In Mid-L9th- the Common Perception We Have of the English System in Financial Organi- the Pre-1870 Era Is One Ofcorruption Zation

Before the Precedents, Problems, and were set up in a number ofAtlantic Progress ports including Charleston, South Surgeon General: Carolina, and Norfolk, Virginia. Historians have paid relatively lit- The legislation passed by the U.S. Marine Hospitals tle attention to the early decades of Congress in 1798 built on these colo- operation ofthese marine hospitals. nial precedents and was modeled after in Mid-l9th- The common perception we have of the English system in financial organi- the pre-1870 era is one ofcorruption zation. A tax of20 cents per month on Century America and inefficiency and ofunsuccessful sailors' wages theoretically entitled efforts by good people to impose order actively employed mariners to govern- JOHNJENSEN upon chaos. This view, while accurate ment-paid health care including room, board, physician care, and T he "Act for the Relief necessary medicines. While of Sick and Disabled the tax was intended to Seamen" ofJuly 16, 1798, fund the construction and laid the foundations for a operation ofFederal hospi- national system ofhospital tals at major ports, few care for sailors and, ulti- were built by the govern- mately, for the establishment in the years before ment ofthe U.S. Public _ | ~1820. Health Service (PHS). The administrative Creating a powerfil public organization of the Marine health bureaucracy, how- Hospital Fund appears ever, was not the intention straightforward on first ofthe Act's legislative $ glance. The master or ves- fathers. Public health sel agent deducted the hos- remained a local concern _. pital tax from mariners' and a local responsibility in _ wages and paid it to the 1798. It was not until 1870, local Collector ofCustoms, when Congress established it,ito an appointed agent ofthe a more tightly organized Marine Hlospital Service doctors from the Chicago hospitbl, 1878. Federal government. To Marine Hospital Service apply for aid, a sick or and the first Supervising Surgeon to a point, overlooks the program's injured mariner provided the Collector (later the Surgeon General) was broader place in American history and or his agent with a note from the cap- appointed, that an efficient medical its very real implications for the lives tain ofhis previous vessel attesting organization began taking form within of mariners. that he was indeed a mariner and had the Federal government. The 1798 "Act for the Reliefof paid the hospital tax. The Collector Although not a modern medical Sick and Disabled Seamen" was based would then issue an entrance permit, bureaucracy, the Marine Hospital upon older English precedents. In which entitled the mariner to hospital Fund established in 1798 still pro- 1588 England emerged as a sea power care. vided an important safety net for by defeating the Spanish Armada; rec- In practice many problems hundreds of thousands of mariners ognizing t-he importance of seamen, emerged. There were questions regard- who served on American sailing the Crown created a marine hospital ing qualifications for hospital admit- ships and steamboats during the 19th program. Funded through a tax ofsix- tance. Had the sailor served long century. The program also served as a pence per month on Royal Navy sea- enough? Were lake, river, or canal major stimulus for the development men!s wages, the program soon mariners subject to the tax and enti- of hospitals, particularly across the expanded to include merchant seamen. tled to care? What about unemployed midwestern region of the United During the 18th century this practice sailors who had previously paid taxes? States. This essay focuses on the ofproviding health care to seamen Despite the occasional promulgation marine hospitals before the 1870 spread to the colonies ofBritish North ofnational rules under various Trea- reorganization, with emphasis on America. Marine hospitals, funded sury Secretaries, such questions were those located in the Midwest. through a variety oftaxation schemes, most often decided locally. Policies

November/December 1997 * Volume 112 Public Health Reports 525 side ofscattered farms and towns into ucah, Kentucky; Napoleon, Arkansas; a settled region ofcultivated land- Chicago, Illinois; St. Louis, Missouri; scapes and burgeoning cities." Evansville, Indiana; Vicksburg, Mis- fluctuated depending on the port and Water and waterborne commerce sissippi; Detroit, Michigan; Cincin- the whims ofthe Collector or Sur- built the Midwest and created tremen- nati, Ohio; Burlington, Ohio; and veyor in charge. Tax collection was also dous pressure for new marine hospi- Galena, Illinois. uneven and often insufficient to meet tals. By 1820 an estimated 20,000 men local health care costs. Such funding were working on the Ohio River Jacksonian Politics and Maritime shortfalls contributed to the low or alone. Sixteen years later, Dr. Daniel Medicine nonexistent levels ofcare that existed Drake ofCincinnati calculated that at in many communities during the least 40,000 men were working on the While the rapid mid-continental Fund's first three or four decades. rivers ofwhat was then the western settlement drove the Federal marine Despite problems, the marine hos- part ofthe country. Other estimates hospital program's expansion,Jackson- pital program stumbled along and were even higher. ian politics provided its character. grew from a handful ofFederal hospi- Marine medical care had been Corruption and incompetence in gov- tals in 1820 to a collection ofroughly available in many river and lake ports ernment grew rampant during the two dozen government-built hospitals by the eve ofthe Civil War. In addition, thousands ofmariners received care through Marine Hospital Fund contracts with local physicians, city hospitals, almshouses, and charitable hospitals operated by religious organizations. Westward Expansion Westward expansion and internal commerce broke decades ofofficial lethargy regarding marine hospitals. Between 1800 and 1860 the mid-continental United States was settled at a rate unprecedented in history. The key to rapid development was water; the Mississippi River system and the chain ofgiant fresh water lakes that stretch from western New York to Northern The Marine Hospital at St. Louis In the mid- I 9th century. Minnesota provided efficient natural highways for moving goods and through contracts with local institu- Jacksonian period (1829-1861). Politi- people. tions and physicians at least as early as cal connections rather than profes- It was technology, however, that 1833 (ust as contracts had been used sional merit became the main qualifi- unlocked these waterways' vast poten- to provide care in some eastern sea- cation for public office, including the tial. The construction ofpractical ports from the early days ofthe lucrative post ofFederal Marine Sur- steamboats beginning with Robert Marine Hospital Fund). Responding geon. In addition to paying about Fulton's Clermont in 1807 made to political pressure from western S1000 per year, the job left plenty of upstream navigation inexpensive and states, in 1837 Congress appropriated time for private practice and other even luxurious. With the opening of funds to purchase sites for marine hos- professional activities. the Erie Canal in 1825, Great Lakes pitals in seven Mississippi Valley The importance ofthe Marine commerce boomed. The success ofthe cities. More land purchases soon fol- Hospital Fund to American mariners, Erie Canal spawned a canal building lowed. It took a decade or more, how- however, should not be overlooked. craze that fiurther enhanced the mid- ever, to complete most ofthe hospi- Mariners, by the nature oftheir work, continental maritime network. Urban tals. Between 1849 and 1859 the new were usually away from home during historian Richard Wade has captured Federal hospitals opened in New period ofillness or injury, so even the the steamboat's place in midwestern Orleans, Louisiana; Pittsburgh, Penn- flawed safety net provided by the Fund history: "It was an enchanter's wand sylvania; Louisville, Kentucky; Cleve- became an important comfort. By the transforming an almost raw country- land, Ohio; Natchez, Mississippi; Pad- 1850s more than 10,000 mariners,

526 Public Health Reports November/December 1997 * Volume 112 between 5% and 1096 ofthe American Edwards (an Ohio physician who later care provided by the Sisters ofMercy maritime workforce, were receiving served in Congress) investigated at St. Louis and the "great neatness marine hospital benefits each year. American marine hospitals. They and intelligent care" ofthe Sisters of The sick and injured marners in reported that mariners in New York Mercy at Pittsburgh. Travelers' mem- Jacksonian America were taken care of and Boston received good care in oirs as well as letters and petitions by medical practitioners ranging from proper hospitals, at least by contempo- from mariners indicate that the care villains to medical giants. In port after rary standards-although overcrowd- Catholic hospitals provided mariners port, at least in the Midwest (the region ing was reported to be an increasing across the Midwest was generally I have studied most dosely), men of problem. The facility in Mobile, excellent, in spite ofthe financial con- high professional standing served as Alabama, represented the far end of straints under which these institutions marine physicians. Buffalo's Austin the spectrum. Patients were "[c]row- typically operated. Flint, Sr., Cleveland's Horace Ackley, ded in large numbers in the lower and Cincinnati's Daniel Drake (popu- wards, without regard to disease." The The Results of Federal Medicine larly known as the Benjamin Franldin hospital in New Orleans, apparently, ofthe West) are but three examples of was even worse. Despite the possibility ofencoun- elite physicians who tended mariners But the South had no monopoly tering a corrupt or incompetent physi- during the mid-19th century. These on misery: in New Haven, Connecti- cian or ofbeing displayed as an inter- men all enjoyed professional reputa- cut, Newport, Rhode Island, and sev- esting case, on balance American tions that extended far beyond their eral other ports mariners were treated mariners benefited from the Federal own communities. Pioneer medical in "city infirmaries"-often a marine hospital program. The hospital educators, these physicians helped euphemism for paupers' hospitals care mariners received in most ports establish some ofthe Midwest's first (where care was often ofpoor quality). was no worse than what was available permanent medical schools. This practice declined as the century to most other members ofthe com- Yet not all marine physicians were progressed, but as of 1855, Treasury munity. And, irrespective ofmedical ofsuch high standing, nor did the care Department investigator William issues, the fact that marine care was they provided always serve the best Gouge reported that mariners in at government-paid and that patients did interests ofmariners. Inferior or least six ports were still being treated not have to be pauperized to receive it unorthodox doctors (for eaxmple, a in facilities intended for paupers. made it far superior to the options homeopath in Cleveland in 1869) at The overall quality ofhospital care open to other non-wealthy people. By times gained office. And even highly available to mariners appears to have the 1850s, at least, the Marine Hospi- respected teaching physicians could not improved as the century progressed. tal Fund frequently helped mariners resist capitalizing on mariners as a par- By the 1850s, marine hospital care avoid the poorhouse or charity infir- ticularly valuable brand ofclinical may have been consistently ofthe mary during periods ofmedical material. Typical hospital and highest quality in the midwestern dependency. almshouse patients ofthe period gener- United States. In that region, urban The Federal government has been ally suffered lagely from chronic con- development and the creation ofa in the business ofproviding health ditions brought about by poverty, age, medical infrastructure were directly care services for a very long time. Dur- or dissipation. In contrast, hospitalized linked to and shaped by the expansion ing the 19th century, despite unending mariners, usually younger and healthier, ofmaritime commerce. In city after administrative, financial, and political frequently suffered from acute ailments city, from Buffalo to St. Louis, the problems, tens ofthousands ofcitizens and traumatic injuries-the types of establishment ofpermanent hospitals received needed medical care through conditions aspiring physicians expected reflected, in part, both the need to care the Federal government's marine hos- to encounter in private practice. The for sick or injured mariners and the pital system-care that would have opportunity to receive clinical instruc- financial opportunities provided by the been unavailable or at least grossly tion in a marine hospital ward attracted Marine Hospital Fund. deficient without government inter- medical students, and schools such as Caring for mariners at different vention. Western Reserve Medical College in times in Buffalo, Detroit, Chicago, Cleveland advertised their marine hos- Milwaukee, St. Louis, Pittsburgh, and JohnJensen is a PhD candidate in the pital connections accordingly. a number ofother river and lake ports, Department ofHistory at Carnegie Catholic hospitals were a vital part of Mellon University. Marine Hospital Care the American marine hospital system. at Mid-Century The Catholic church founded many Address correspondence to Mr. Jensen, early midwestern hospitals and Carnegie Mellon Univ., Dept. ofHistory, In 1849, at Congressional request, became an important provider ofhigh Baker Hall240, Pittsburgh PA 15213; tel. Drs. George Loring (surgeon at the quality care for mariners. Loring and 412-638-5435; e-mail .

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