1805, students attending instruction at the institution had to purchase a ticket for eight dollars (presumably for a year). If two tickets were purchased, the student was given "perpetual privileges." (2)

It was customary at this time for students who were attending the university medical school to require a ticket at Pennsylvania Hospital. The Almshouse requested that a ticket at either Pennsylvania Hospital or the Almshouse would count toward this requirement which was approved in 1815. The sister hospitals entered into a cooperative spirit and shared medical experiences with each other from this point on. By 1818, there were 53 students attending the Almshouse for clinical activities and over one hundred in 1819. In 1860, the hospital was open to students for free clinical instruction. (2)

In 1814, the first attempts were made to establish a museum. In 1840, the collection was moved to another room under the charge of the apothecary (pharmacy). Dr. Agnew became the curator of the then pathological museum in 1860. (2)

In 1808, one hundred and fifty dollars was appropriated to establish a library with a senior resident student appointed as librarian. A lifelong lending privilege was extended for the price of thirty dollars. Later, free access was granted to physicians and students who served the institution for two years. The apothecary was appointed librarian in 1816. By 1818, the library contained 1022 volumes and by 1824 the managers approved an annual gift of two hundred dollars per year. (2)

Originally the Almshouse didn't have accommodations to handle any type of violent mental patient. These patients had to be transferred to Pennsylvania Hospital. This added expense was always a complaint with the Board. In 1983 the Almshouse built a safe location to house the violent mental patients and brought ten patients back from Pennsylvania Hospital. This section quickly became overcrowded, requiring two patients to be placed in some cells. The basement where the cells were located was damp and cold and the patients were noisy. In 1833 the insane were moved to a newer building with accommodations for these patients built in. It was common at this time for sightseers to visit the insane wards as a form of entertainment. From 1834-1861, the men's ward alone received 3,858 insane patients. (2)

In 1859, the insane department was separated from the other hospital departments under the direction of Dr. Butler at a salary of one thousand dollars per year. Dr. Butler initiated a lot of changes and brought a sense of "order, comfort, and cheerfulness" to the department. (2). Industry took the place of idleness and patients raised vegetables, made shoes, made garments, and played musical instruments. (2)

Before 1788, medicines were not prepared in-house. In June, 1788, the apothecary shop (pharmacy) was established with John Trust being appointed to the office. He was a very busy man. Besides preparing prescriptions for the physicians, he also attended to ward dressings, and kept an account of all patients. He received no salary but received room, board, and washing. In the next few years, assistants were added totaling three in 1802: Senior Student, Junior Student, and Apothecary to the Pharmacy. Each had specific duties depending on their title and experience. (2)

During this period, the most common way to become a doctor was to go through an apprenticeship with an established physician. This could include some university classes and experience visiting the sick at the Almshouse or Pennsylvania Hospital. In 1811, the Almshouse had four apprentices or house pupils of their own: four in the winter and three in the summer. After 1813 there were four all year long: two juniors and two seniors. For this privilege the students had to pay one hundred dollars to the Almshouse treasury. To be appointed to this position, they had to have been under the instruction of a practitioner for two years and attended at least one course in medical lectures. (2) As the need arose, the number gradually increased and the name was changed in 1820 to house surgeon and house physician. In 1828, the name was again changed to junior resident and senior resident. It can be said that the residency system at Philadelphia General Hospital was established in 1788. (2)

During its rein, the Almshouse went through many epidemics just as the city had. In 1841, the Almshouse established an isolation wing called the "outer hospital" away from the main buildings for cases of infectious disease. (2) A report in 1856 describes the hospital as comprising "A smallpox hospital, a lunatic asylum, a children's asylum, a lying-in department, a nursery, a hospital for medical, surgical, venereal and mania-a-potu cases, besides the Almshouse properly so-called." (2)

From the early 1900s on, our views again changed and outdoor relief was again instituted and continues today; the poor can remain in their homes receiving welfare payments and food stamps. The mentally ill were moved to a new state mental facility "Byberry" and the criminals were moved to the newly developed "Holmsburg Prison." With the mentally ill, paupers, and criminals removed, there were only the sick remaining at Philadelphia General Hospital by 1927. (2)

The Voluntary Hospital Model

An institution which from its beginning most resembles what we think of as a modern hospital was the voluntary hospital. The term voluntary in this instance applies to the hospitals that were maintained by contributions of citizens and operated without state control and evolved into general community hospitals. One such institution is Pennsylvania Hospital which will be used in this discussion as a model.

In England, there were approximately 700 hospitals built between the twelfth and fifteenth centuries, but it wasn't until the eighteenth century that hospitals resembling our general hospital developed in America. "In 1752, Pennsylvania Hospital became the first general hospital in America built specifically for the care of the sick." (18) It was founded by Benjamin Franklin and Dr. Thomas Bond. (17) Pennsylvania Hospital would launch many innovations in modern healthcare including: "the first outpatient clinic (1752), first hospital pharmacy (1755), first medical library (1762), first medical resident (1773), and first surgical amphitheater (1804). (17) Franklin envisioned a teaching hospital with numerous types of patients that would expand a physician's knowledge and allow students an experience that was unequaled which they could keep with them wherever they eventually practiced. (4)

Many have defined Pennsylvania Hospital as the first American hospital in continuous operation. The wording is significant as several other hospitals claim to be America's first. In 1658, a hospital was built to care for sick soldiers in New York City. In 1680, this building known as "Old Hospital" or "Five Houses," was sold and a new building erected. (14) This certainly qualifies as the first hospital but did not remain in continuous operation. Historians of Blockley claim that the almshouse functioned as a hospital in the 1740s, however, historians of Pennsylvania disclaim the almshouse for two reasons. (2) The first was that according to the first definition, Pennsylvania Hospital was the first hospital in America built specifically for the care of the sick: the almshouse was built specifically to house the poor. The second reason was that Pennsylvania Hospital has documents showing that inmates from the almshouse were treated for illness at the Pennsylvania Hospital, for a fee. (8)

Money was raised by contribution and investments made with these contributions. Throughout its existence, raising funds was always a problem because the hospital was intended for those who couldn't afford care in their home. The hospital relied on numerous fund raising schemes. Three notable ones were: contribution boxes were placed in locations throughout the city; Ben Franklin wrote a history of the hospital which was sold, and a large oil painting titled "Christ Healing the Sick in the Temple" was displayed for a fee. (8) The painting can now be seen, free of charge, at the hospital. Tickets were sold to walk the wards of the hospital, view surgery in the amphitheater (which was open to anyone interested), or pay a fee to walk the ground and observe the insane, which was a particularly popular Sunday activity. (8)

A problem noted by the managers before the hospital opened concerned the expense of hiring physicians to see patients once the hospital was opened. Drs. Lloyd Zackary, Thomas Bond, and Phineas Bond offered their services for three years without compensation and agreed to provide all medications used. (8) This practice continued thereafter for many years and there never seemed to be a problem recruiting doctors to the staff.

The notion of care for the sick in the 1700s is a complete reversal of today's thinking. In the colonial period, people were generally cared for in their home, with or without visits from a doctor. Most people lived in extended families so nursing care was provided in the home by the women of the household. Most villages and households had a person who knew herbal remedies that helped as much as being seen by a physician. Oftentimes bleeding, emetics, and strong cathartics prescribed by doctors caused more harm than good. Often the sick recovered just as well at home with good nursing care delivered by a family member. The voluntary hospital was originally built to care for those who had no family close by and couldn't afford to hire people to care for them. This included single people, travelers, and seamen in port. (8)

All those who made contributions to the hospital were called "contributors" which entitled them to one vote at the annual meetings. From the contributors a group of managers were elected and functioned as the board of directors. The managers met regularly to deal with the administration of the hospital including developing standards for and the election of physicians and surgeons. Managers developed a policy for the admission and discharge of patients. The managers decided to refuse three types of patients:

"1. All those judged incurable except lunatics;

2. All those suffering from smallpox ... until proper apartments were built; and

3. Women with young children unless the children were taken care of elsewhere." (9)

To be admitted, a patient had to have a letter of reference from an influential person, contributor, or staff physician that was presented to the managers for approval. The patient also had to put up a deposit to cover possible burial expenses and travel expenses. If the managers agreed, the patient was admitted, but only on admission day which was once a week at a specific time. Although the managers occasionally had a physician as a member, the board was generally lay people. The hospital managers had a great deal of power in the early days. Any one of the managers or physicians to the hospital could commit a person to the insane wards merely by writing an order. There was no legal formality required where a person could be deprived of his liberty and classified as mentally unfit to take care of his affairs. (8)

Although the hospital was intended for the sick-poor, the managers made provisions for paying patients, if there was room. Obviously this became popular, especially with the insane patients. (8) Mrs. Steven Girard from a very prominent Philadelphia family was admitted to the insane department in 1790 where she remained until she died in 1815. Mr. Girard gave the hospital $2,000 after her death and left $30,000 in his will. (8) Paying patients were generally indentured servants and slaves whose masters paid the bill, paupers paid for by the overseers of the poor, and the insane from middle and upper class families. (19)

In a measure to protect the community's health in 1808, Pennsylvania Hospital offered free smallpox vaccinations to anyone who came to the hospital. The hospital had been active in community health before 1753 as the minutes record that one of the duties of the apprentices was to "visit the poor sick in the City." (8)

The managers hired two people who were in charge of the day to day operation of the hospital, the matron and the steward. The first matron, Elizabeth Gardner, functioned as the highest executive with the steward second. She received a salary of 20 English pounds per year plus room and board for herself and her two children. (19) When she retired, the steward became the highest executive and the stewardship evolved into the present chief executive officer. The steward, who was always a man, supervised the male employees and handled the financial records. The matron, always a woman, purchased supplies and supervised the female employees. The responsibilities, salary, and living arrangements changed over the years and it became common for the matron and steward to be married. Room and board were provided for all employees; however, the matron and steward quarters were larger and their children were also provided for.

From 1752 to 1755, Jonathan Roberts served as the first apothecary at a salary of 15 English pounds per year plus room and board. (19) Frequently after this the steward served as steward-apothecary. After about 1784, the apothecary became a separate function and the first apothecary worked for room and board only. Later when the hospital developed its apprenticeship program, a resident medical apprentice filled the role of resident-apothecary. (8)

A fourth category of employee was called "cell keepers" who cared for the lunatics. By 1753, twenty two percent of the patients were classified as lunatics and many were potentially violent. The salaries of the cell keepers were low and the turnover was very high. Many were discharged for drunkenness or abusiveness (to patients and stewards). As the number of the insane population increased so did the need to obtain additional cell keepers. There became two categories, one of cell keeper and another of assistant cell keeper. The first mention of a nurse entering the cells was not until 1800. (19)

Nursing in the middle 1700s was quite different than it is today. People listed as nurses were largely untrained and functioned as servants or maids. In fact, the first mention of nurses in the hospital record lists them as maid-nurses. So low was the job of the nurse that frequently the hospital record showed a person listed as a nurse one year, a maid or washerwoman the next, and a nurse again the next. Elizabeth was a cowherd in 1788 and later became an assistant nurse. Catherine Burns and Ruth Carrigan were listed as cooks one year then were listed as nurses another. Ann Burns started as a cook, became a nurse, then returned to the kitchen. (19) Apparently, there was absolutely no special requirement or qualification separating nurses from other female employees. Frequently, they were people who had been patients and recovered. They were uneducated and the pay was small so the positions attracted a lower class of people. (8) By about 1793, assistant nurses were hired and nurses became more specialized. Their job involved "carrying food, tending fires, bathing patients, emptying vessels, handling dressings, quieting disturbances, and even burying the dead." (19) In 1750, their salaries ranged between eight pounds and twenty pounds per year plus room and board. Some nurses became specialized in laying out the dead in their spare time for extra money. Nurse Kitty Burns received between seven shillings and one pound per body and in some years laid out as many as 20 bodies. (19)

Housemaids and washerwomen were continuously employed and in 1788, a cowherd was hired to tend the garden and livestock. There was also a cook and one or more assistant cooks. The patients' diet was an improvement over the almshouse. The diet seemed varied and included beef, veal, pork, mutton, fowl, oysters, butter, cheese, milk, coffee, tea, and rum. During the summer the hospital planted vegetables in the garden. This varied diet originally may reflect an attempt to satisfy the paying patients and their families, but after 1768 paying and non-paying received the same diet. In 1786, the Board's Committee on Economics complained that the cost of wine and rum had continually climbed between 1773-1785. Besides what the help drank, alcohol was used to pacify and tranquilize patients "who were unruly or in pain." (19)

Sanitation was always a problem as the hospital had a "rudimentary water supply" and chamber pots were used through the hospital. Body waste and garbage was buried right on the hospital grounds which attracted rats. Insane patient David Gibson complained that "House Ratz ... ran over his face in the dead of night and threatened to eat him." (19) One patient lost her life when a chamber pot she was using broke and caused a wound on her buttocks. By 1840, the hospital on any given day accommodated 216 resident patients. (19)

In 1875, the Board of Managers hired Miss Frances Irwin to be the Chief Nurse, a newly created position. Her duties required that she supervise the diets of the patients, make sure the wards were properly ventilated and heated, and that the facility was kept clean. In 1883, the hospital established an independent nursing school and Miss Anna Bunting was appointed Superintendent of Nurses. The course was one year and the students could only serve on the women's and children's wards. Although the managers resisted nurses working on the men's wards, three graduates of the class of 1885 were appointed to the men's ward. The length of the program increased in the following years and lectures were delivered to the students by members of the staff. (8)

From its very beginning, Pennsylvania Hospital cared for the insane. This was one of the very few instances in our early days where the mentally ill were also housed in the voluntary hospitals until more recent times. Initially, only a portion of the hospital was built, referred to as the East Wing. In the basement is where the insane were housed in individual cells. There was a corridor used for indoor exercise and a "moat" for outside exercise and fresh air. The moat was directly outside the cell windows and was half way below ground. This allowed the patients to be outside and have visitors without being a danger. Sightseers could purchase tickets to view and taunt the insane in the moat by paying a gratuity of four pence. (8)

There were many disturbances to the general hospital by having the insane housed in the same building as the other patients. There was a lot of noise as well as escapes and other types of disruption. In one case, Thomas Perrine, a sailor, was admitted to the insane cells in 1765. He escaped and running through the hospital made it to the cupola on the East Wing. He could not be dislodged and after all attempts failed, he was provided with blankets and food. He remained in the cupola until his death in 1774. (8)

If needed, the patient could be restrained and chained to the walls of the cell. The cells were unheated, cold and damp most of the year. It was felt at that time that the insane couldn't feel cold. Dr. Rush convinced the board to install charcoal burning stoves in the basement around 1789. The insane remained in the basement cells until about 1797 when the west wing was completed and all of the insane were moved there. Around 1840 the insane were moved to a separate facility, outside the city, on a 101 acre farm called The Institute of Pennsylvania Hospital. (8)

The Center Building was completed in 1804 and joined the East and West Wings. The Center Building became the main entrance, with the apothecary, surgical amphitheater, medical library, and employee apartments housed there. From time to time a baby had been delivered in Pennsylvania Hospital but the Board of Managers did not recognize the specialty of obstetrics until 1803. The second floor of the East Wing was set up as the "Lying-in Ward." (8)

From the very beginning, the Pennsylvania Hospital was an important facility for medical education. Apprentices with their physicians walked the wards and observed the practice of medicine in an institution. In 1752 it was noted that each student had to pay one English guinea per year for this privilege. It was customary in England to give this fee to the physicians and surgeons of the hospital. However, Pennsylvania Hospital used these fees to establish a medical library.

Lectures were given early on by attending physicians. Dr. Bond started giving clinical lectures at the hospital to supplement the College of Philadelphia's medical program. The first lecture, "An Essay on the Utility of Clinical Lectures," was held in 1766. These lectures became very popular with students and the hospital began charging five pounds per course for students who were not apprenticed to one of Pennsylvania Hospital's physicians. (8) Dr. Shippen Jr. began giving lectures on anatomy using drawings and anatomical casts that had been sent from England by Dr. Fothergill in 1763. Students paid one English pistole, "the money to be used for the benefit of the hospital." (19) When physicians brought their apprentices to the hospital to visit the wards they used them as "dressers and assistants." (8) In 1868 the Board of Managers allowed the first woman medical student to attend the clinical lectures and the next year 30 women attended. The students were at times disruptive to the hospital and a special irritation to the steward and Board. Being young, they were full of pranks and were accused of "unruly behavior, unauthorized use of dead bodies, and numerous transgressions of hospital etiquette." (19)

In the early days of the hospital there were no resident physicians on duty except when one was visiting a patient. Sixteen year old Jacob Ehrenzeller, Jr. was apprenticed to Pennsylvania Hospital by his father in 1773. His contract for five years and three months had the following stipulations: "He was forbidden to fornicate, play at cards, buy or sell goods or run away." (12) They combined their apprenticeship with clinical lectures at Philadelphia College. The practice of having hospital apprentices continued until 1824 when the Board of Managers decided that residents from this point must be a graduate physician with a Medical Degree. (12)

The first book was received by the Pennsylvania Hospital in 1762, thus beginning the first and largest medical library in America for 100 years. (10) The fees charged to students to walk the wards were used to purchase books. Medical students, physicians and their apprentices had access to the medical library. These fees called the "Medical Fund" increased to such an amount that it not only covered the cost of books for the library but was used for other purposes. (8)

The top floor of the Center Building is where the first American surgical amphitheater was built in 1804. (11) The gallery could accommodate 130 students and spectators. The room is round with rows of circular benches surrounding the room on two floors. In the center of the ceiling is a large skylight. In the beginning, surgery could be done only at noon, on a sunny day. Notices were posted around town and the curious could observe the surgery (for a fee of course).

A strong attendant would meet the patient's carriage at the front door and carry the patient, slung over his shoulder, up the stairs to the third floor. The patient was placed on a rectangular table and four strong men held the patient down while the physician operated. There was no anesthesia, the instruments were crude, and the sanitation was poor. There was no sterilization of equipment as Lister didn't publish his principles of antiseptic treatment until 1867. (11)

For the most part, funding the hospital continued by contribution; however, paying patients became popular. From the beginning, many of the insane paid their way. Most of the insane patients were cared for much longer than the other patients and many were from wealthy families. Mary Girard, wife of Stephen Girard, merchant and founder of Girard College, was a patient there the last twenty-five years of her life. Families that could afford it were charged a fee for room and board and many mentioned the hospital in their wills. (8)

Today, the hospital is opened as a museum weekdays and information about it is handled through public relations. Pennsylvania Hospital has truly been in continuous use as both the east and west wings of the old hospital are now used as offices and clinics. The center building and grounds are a museum and open to the public. Visitors can tour the Gallery Pavilion on the first floor displaying "Christ Healing the Sick in the Temple," the medical library on the second floor, and the amphitheater on the third. It is a great field trip for anyone interested in healthcare history.

Summary

Before the twentieth century, the average citizen lived in an extended family and had very few dealings with the medical system and hospitals. This is a complete reversal of our thinking today where the hospital is viewed as the hub of medical care. People who were ill were taken care of at home using home remedies and seen infrequently by a doctor. The only contact a person had with a hospital was if they were extremely poor or were away from home. As a complete reversal of our thinking today, going to a hospital before the late 1800s was almost thought of as a death sentence. Physicians made rounds only occasionally, the help was untrained, unskilled, and from the very lowest class of workers, and all decisions were made by lay managers who had no medical knowledge.

Several models of hospitals developed independently to deal with actual problems this newly forming country was dealing with: pest houses, inoculation or isolation hospitals, almshouses, and the voluntary hospital. The pest house, inoculation hospital, and isolation hospital disappeared as the medical and public health communities gained a better understanding of how disease is spread and could better treat epidemics. The almshouse and voluntary hospital survived and evolved into our present hospital and medical center that is the hub of high technology and treatment.

The clinical laboratory in hospitals as we know it is a product of the twentieth century. Autopsies had been performed by doctors as a teaching tool rather than an investigative tool. Both Pennsylvania Hospital and Philadelphia General Hospital had pathological specimens in a room as a museum and teaching tool rather than part of a patient's treatment program. The only specimens looked at by the visiting physicians were urine and sputum. There were no professional clinical laboratory technicians and technologists before the twentieth century.

The clinical laboratory was first established at Philadelphia General Hospital in 1903 and included investigation "of milk, of gastric and intestinal content, of tumors, of the constituents of the blood and of the secretions of the throat." (2) The Ayer Clinical Laboratory at Pennsylvania was opened sometime in the early 1900s. In 1898, Mrs. Josephine Mellen Ayer donated $50,000 to the hospital and her son Frederick Fanning Ayer donated another $25,000 plus an additional $51,000 to publish bulletins of the laboratory's work. (8)

Bibliography (1.) Blake, John. "Smallpox Inoculation in Colonial Boston." Journal of the History of Medicine. (July, 1953).

(2.) Croskey, John Welsh. History of Blockley. (Philadelphia: F.A. Davis Co., 1929).

(3.) Freymann, John Gordon. The American Health Care System: Its Genesis and Trajectory. (Malabar, Florida: Krieger, 1974.)

(4.) Hirschmann, J.V. "History of Medicine: Benjamin Franklin and Medicine." Annals of Internal Medicine (2005) 143:830-834.

(5.) Hospitals: "Old Blockley": Philadelphia General Hospital. Accessed on 5 March 2007 at: www.phila.gov/health/history/parts/part_5.htm

(6.) Marks, Geoffrey, and William Beatty. The Story of Medicine in America.. (New York: Charles Scribner's Sons, 1973).

(7.) Novick, Lloyd and Glen Mays. Public Health Administration. Gaithersburg, MD: Aspen Publishers, 2001.

(8.) Packard, Francis R. Some Accounts of the Pennsylvania Hospital from 1751 to 1938. (Philadelphia: Engle Press, 1938).

(9.) Pennsylvania Hospital. Admission. Retrieved March 12, 2007 from http://www.uphs.upenn.edu/paharc/features/admission.html

(10.) Pennsylvania Hospital. Library. Retrieved March 12, 2007, from http://www.uphs.upenn.edu/paharc/collections/library.html.

(11.) Pennsylvania Hospital. Surgical Amphitheatre. Retrieved March 12, 2007, from http://www.uphs.upenn.edu/paharc/collections/exhibits/amph/

(12.) Pennsylvania Hospital. Time Line. Retrieved March 12, 2007, from http://www.uphs.upenn.edu/paharc/timeline/1751/.

(13.) Pozgar, George. Legal Aspects of Health Care Administration. (Sudbury, MA, Jones and Bartlett, 2007).

(14.) Ranson, John E. "The Beginning of Hospitals in the United States." Bulletin of the History of Medicine (1943) 13: 514-39.

(15.) Rosenberg, Charles. Explaining Epidemics and Other Studies in the History of Medicine. (New York: Cambridge University Press, 1992).

(16.) Rosenthal, Leon. A History of Philadelphia's University City. (Philadelphia: The West Philadelphia Corporation, 1963).

(17.) Savage, Todd. "Oldest Living Hospital Tells All." Hospitals & Health Networks. (1998) 72:48-52.

(18.) Starr, Paul. The Social Transformation of American Medicine. (New York: Basic Books, Inc., 1982).

(19.) Williams, William H. America's First Hospital: The Pennsylvania Hospital, 1751-1841. (Wayne, Pennsylvania: Haverford House, 1976).

Kenneth Brownson, MSMgt, MSPsy, RNC, AHI is an Assistant Professor, American Public University System, Charles Town, WV. He is author of College at Home for Nurses and all Healthcare Professionals.
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