In her examination of hospitals in
London and Paris, Florence Nightingale delineated
several deficiencies in hospital design and
construction and outlined her vision of proper
hospital sanitation, construction, and care.
Among the primary considerations were the
hospital site and the local climate. Clay,
gravelly, and sandy subsoils were to be avoided
as well as old graveyards and other soils with
high concentrations of organic matter. In her Notes
on Hospitals published in 1863, Nightingale
wrote:
Although
hospitals are intended for the recovery of
health, people are very apt to forget this,
and to be guided in the selection of sites by
other considerations -- such as cheapness,
convenience, and the like; whereas, the
professed object in view being to secure the
recovery of the sick in the shortest time,
and to obtain the smallest mortality, that
object would be distinctly kept in view as
one which must take precedence of all others.31
Construction of
hospitals in crowded neighborhoods, near high
walls, smoking chimneys, or on narrow streets was
to be avoided. Nightingale advocated the
evacuation of the sick to sites outside of the
city where the restorative powers of fresh
country air would facilitate recovery. Suburban
sites had several advantages. The removal of
hospitals to the country would reduce the
concentration of the sick in dense, urban
populations. Patients already living in the
country would travel shorter distances to reach
medical attention and would not be subjected to
the "additional risk of coming from the
fresh air of their homes into the foul air of the metropolis."32 Medical education would
also be advanced for students would learn more
from patients who were actually recovering from
rather than lingering in disease. Such sites
would also provide fewer distractions to students
for the "quiet and studious habits of a
college would be substituted for the desultory
lecture-hunting and hospital-walking of London."33
Hospitals should
be designed so that external air freely
circulated. The common architectural forms of one
closed court with high walls or, worse yet, two
closed courts, were defective designs which
impeded the ventilation of stagnant air. Wards
should be of sufficient height and width, each
with their own means of natural ventilation, to
permit adequate circulation of fresh air. Large
plate glass windows, one for every two beds, were
necessary for light, ventilation, and to permit
patients to read in bed.34
Properly placed
sewers, well-constructed sinks, external water
closets, and bathhouses were essential to the
health of patients. To prevent the "regurgitation
of foul air," drainpipes should be placed in
outside walls so that drainage runs away from
rather than under the hospital.35 Nightingale wrote:
In one
hospital I knew, if the wind changed as to
blow up the open mouths of the sewers, such
change was frequently marked by outbreaks of
fever among the patients, and by relapses
among the convalescents from fever. Where
there are no means for externally ventilating
the sewers, no traps, no sufficient water
supply, no means for cleansing or flushing
them, and where the bottoms are rough and
uneven, such occurrences cannot fail to take place.36
Oak floors
saturated with beeswax and turpentine produce a
non-absorbent finish able to withstand frequent
and thorough washings. Although walls should be
plastered, Nightingale warned that the surface
could become saturated with organic matter,
producing a dangerous vegetative bloom that
sickened even the workmen who scraped and limed-washed
the walls.37 Furnishings consisting of
iron beds with hair mattresses and linens washed
in specially constructed hospital laundries were
necessary for the health of patients.
While Baltimore's
hospitals do not appear to have achieved Florence
Nightingale's ideal, they do reflect the wide
range of quality found in the city's medical care.
In the early nineteenth century, the primary
hospital for the treatment of the poor, including
those incapacitated by diseases, old age, and
insanity, was the Baltimore Almshouse, which had
been established in 1773. Care was provided by an
attending physician appointed by the Trustees of
the Poor and a group of resident medical students
for whom the attending physician acted as
preceptor. In 1822, the Almshouse moved to a
converted private dwelling in Calverton,
containing quarters for the resident medical
students, the overseer and his family, and the
apothecary. Additions to the central building
contained dormitories and wards for lying-in
patients, the sick, and the insane. In 1834, Dr.
James Lawrence Cabell (1813-1889) who went to
work at the Almshouse following his graduation
from the University of Maryland, described his
experience as follows:
The
subjects, though paupers are not, as I had
supposed, generally old & helpless, for
we have them of all ages from birth upwards
& many are stout able-bodied men &
women who come to this place where they can
good get fare & medical attendance for
little or nothing. This house is now crowded
with the sick & every moment of my time
will be engaged until I become more ready and
expert in the practice. We live in a centre
building occupied by the officers &
physicians of this establishment, while the
sick occupy two lateral buildings, one for
male, the other for females, only connected
with the centre by a covered way. The whole
institution is managed with great liberality
and is as free from imperfection as is practical.38
By 1841, nearly
600 paupers resided in the Almshouse, of which
more than 100 were sick and 188 were considered
paupers for life. A separate area known as the
"Children's Department" was set up for
the younger residents, providing "removal
from the immoral influence of vicious adults"
as well as a schoolroom, two dormitories, and an
area for meals. A fenced area provided yards for
the insane and children. Male residents were
segregated by race, while a separate building,
then under construction, would house white female
residents, thus totally separating white and
African American inmates. The Almshouse
maintained a separate lying-in ward, charging
twenty to thirty cents per day. Mothers were
allowed to leave; however, if they did not take
their babies, they were required to return at
certain intervals for breast-feeding.39
The Trustees made
a distinct and moral distinction between those
viewed as the "unfortunate poor" and
others classified as "vagrants,"
arguing that the former should "experience
that sympathy and kindness which would help to
make them forget their misfortunes, [while] the
latter should be taught to regard the Alms and
Work-house rather as a place of punishment to be avoided."40 It was the seeming
ingratitude of the vagrants -- receiving free
medical care, food, housing, and clothing only to
"elope" -- that rankled the
sensibilities of the Trustees. Without a suitable,
separate building to serve as a work house, the
Trustees were unable to separate vagrants from
the general inmate population and deter such
escapes.
Paupers at the
Almshouse were expected to provide manual labor,
ranging from spinning and weaving, sewing of
quilts and clothing to shoemaking, carpentry,
painting and glazing, and building of coffins. In
addition, pauper manual labor was used for
completion of improvements to the facility, such
as converting a coal room to a space for weavers,
tailors and shoemakers, enlarging the spinning
room, and improvements to the Children's
Department and the Female Wing. Men were paid
between seven to fourteen cents while women
received six to ten cents. Since inmates were
charged for their food, clothing and other
expenses, this money was used to repay their obligations.41
The Almshouse also
maintained a 350-acre farm, cultivated by pauper
labor, which provided food for the institution's
inmates. Their diet consisted of a meal of coffee
sweetened by molasses accompanied by bread.
Dinner included soup, meat or fish, vegetables,
potatoes, corn or rice. The bread portion for who
worked was 20 ounces, reduced to 16 ounces for
those unemployed. Milk was also available for children.42
In 1843, a
waterworks was built, providing every room and
water closet with spring water as well as the
stables and barn. This was particularly momentous
for the hygiene of the institution, since "all
offensive matter of every description, that
unavoidably accumulates in hospitals, is at once
emptied into the water closets, and a jet of
water turned upon it, which instantly carries it
off beyond the outer walls into a receptacle
prepared to receive it; from whence it is
regularly removed to the fields."43 In the same year,
preparations were made to remove the hospital for
the insane to a separate building. Using pauper
labor, building stone was prepared for the
foundation from a nearby quarry. It appears that
further improvements in the care of the mentally
ill were slow in coming. In 1850, additional
stones were quarried for a separate male insane
asylum, but outbreaks of cholera and smallpox
induced the Trustees to use the funds for the
erection of the infectious hospital. In the end,
the gradual deterioration of the buildings and
the unhealthy site prompted the construction of a
new facility overlooking the Chesapeake known as
Bay View Asylum. In October 1866, the Almshouse
inmates were transferred to the new facility
which took on the responsibility of caring for
the city's poor.
The treatment of
infectious diseases had long been a serious
problem at the Almshouse. In an attempt to
safeguard the city from infectious diseases
entering the port, the city opened a quarantine
hospital at Hawkin's Point southwest of Lazaretto
Light. Established in 1797 in response to an
outbreak of yellow fever, the hospital was
probably only reached by water. In 1830, the
hospital came under the supervision of the city
health department that refitted the building to
handle ship passengers carrying contagious
diseases. In 1836, the building was destroyed by
fire and was not replaced until 1845 when the
Marine Hospital was built south of Fort McHenry.
The hospital continued to handle ship cases, but
also served as a pest-house.
In contrast, the
Maryland Hospital was founded in 1797 as a
lunatic and general hospital.44 Funded by
appropriations from the Maryland legislature and
charitable contributions by local philanthropists,
the hospital usually accommodated 40 lunatics and
150 general patients.45 In 1838, the hospital was
converted to provide solely for the care of the
mentally ill. Despite their exemplary care, the
Sisters of Charity were replaced in 1840, when
the resident physician assumed management of
patient care.
The Maryland
Hospital cared for two classes of patients:
private patients who paid from three to five
dollars per week46 and public patients who were on
the public roll by court order. Charity patients
were limited to sixty and most of these remained
inmates for the remainder of their lives. The
majority of patients came from Baltimore City,
but residents from other localities could be
committed to the hospital at the expense of that
county. By the 1850s, the cost of maintaining a
patient at the hospital ranged from thirty to
fifty dollars per year.47
The annual reports
of the President and Board of Visitors and the
Resident Physician provide an almost cheerful
depiction of life in the asylum. In 1843, Dr.
William Fisher,48 the Resident Physician, reported
that although the number of deaths had increased
over recent years, the hospital boasted an eighty-two
percent recovery rate in those cases of less than
one year in duration. Inmates were housed
according to their illnesses, separated by sex.
Female patients were occupied with sewing,
needlework, laundry, and gardening. Male patients
could work in the carpenter's shop, split wood,
or participate in a variety of manual chores on
the Hospital's eight-acre farm. Encouraged to
enjoy the restorative powers of fresh air,
patients could enjoy daily, long carriage or
horseback rides, take long country walks, and
visit local areas of interest. A library49 and
school were maintained and patients were
encouraged to follow intellectual pursuits. At
the very least, patients were able to keep up
with the daily news as the editors of several
local newspapers -- the American, the Sun, the Patriot, and the
Clipper
-- donated subscriptions to the library.50
Despite the
depiction of the Maryland Hospital as a near
idyllic life, it would appear that hospital
conditions did not match the rosy picture
portrayed in the annual reports. In 1851,
Resident Physician John Fonerden,51 delineated the
problems faced by the Hospital, including
insufficient heat in the winter and an inadequate
water supply in the upper stories of the building.
The increasing number of patients admitted each
year necessitated the conversion of two sitting
rooms to bedrooms, each containing fifteen beds.52
The number of applications of public patients
were increasing rapidly while patient turnover,
either from discharges or deaths, remained low.
In 1851, the President of the Hospital approved
certain improvements to the buildings, including
improvements in lighting and ventilation in the
living quarters.
The difference in
the recovery rate between public and private
patients raises the question of whether paying
patients were treated better than those dependent
upon charity. In 1851 only two public patients
were discharged in comparison to the twenty-four
private patients deemed recovered that year.
Underappropriated by the Legislature, the
hospital was forced to be self-sustaining.53 Since
the hospital could charge more for private
patients -- the cost of public patients was
dictated by law -- and families could not afford
to support a mentally-ill family member
indefinitely, it was in the financial interest of
the hospital to make sure that private patients
had a good recovery rate.
At least on the
surface, the Maryland Hospital does not seem to
have suffered greatly from the variety of
diseases appearing in the public at large during
this period. The reports of the Resident
Physician make no mention of the general health
of the inmates until 1857, when Dr. Fonerden
notes that this is the first year that the usual
seasonal outbreaks of dysentery and diarrhea had
not occurred. While illnesses may be elsewhere
recorded in the records of the hospital,
outbreaks of disease are not reflected in the
annual reports.
In 1851, the
number of patients diagnosed as mentally ill in
Maryland had grown to five hundred, prompting
calls for a second mental hospital.54 Although
initial proposals called for an expansion of the
Maryland Hospital, the Legislature appropriated $10,000
in its 1852 session for the purchase of a new
site and construction of a hospital.55 After many
false starts, the new hospital, Spring Grove in
Catonsville, opened in 1872.
Those patients
able to afford the three dollar admittance fee
were able to benefit from the resources of the
Baltimore Infirmary, the clinical teaching arm of
the University of Maryland School of Medicine. In
1823, the Baltimore Infirmary was founded by the
professors of the medical school, who funded the
establishment of the hospital from their own
personal resources. The Infirmary, located on the
corner of Lombard and Greene Streets, was
composed of four wards, including one for eye
cases, and sixty beds, expanding to eight wards
and ninety beds by 1832. Of those eight wards,
three were reserved for the treatment of seamen;
three for white, male patients; one for women,
and one for African Americans.56 The building
included a semicircular surgery theater with
seats for students to observe operations. Nursing
was provided by the Sisters of Charity who
supervised the day-to-day operations of the
Infirmary in return for rooms at the hospital and
medical care when necessary.57 Patients were
prohibited from leaving the Infirmary without the
permission of the attending physician, surgeon,
Sister Superior or the Senior Student. Neither
smoking or drinking was permitted in the wards.
Like the Almshouse,
the Baltimore Infirmary treated the usual range
of fevers and diseases indigent to Baltimore in
the early nineteenth century. During the 1830s,
most of the Infirmary's cases were from the
various public improvement projects, providing
patients who have suffered injuries from
accidents as well as seasonal fevers and
dysentery. The Infirmary was also concerned with
the medical care of sailors, many of whom were
suffering from yellow fever and malaria. In the
1840s, the Marine Hospital was under the
supervision of the Infirmary, giving students
additional opportunities for clinical instruction
and experience.
A more personal
view of medical care is provided by the case
history book maintained by Dr. J. Emory Tull,58 and
his fellow clinical assistants59 during their
tenure at the Baltimore Infirmary. The clinical
residents documented the condition, diagnosis,
and treatment of 334 patients admitted to the
Infirmary between 1853 and 1854. The Infirmary's
patients were drawn from the working classes of
Baltimore, and included servants, laborers,
sailors suffering from a variety of infectious
diseases and industrial injuries.60
Between 1853 and
1854, at least twenty-eight cases of tuberculosis
were admitted to the Infirmary. Of the ninety-two
patients admitted to the Almshouse with
consumption in 1854, ten patients were cured,
fifteen relieved, sixty-eight died, and eight
"eloped."61 During the same year, 928
Baltimoreans died of the disease.62 Few patients
found relief, much less a cure, in the standard
treatment of the day. Joseph Price, a laborer
admitted to the Infirmary on November 10, 1853,
suffered from a "persistent long hacking dry
cough and died November 17th, after
choking on mucous. An autopsy showed that both
lungs contained "a great deal of tubercular
matter."63 Joseph Kimsel was admitted January
20, 1854 after complaining of stomach pains,
especially after meals, and a painful cough. He
had attributed his illness to exposure to the
cold and wet followed by sleeping in "a very
open and cold room." By February 4th,
doctors predicted that he would not live long.
Despite treatment with a chalk mixture and cough
remedy, Kimsel continued to decline and died on
February 16, 1854.64 Peckham Williams, a Kent
County farmer admitted to the new wing of the
Infirmary on November 15, 1853, had suffered from
a cough for the past year with occasional night
sweats. During the summer while shucking wheat,
he coughed up two tablespoons of blood. He
recently got wet while in Baltimore and cough
cold, resulting in persistent coughing, pain in
his left side, and sweating. An earlier physician
prescribed cod liver oil, of which he took four
bottles, quinine, and a cough mixture without
apparent benefit. After an additional treatment
of Brown's Mixture by the Infirmary doctors,
Williams went outdoors and caught cold. Fortified
with Brown's Mixture, cod liver oil, and a
rhubarb pill, Williams left the Infirmary on
November 22nd, "about as when he
entered."65 The Infirmary casebook shows that
tuberculosis patients were treated with a variety
of cough mixtures, sodium bicarbonate, caster oil,
cod liver oil, strychnia, and blistering, but
usually with little relief from the symptoms of
the disease.
It is interesting
to note that only a few cases of certain
prevalent diseases were recorded in the casebook.
For example, despite a minor outbreak of smallpox
in 1854, only one case was recorded in the
casebook, and the patient, who was initially
admitted for chills and fever, was quickly
transferred to another hospital.66 Likewise, a
cholera epidemic in the same year resulted in no
diagnosed cases being recorded in the casebook.
The Infirmary
doctors employed a wide variety of medical
treatments, including bloodletting, calomel, and
other purgatives and emetics. For the nineteenth-century
medical practitioner, diagnosis and treatment
were based upon the notions that superficial
observation of external symptoms would explain
the pathological state of the patient and that
any treatment which produced extreme changes in
the patient's symptoms was desirable and
therefore medically sound.67 Calomel, a mercury
compound that was therapeutically useless, was
often prescribed at the Infirmary for chronic
diseases. Charles Garrison, a sailor from New
York, had never been sick prior to his attack of
rheumatism, which had been brought on by
stand[ing]
in water knee deep at work, for several hours:
this exposure was followed by erratic pains
in all his joints so that to turn in bed
caused excessive pain: had neither chill nor
head ache: sleepless at night on account of
pain: on the 2nd
or 3d day of
sickness the pains disappeared from the R.
shoulder and arm: on Thursday last, the knee
joints began to swell, but were not red: has
had some cough….
Treated with
calomel and other preparations, Garrison appeared
to improve until he was suddenly seized with
chest pain. On March 25th, he was
cupped and given additional calomel. The
following night, he was cupped again over the
heart "to relieve the organ of pain."
Miraculously, in spite of heroic medical
treatments, Garrison survived and was discharged
several weeks later.68 Another sailor, John
Reboe,
was admitted with gout. His treatment included
purging with calomel and ipecae. Suffering from
abdominal pains, and diarrhea, Reboe's condition
worsened as the treatment continued. Within days,
the patient was in a coma, paralyzed on the left
side of his face. The following morning he died
after suffering convulsions, which had been
treated by blistering.69 Thomas Barrett, a laborer
on the railroad and native of Ireland, had
contracted ague two years before "from which
he has never been free for more than a month at a
time." After treatment with quinine and
cinchona – one of the few medically valid
treatments of the period — Barrett left
nearly three weeks later improved in health.70
John Mattigan
represents one of the more curious cases treated
at the Infirmary. Mattigan, a stone mason of
temperate habits and previous good health, was
admitted suffering from paralysis below the waist
for which there was no known cause. Treated with
blistering and poultices, Mattigan left three
weeks later, his condition unimproved.71 At some
point, it would appear that Mattigan's health
improved, for not only did he continue to be
listed as a stone mason in the federal census and
city directories, but he fathered two additional
children in 1856 and 1860.72
The clinical
assistants were exposed to far more than just a
medical education. It was not unusual for the
medical students to fall victim of the diseases
of their patients. During the 1849 cholera
epidemic at the Baltimore Almshouse, most of the
medical staff, including three clinical residents,
came down with the disease. At the Infirmary, Dr.
Tull himself seems to have fallen victim to
typhoid fever while researching the disease for
his dissertation and was so ill that he was
barely able to complete his degree.73
A reading of the
case history book makes it clear that Tull's
tenure as a student at the University of Maryland
occurred at a crossroads in American medicine.
Although the Rudolph Virchow's discoveries in the
field of cellular pathology began in the 1840s,
the University did not include Virchow's textbook
as part of the curriculum until 1860. Dr. Tull
participated in the clinical observation of a
wide variety of infectious diseases, including
yellow fever, typhoid, and tuberculosis. Yet his
medical education came too soon to incorporate
the bacteriological advances in treatment and
diagnosis heralded by improvements in the
microscope and the development of methods to
stain and mount tissue samples. His own
examination of typhoid fever showed him the ease
in which the water-borne move from neighborhood
to neighborhood, but his medical tools to fight
the disease would be based upon a limited
knowledge of materia medica. The introduction of
ether and chloroform transformed surgery during
Tull's tenure at the University, but another
decade would pass before Joseph Lister's work
would lead physicians to fight infection by
keeping bacteria from the incision. Furthermore,
Tull's impression of hospital nursing came
through his interaction with the Sisters of
Charity who not only provided nursing care for
the Infirmary patients, but who disciplined the
Infirmary's medical residents. Tull would not
live to see the publication of Florence
Nightingales' views on hospital organization and
the professionalization of nurses and their
incorporation into the nursing profession.74 In
short, the rapid improvements in diagnosis and
the advances in bacteriology and pathology would
make Tull's medical education was nearly obsolete
by the time he graduated in 1854 and later
established his medical practice in Somerset
County in the 1860s.
After the war, the
Infirmary experienced an expansion in clinical
teaching, including clinical emphasis in
obstetrics. In 1866, the University established
an obstetric out-patient clinic which attended
patients in their homes. By 1887, the faculty had
established a free lying-in hospital in a nearby
house. In 1868, an out-patient department was
established at the hospital manned by students
who dispensed free medical advise and drugs to
walk-in patients. A separate eye and ear
infirmary was founded in 1870 by J.J. Chisolm,
the ophthalmology professor, but it proved too
expensive to maintain and control was given to
the Presbyterian Church, creating the
Presbyterian Charity Eye, Ear and Throat Hospital.
Residencies were established in nearby hospitals,
including Bay View, Marine, City, and Hebrew
Hospitals.75
During the 1840s,
the numbers of immigrants entering the city
greatly increase. As many of the newcomers were
destitute, numerous charitable organizations and
private and semi-private benevolent associations
were formed to improve the plight of the poor. In
addition, several hospitals such as Union
Protestant Infirmary (1854), St. Joseph's (1864)
and St. Agnes (1878), maintained by private
organizations, also supported charity patients,
and at least one, St. Joseph's, operated a free
dispensary. The city also established several
dispensaries, including Baltimore General (1808),
Eastern (1818), Western (1847), and Southern (1847).76
Nightingale, Notes
on Hospitals, p. 26.