Medical History for Medical Students

HOSPITALS Through History

Brian Dolan, PhD

Chapter Title 1 © Copyright 2015

University of California Medical Humanities Press 3333 California Street, Suite 485 San Francisco, CA 94143-0850

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General Editor: Dr. Brian Dolan, University of California, San Francisco

Medical History for Medical Students Titles in this series:

Issue 1: Healers Through History Issue 2: Through History Issue 3: Through History Issue 4: Lungs Through History Issue 5: The Heart Through History Issue 6: Metabolism and Nutrition Through History Issue 7: Through History Issue 8: Cancer Through History Issue 9: Through History Issue 10: Through History Issue 11: Through History Issue 12: Alternative Through History

ISBN: xxx-x-xxxxx-x-x The Cult of

Fig. 1: Frescoe in the of Santa MariaDellaHospitals Scala 1 n the United States, the existence of hospitals as centralized organizations for urgent healthcare is taken for granted. For medical students, imagining Ia career in medicine is often imagining what it would be like to work in the wards. One of the privileges many medical schools enjoy is access to a “,” either a university medical center or where students receive clinical training. In the course of , students across the country will also be placed in preceptorships in private practice clinics, specialist care centers, professional offi ce buildings, and some even in shopping malls. The institutions of medicine are diverse, complex, and rarely run the same way as one another. Yet despite the diversity and degrees of specialization in modern medical centers, the fundamental idea that rituals of healing should be located at designated places stems back to the ancient world.

While specifi c sites have been associated with the art and craft of healthcare for thou- sands of years, the practices themselves – or the medical knowledge that underlay rituals of healing – were not specialized in the modern sense of the word. One interesting lesson from the history of hospi- tals is that their development refl ects the professionalization and specialization of the practices that occur within these sites. The history of places of healing is a history of the practices that defi ne the healer. In turn, the very ideas that defi ne a , a sick- ness, or medical care (as opposed to a spiritual or charitable act) are tied to the way we think about specialized spaces of sickness.

2 Medical History for Medical Students Temples and Xenodocheia

The healing arts have long been intertwined with mysticism, religion and alternate belief systems regarding sickness and health. We know of many ancient associations between healing rituals and religious practices and beliefs. Take, for example, the small city of that once existed on what is now the Peloponnese peninsula in a southern region of Greece. In the fi fth century BCE (Before the Common Era) it was determined that this is where Apollo’s son Asclepius was born. This thought provided comfort to a growing pop- ulation that was displaced by war and ravaged by plague. Around 430 BCE, Epidauran priests constructed a sprawling temple in Asclepius’s honor where the sick, dying, birthing mothers, and visitors could lodge, feast and offer sacrifi ces to the god in the hope of prolonged health. Within a main shrine sat a statue of Asclepius, a middle-aged bearded man wearing a tunic tossed over his left shoulder, resting next to his dog. Plaques commemorated miraculous cures. Soon after, another Asclepian temple was erected near the Acropolis in Athens, then another in Pergamom, and then in . Being not only shrines to worship the god, they offered a sanctuary for residents surrounded by a sacred wall surrounding spring baths which cleansed their bodies. Historic accounts suggest they were hugely popular, with over three hundred temples founded throughout the Mediterranean world and the by the new millennium. The practitioners, visitors and supplicants formed what is referred to among classicists as “the cult of Asclepius.” [1]

Fig. 2 (Opposite): Claybury Asylum, Woodford, Essex Fig. 3: Asclepius with his serpent-entwined staff, Archaeological Museum of EpidaurusHospitals 3 These temples, known as of homage and piety, the design and of Judeo-Christian moral duties. Asclepieions, became an “interna- chosen location of Asclepieions In fact the very rituals of care tional institution of worship,” – near the seaside or scenic groves practiced by Asclepiads are notable according to medical historian – made them more akin to “health for relying less on prayer than Guenter Risse. “In an effort to resorts,” to use classical scholar rationalized care, acts that – while expand their healing options, which Alice Walton’s analogy. beginning to be separated by ranged from divine intercessions An important point here is not space – were not mutually exclusive. by Apollo, opinions of healer to over-determine the languages Simultaneously, the population in seers, magicians, , athletic of divine worship in these shrines the ancient world worshipped gods, trainers, and herbalists, the ancient dedicated to healing nor to assume dreamt in temples, and followed Greeks may also have targeted they existed solely within religious health regimens as spelled out in the human disabilities as the proper rituals. The pan-Hellenic Asclepian rational writings of Hippocrates. concern of a former healer turned cult provided welfare and care Such a seemingly varied set of hero and now a major deity: according to a social ideology that beliefs and practices has been Asclepius.” [2] Devotees of the was not directly linked to any one characterized as expressions of the healing arts, called Asclepiads, particular religious cult. The tenets “polarizing mind” of the Greeks, were now associated not only with of philanthropy – providing food though as Cicero said, “few divine powers and certain rituals of to the hungry, a refuge for the owe their lives to Asclepius rather practice but temples and dormito- homeless, shelter for travelers, and than Hippocrates.” [3] ries of worship and recovery. While beds for the sick – were principles very much like temples to other adapted as much by the evolving gods, encompassing common acts medical discipline as by advocates

Figs 4 & 5: Google earth view of Pergamum’s Sanctuary of Asclepius, or Asclepieion, on the outskirts of modern Bergama, in western Turkey.

4 Medical History for Medical Students Large Temple of Asclepius

Small Temple of Asclepius

Alter of Asclepius

Temple of Apollo

Figs 6 & 7: Top, rendition of an Asklepieion on , a Greek island off the Anatolian coast of Turkey. Built in 357 BCE, the sanctuary was one of the main seats of the Asklepiadai, supposed descendants of Asclepius, who were a hereditary order of priests and guardians of the secrets of medicine. The rich court Xenophon (who helped to poison the Emperor Claudius), on his return to Kos, lavished the sanctuary with statues he had collected in Rome. In the sixth century, all was overwhelmed, either by an earthquake or in 554 when Anatolian hordes ravaged the island. The Knights of St. John used the ruins as a quarry. Below, a modern tourist attraction of its ruins (Wikipedia photo).

Hospitals 5 Certainly the church has historically hostels reserved for the poor. xenodocheia complemented the brought a powerful organizational Xeno means traveler or foreigner, monastic system of , structure to institutions of docheion means place of reception. where facilitated healthcare. Religion’s philanthropic Translated into what we commonly for the sick and commitments have created spaces refer to as hostels, xenodocheia redistributed resources accumulated in which the poor and impoverished grew to undertake care of the by . are helped. In the fourth century, sick, the homeless, widows, and the Syrian church – reacting to a orphans. [4] Appearing in every vacuum left by the impoverishment city of the Empire from early of the local municipal government encouragement by Pope Gregory strained by surges in population I (“Gregory the Great,” ca. 540 - growth – organized relief programs 604) and administered by , around xenodocheia, the name for throughout the the

Fig 8: Albucasis (Al-Zahwari) blistering a patient in the hospital at Cordova, 1100 AD.

6 Medical History for Medical Students From Hospitality to Hospitalization

The very etymology of the word or the destitute), but began dividing hospital reinforces the emphasis space and service according to dif- on physical recovery and welfare ferent types of illness. The concept that came to dominate its history, for this relates back to an Islamic and is suggestive of its origins in hospital built in Cairo, Egypt, in xenodocheia. Today we don’t usually 1283 by al-Mansur Gilafun: think of “hospitality” in regard to hospitals. We reserve that for hotels, Every class of patient was accorded a hostelry, or, minimally, a hostel. separate accommodation: the four Yet hospitals, and likewise hospices, halls of the hospital were set apart as well as these other venues, derive for those with fever and similar from the Latin stem hospes, from complaints; one part of the building whence the monastic term hospitium was reserved for eye-patients, one or hospitalis domus. Medieval French for the wounded, one for those turned hospitium into hospice, suffering from diarrhea, one for and then English turned it into women; a room for convalescents hospital. But over the course of its was divided into two parts, one for linguistic evolution, “it” – the place men and one for women. Water was of rest and recovery – also adapted laid on to all these departments. One specialized functions depending room was set apart for cooking food, on what sort of guest it had. Thus preparing medicine and cooking friends will host friends, hotels with syrups, another for the compounding receive guests, and hospitals treat of confections, balsams, eye-salves, patients (from the Latin participle etc. The head-physician had an patiens, meaning suffering; the word apartment to himself wherein he patient historically meant someone delivered medical lectures. The num- suffering—not necessarily the case ber of patients was unlimited, every today). sick or poor person who came found Over the course of the next eight admittance, nor was the duration of hundred years, hospitals not only his stay restricted, and even those provided care specifically for the who were sick at home were supplied sick (as opposed to tired travelers with every necessity. [5]

Figs 9 & 10: Al-Mansuri Hospital in Cairo, Egypt. Photographic image from Museum Without Frontiers.

Hospitals 7 The charitable mission that tied religious benefi cence to the medieval origins of hospitals remained a dominant force in the maintenance of such institutions until the nineteenth century. From the time of the founding of the fi rst hospital in the city of Paris in 651 – the Hôtel-Dieu – until it mostly burned down in 1772 (rebuilt thirty years later), medical care was driven by what historian Colin Jones called “the charitable imperative.” [6] However, after the French Revolution of 1789, when religious faith in divine healing was less persuasive and the government lent its efforts to medical reform, a medical marketplace emerged Fig. 11: Aerial view of Hôtel-Dieu next to the Notre Dame in Paris, that relied less on endowments depicted before its destruction by fi re in 1772. Originally built around 650 CE, and donations and more on state the “Hostel of God” is one of the oldest in institutons in Europe for the care support (particularly for military of the poor and sick. In 1580 it was established that physicians would tend to hospitals) and paid services. patients twice a week, leading to the development of regular medical house staff. By the end of the eighteenth century, Paris was the largest city in the European continent, but overcrowding and unhygienic conditions created an alarming mortality rate. The French Revolution, beginning in 1789, deposed the monarchy and displaced the function of the church in hospital duties. Fig. 12: Religious orders at the wards of Hôtel-Dieu. The French revolutionaries converted religious buildings into more wards and expelled the Augustinians (a Catholic ), dispossessed the Brothers, and dispersed the Sisters of Charity. Nurses, traaditionally organized through religious orders, saw their lives, vocations, and notions of hospital management radically change. The Hôtel-Dieu, and some twenty other city hospitals, grew under the professionalized manage- ment of a new medical order. [10] 8 Medical History for Medical Students Fig. 13: St. Bartholomew’s Hospital, the oldest hospital in Britain, founded in 1123, and which today remains on the original site. The Great Hall and other wings were built in the 1730s and 1740s.

In , few hospitals exist boost when Henry VIII chartered work were the “idle poor” and today that can trace their brick the College of Physicians in were whipped publicly in streets. In and mortar origins to medieval in 1518 (becoming known 1601 the Elizabethan Poor Law was times. Monastic institutions and as the “Royal College” under passed which imposed a tax that lazar-houses (hospitals that cared Charles II)—a board that controlled would raise funds to support the for patients until its decline examinations, licensing, and govern- institutionalization of the deserving in the fifteenth century) were ing practice in London. poor. dissolved by Henry VIII, with the Justices of the Peace were After Henry VIII turned Britain exception of St. Bartholomew’s and empowered to raise compulsory toward a Protestant future, the char- St. Thomas’s hospitals in London funds for the relief of the poor, a itable conscience shifted away from which survived through special peti- group defined in two ways. First, organized and centralized church tion. After the (when anyone who was too young, ill, functions and into local parish and the was formed or too old to work, but otherwise municipal government concern. as an alternative to the Catholic could, were the “deserving poor” Consequently, particularly beginning Church), institutionalized healthcare and were cared for in almshouses in the eighteenth century, local com- was scant. Even the existing few or sent to the “poor house” – a munities rallied support to establish secular hospitals in London were Dickensian facility providing general hospitals to care for the very small, accommodating a few housing to downtrodden. In the “sick and lame” as an alternative to hundred patients—a mere gesture United States such “workhouses” the Poor House. Through philan- to serve a population that reached were on farms where residents thropic contributions that created 200,000 by 1600. However, the were put to work. Second, those what historian Keir Waddington medical profession itself received a who were able-bodied but did not called the “benevolent economy,”

Hospitals 9 Fig. 14: Guy’s Hospital, founded in 1721 by Thomas Guy, a publisher of unlicensed bibles and illicit stock investor. Exterior view of main entrance with the statue of the hospital’s founder by Scheemakers.

voluntary hospitals multiplied, the inhumane treatment of infants largely through social ideologies of establishing Guy’s Hospital and left abandoned on the docks of biological differences and special the Westminster in London, the London by destitute families, the needs, other facilities driven by Royal Infirmary in shipbuilder and successful merchant scientific developments caused , and, more provincially, Captain Thomas Coram funded many defenders of general practice Addenbrooke’s Hospital in the establishment of London’s to criticize the narrow approach Cambridge and the Bristol Royal first Foundling Hospital in 1739, to they fostered, accusing Infirmary. [7] Later in the eigh- which, in an act of prescient specialists of breaking the body into teenth century, spurred by concerns entrepreneurship, raised additional pieces and into disease fragments at over factory workers’ health in the money through charity concerts the expense of treating the whole heyday of the Industrial Revolution, offered by Handle and an hosted a person. hospitals were founded in north- gallery with works by artists such The creation and administration ern cities such as Manchester, as Hogarth. In 1843, the Hospital of specialized hospitals spurred Birmingham, and Glasgow. [8] for Women in Soho Square became tensions between the different Similar voluntary, philanthropic, the first gynecological hospital in stakeholders who supported them. and Evangelical initiatives led to London, specially prepared for the Questions of who controlled the the creation of specialist hospitals “delicacy of treatment” and “ner- type and quality of practice – the devoted to maternity care, ortho- vous sensibility” of women patients. physicians, the nurses, the wealthy paedics, eye, and ENT (ear, nose, [9] While special hospitals for patrons, the politicians, or the board and throat) medicine. Appalled by women and children were justified of governors – often led to conflict

10 Medical History for Medical Students Establishing Specialist Hospitals

Fig. 15: Engraving designed by William Hogarth depicting the Foundling Hospital, a home for abandoned children. Founded in 1739 by marine captain Thomas Coram. At that time, mortality rates were extremely high: 74% of children born in London died before age 5. This institution accepted all children and is a product of what Hogarth called “the golden age of English philanthropy.”

Fig. 16: The Hospital for Women, Soho Square, London. Established in 1843 through public membership sub- scription, where doners were permitted to recommend a certain number of patietns for admission and care free of charge. In 1869, a new wing was opened by Princess Mary Adelaide to accommodate patients who could afford to contribute towards the cost of their maintenance and treatment, and in 1877, when a system of training nurses was established in the Hospital.

Fig. 17: The Hospital at Bethlem (Royal Bethlem) at Moorfields, London. First built in 1247 as the Priory of the New Order of St Mary of Bethlem. Originally a base for passing church ecclesiastics, the first record of admission of psychi- atric patients was in 1403, and later, in 1436, it sought donations for the “sick and insane.” Moving to its location at Moorfields in the seventeenth century , it became principally associated with care for the mentally ill, and the moniker “Bedlam,” a medieval morphing of Bethlem, became a general reference to “madhouse.” The hospital was moved to Lambeth, London, in 1815. Hospitals 11 Hospitals and the Environment of Disease

iven the long history of inpatient antimicrobial drugs to deal nineteenth-century laboratory hospitals as privileged with infections acquired on site. investigations represented in the Gsites for the care of Our understanding of these infec- pioneering work of scientists such patients, one could reasonably ask tions is based on our knowledge of as Louis Pasteur and Robert Koch. if there was ever any perceived bacteria and microorganisms, and But before this, assumptions about problem with gathering all the sick how drug-resistant gram-negative disease causation referred to envi- in one place. Today, nosocomial bacteria harm immune-compro- ronmental conditions, such as bad infections, or healthcare-associated mised patients. air, “miasma,” or a broad concept infections (HAIs), are a recognized But taking the historical view, of “contagion.” The idea that the problem by the Centers for Disease understanding infectious disease air itself might become bad, putrid, Control and Prevention, which as a result of bacteriological or or “fetid,” and make people sick, produced a study showing that 1 virological spread is relatively stretches back to antiquity, with a in 25 hospital patients required recent – stemming from late famous work in the Hippocratic

Fig. 18A: Hospital Plan from Nightigale’s Notes on Hospitals 12 Medical History for Medical Students corpus called “Airs, Waters, Places.” Disease (dis-ease), particularly with symptoms expressive of pulmonary disorders, was often attributed to bad air. Sometimes the for the patient was traveling away from the source of bad air, away from an urban environment, swamplands, fens, or hot and humid regions. This all seems quite vague, but in the eighteenth century instruments were developed that purportedly measured the “goodness” of air, something discussed more thoroughly in the module as part Fig. 18B: TB patients at Adirondack Cottage Sanitarium, Saranac Lake of this series on “lungs.” But two developments emerged as a result of medical interest in good and bad undertaken in Britain to see if the construction of other institutions airs that are relevant to the history chemical properties of different of close quarters including schools of hospitals. kinds of air had medicinal qualities and prisons) accommodated airflow First, given the idea that air itself for sufferers of lung disease. In the and ventilation. However despite might become bad, the concern late eighteenth century, tuberculosis these early interests, inconsistent about the quality of hospital – then called “consumption” in policy and weak sup- air emerged. As a public health reference to the way the disease port for hospital development led exercise, chemists and physicians consumed the patient, extinguishing to many examples of overcrowding studied the quality of air in insti- life – was a leading cause of death and poor . Addressing tutions and warned of its possible across Europe and America. One this in 1859, effects on patients. In in the physician, Thomas Beddoes, published Notes on Hospitals, an 1770s, Antoine Lavoisier – famous established a “Pneumatic Institute” influential tract on the importance for having identified the chemical where patients were treated with the of hospital architecture to the care properties of atmospheric air and administration of air (particularly of patients. With regard to tuber- giving us the terms “oxygen” and nitrous oxide) dispensed through culosis patients, special hospitals “hydrogen” among others – took carefully prepared balloons. Yet the were constructed called “sanatoria,” air samples from hospitals using an very idea of bringing consumptive which were built in geographical instrument called a eudiometer. As patients together in one place areas like the Swiss Alps, the Rocky a result, he drew up recommenda- alarmed contemporaries who Mountains in Colorado, or the tions for hospital ventilation and thought that the air would become Adirondacks in upstate New York, advised on plans for rebuilding the contaminated and foster disease. where the high altitude air was Hôtel-Dieu. Shortly after Lavoisier’s For the next hundred years, considered pure and salubrious. experiments, more research was hospital architecture (as well as the An interesting feature of sanatoria

Hospitals 13 was that their function bridged the transition between pre- and post-bacteriological science. Sanatoria established throughout Germany beginning in the mid nineteenth century, for example, had physicians who enthusiastically embraced a new treatment for tuberculosis put forward by their compatriot Robert Koch, a German physician who gained immense prestige in 1892 as the discoverer of the mycobacterium tuberculosis. Koch’s original tuberculin was a glycerin extract of the tubercle bacilli and offered as a remedy that was widely applied to patients without clinical trials. Its ineffectiveness was an immediate blow to the new science of bacteriology and led to popular movements to expand sanatoria to encourage convalescence and open-air therapy. [33] Eventually organi- zational and structural problems with these hospitals which were understaffed and poorly equipped earned them a bad reputation and in the mid-twentieth century were portrayed as dehumanizing institutions akin to coercive asylums or prisons, leading to their demise. [34]

Women’s (and Children’s) Hospitals

he sanatorium, sometimes thought of more as a T‘resort’ than a hospital, was unique both because its geo- graphical location was considered important to support the health of the patients and because they concentrated specifically on one disease, tuberculosis. But through- out the nineteenth century, other specialist hospitals were established focuses on particular , such as , , mental health, and orthopedics. In London alone, over 80 specialist hospitals were founded between 1800 and 1900, although not always with the approbation of the whole medical profession, some of whom saw the narrowing of services as reduction- ist and overly commercialized. Still

14 Medical History for Medical Students other hospitals were established “deserving poor.” Founded through of healthcare is linked to the which provided healthcare to the efforts of Dr. Protheroe Smith, development of the “women’s and patients who were otherwise the original rented building offered children’s hospitals” as specialized excluded from services provided by two wards and eleven beds. During sites. In the late nineteenth century, voluntary (philanthropic) hospitals its first operational year, it admitted when and gynecology because their healthcare needs twenty-eight in-patients and seventy had strengthened the idea that the were morally objectionable, such out-patients. [35] Seeing a need to hospital was the proper place for as treating venereal disease, or expand, Smith attempted to raise child delivery, newborns were put not “medical,” such as childbirth. philanthropic support but the into glass “isolation cubicles” to Hospitals for women fell into a reference to Diseases of Women in protect them from germs. In the category of specialized practice the name evoked venereal disease first few decades of the twentieth that was created in part because of and prostitution in the minds of century, however, new theories perceived uniqueness of women’s the public, and so the name was regarding childhood development health. It was within women’s changed to Hospital for Women. were advanced that stressed the hospitals that the specialist practice The founding of additional importance of mother-child bond- of gynecology developed. women’s hospitals in Europe was ing and social interaction. Thus Maternity hospitals, called in large measure justified on the playrooms were provided in wards “lying-in hospitals” in the early basis of the sanitary conditions they for hospitalized children (one of the nineteenth century, first appeared in offered for surgical procedures. first being in Buffalo, New York, in America with the founding of the Therefore the history of hospitals 1911). By the 1950s, recommenda- Boston Lying-In Hospital (1832, is closely tied with contemporary tions were made that wards should an antecedent of the Brigham developments in medical practice be designed to accommodate and Women’s Hospital), The first (such as obstetrical ) and admitting the mother to the hospital specialist women’s hospital in medical theory (regarding “germs” with the child, limiting any isolation Britain was the Hospital for the as causes of disease). To be sure, a or separation. The evolution of the Diseases of Women established in detailed history of hospitals reveals “women’s and children’s hospital” London in 1842. Their credibility differences of opinion within the commenced, with examples like the and social acceptance was linked medical establishment about appro- New York Infirmary for Indigent to the increased physician staffing priate techniques and theories, and Women and Children in 1857 fulfilling requirements to provide even of the idea that hospitals were (founded by Elizabeth Blackwell, hospital service for licensing. After sanitary and safe (mortality rates the first woman to receive a medical the introduction of were closely examined and hospitals degree in the US), and the New in the 1840s, more surgical interven- received substantial criticism for England Hospital for Women and tions were worked into the formal them). Children (Boston, 1862), which hospital setting, further solidifying Another example of how hospital pioneered the training of nurses their role in providing service to architecture changed in response and female physicians. [36] a wider population, not only the to emerging medical theories

Fig. 19: The New Hospital for Women, Euston Road, London, f. 1890 by Elizabeth Garrett Anderson.

Hospitals 15 Fig. 20: (center, with beard) observing an operation on the skull in a Paris Clinic, 1900.

The Birth of the Clinic

Many terms in English vocabulary posses a semantic history whose exploration uncovers little-known patients and the medical spaces they and the clinics of doctors with whom nuances. Modern usage of the might occupy. he kept a correspondence. term ‘clinic’ often refers to a During the mid-to-late nineteenth The Mayo Clinic offers a prominent physical space, whether a class or century, instances of the term ‘clinic’ example of how the term ‘clinic’ a specialized medical institution, in medical journals increases expo- operates today. While the non-profit but almost five hundred years ago, nentially. Within these texts, ‘clinic’ organization started as William ‘clinic’ referred only to a person; operates in two ways. First, ‘clinic’ Worrall Mayo’s small private practice more specifically, an ill or bed-ridden refers to the process of teaching in the mid-nineteenth century, today individual. Etymology informs that medicine or to the class of students the Mayo Clinic operates through ‘clinic’ is derived from the Latin whom follow a medical instructor. the collaboration of over 55,000 “clinicus,” which is derived from This allusion to teaching is retained physicians, nurses, students, scientists the Greek word (klinikos), which today in, for example, sports, where and other associated health staff. relates to a bed. Jeremy Taylor, in a something like a “golf clinic” refers Their mission is “to inspire hope and seventeenth-century religious text, to demonstration of technique to contribute to health and well-being clearly defines the term ‘clinic’ as students. ‘Clinic’ also refers to the by providing the best care to every a noun, meaning a person with an physical space where that particular patient through integrated clinical illness. The term surfaces over two medical instruction occurs. practice, education and research.” hundred years after Taylor’s text in By the late nineteenth century, Far from the seventeenth-century a fictional novel set in England. In some medical clinics featured sophis- meaning of a bed-ridden, sick this narrative, a physiologist, during ticated spaces for teaching medical person, and even further from the conversation with dressers, refers to students. Other clinics during this Greek definition that evokes a bed, “the bodies of any of [his] clinics.” period kept records and published today’s usage of the term ‘clinic’ So by the late nineteenth century, their findings in student handbooks in reflects necessary semantic negotia- the term still applied to sick people, an effort to further educate medical tions that occurred concurrently with but specifically, as patients. During students. Sir William Osler, in his The the establishment of medical spaces this time period, however, usage of Principles and Practice of Medicine, for treating and learning how to treat the term ‘clinic’ starts to become repeatedly refers to findings and illness. noticeably interchangeable between observations made at both his clinic – Contributed by Sara Robertson 16 Medical History for Medical Students in hospital administration. [11] for “distraught and lunatic people.” reform of the British health ser- Philanthropy, while literally referring The stigmatism of mental illness, vices. The crisis brought about from to the love of humanity, does not thought by medical theory at this World War II forced an extension always breed humility. time to be a moral disorder, encour- of government control of hospitals, The politics of healthcare as well aged “polite society” (the wealthy) increasingly unable to rely on chari- as social conscience influenced to steer clear of hospitals of this table contributions, and the Labour the shaping of institutionalized sort. party’s victory in government in healthcare. Patrician patrons left In the 1890s voluntary hospitals 1945 allowed for sweeping reform. it to the state to run asylums for contained about 26% of all hospital Aneurin Bevan’s National Health psychiatric patients. Bethlem beds, rising to a little more than a Service Acts brought the voluntary Hospital (a.k.a. “Bedlam”) was one third by 1938, with 20% provided hospitals into public ownership and of the oldest hospitals in London, through the Poor Law, and 47% altered the course of the history of privately founded in the thirteenth through local government. [12] In hospitals, as well as healthcare, in century as the priory of St. Mary’s the 1930s and 1940s, the ideal of Britain. [13] of Bethlehem, and became one comprehensive, universal healthcare example of state-funded support gained support, leading to the

Fig. 21: A Model of a Modern Hospital, 1833.

Hospitals 17 Teaching Hospitals

he legacy of voluntary hospitals is notable for being the place where most medical education in Britain was first developed. Prior to the Temergence of voluntary hospitals, medical training was largely based on apprenticeship. Apothecaries were required to spend five years as indentured pupils while surgeons often served as “mates” in the Army. Physicians pursued a different path. They were required to graduate with a degree in the arts and learn classical scholarship so they could read Galen. The two oldest universi- ties in England, Oxford and Cambridge, offered medical degrees to students for a graduating fee, without requiring any practical training. Universities in continental Europe, however, pioneered a new way to learn medicine. 18 Medical History for Medical Students Early in the eighteenth century, scientifi c pursuits that led to clinical modernizing medical practice by Hermann Boerhaave, known as medicine to lag proportionately inventing what the historian Erwin “the medical instructor of Europe,” behind population growth in the Ackerknecht called “hospital medi- introduced clinical instruction. nineteenth century. [15] cine.” Clinicians in the Paris hospital Students were taken to two wards Until the nineteenth century, system saw a unique opportunity in a local charity hospital, using private anatomy theaters and for rapid clinical observation selected patients as case presenta- certain hospital surgeons in London and experimentation among a tions. In 1770, the in provided the extent of medical critical mass of patients—all in one followed suit, when hospital instruction. While devoid of a building, representing a sample of a reforms provided space for trainees university until University College diverse urban population. As he put to “walk the wards.” “It was only in the hospital that the three pillars it, “it was only Edinburgh University in the hospital was Britain’s response of the new medicine – physical examination, that the three to modern medical pillars of the education, introducing , and statistics – could be developed.” new medicine rigorous scientifi c – Historian Erwin Ackerknecht – physical instruction in chem- examination, istry, botany, and anatomy—with was established in London in 1826, autopsy, and statistics – could be chemistry experiments and which began offering medical developed.” [17] Furthermore, as leading to increased courses in 1834, hospitals were the the sociologist Ivan Waddington popularity among students, fi rst to introduce clinical education suggests, the Paris hospitals also admitting as many as 200 students a to aspiring physicians. Between forged a new form of doctor-pa- year in classes. [14] Edinburgh also 1725 and 1815, nearly 12,000 pupils tient relationship. Unlike the provided clinical instruction, though had registered to attend hospital eighteenth century when a class interestingly only a third of enrolled wards and follow practitioners on of patrician patients manipulated students pursued this aspect of rounds. [16] the “medical marketplace” and training, foreshadowing a diminish- Hospitals played a pivotal role in demanded desired goods and ser- ing interest in clinical as opposed to medical training in Paris, however, vices from their physicians, patients were now passive, somewhat powerless, subjects in the system, laid bare for group examination and experimental treatment. It created a new structure of “client control.” [18]

Fig. 22 (opposite): S. Weir Mitchell examining a Civil War veteran at the Clinic of the Orthopaedic Hospital, Philadelphia, 1929. Fig. 23: Lecture notes from an Edinburgh University student attend- ing William Cullen’s chemistry class.

Hospitals 19 BATTLEFIELDBATTLEFIELD MEDICINEMEDICINE

ll wars bring hospitals and clinics also provide early battlefield medicine remain, and disease, to both care to enlisted men and women in Egyptian papyri discuss measures Acivilians and combatants. other venues and during times of taken to contain dysentery, and Throughout history, societies have peace. [19] there is some evidence that Assyrian dealt differently with the challenge During the Bronze and Iron military manuals also contain of providing care at or near the Ages, armies and weaponry became instructions meant to limit the front lines of battle. The chosen increasingly vast and complex. spread of infectious disease. The arrangements generally reflect the Armies traveled with animals, Greek Iliad and Odyssey both also economics of the armed forces, including horses and elephants, describe wound management on military and medical technology, which also required medical atten- the battlefield, delivered by specially and prevailing medical and social tion. Poor nutrition and exposure to trained soldiers. norms. This paper is focused on extreme temperatures compounded As armies became increasingly care delivered at or near the front the effects of injury and illness. formalized and the use of lines of battle, though military Though few written records of temporary mercenaries declined,

20 Medical History for Medical Students battlefield medicine was similarly opportunity for young men to train Amputations were often therefore transformed. During the reign of as physicians. delayed, but additional surgeons Emperor Augustus (27 BC-14 AD), At various times throughout and support personnel were needed the Roman Army began to offer history, war and wartime medicine at the front to stabilize wounds. comprehensive medical care to have also catalyzed change in the General anesthesia also became soldiers, as part of a larger effort at larger medical culture. Conditions more common. These factors recruitment and professionalization. at Scutari, a large resulted in a considerable expansion As Guenter Risse explains, “Care serving British troops during the of the medical capabilities on both in a valetudinarium [institution (1853-1856), impelled the Union and Confederate sides. for the care of sick and wounded many reforms which later became Clara Barton, who would later soldiers] was part of the bargain the norm for hospital sanitation found the American Red Cross, was struck between the emperor and and patient care. These were a battlefront volunteer, bringing military rookies,” especially in the implemented and later popularized food, comfort, and supplies to northern reaches of the empire. by Florence Nightingale, the British wounded troops. Novelist Louisa [20] In the construction of the nurse and reformer. Nightingale May Alcott and poet Walt Whitman valetudinaria attention was paid to and her nurses improved nutrition, also famously served as Civil War clean water, quiet, and cleanliness; ventilation, sanitation, and careful nurses and would later chronicle the architecture was standardized administration and record-keeping, their experiences for contemporary by the 70s AD. Care was provided all of which contributed to lowering and future readers. both by trained professionals and by rates of infection and death at the No war better exhibits the some fellow soldiers with basic first hospital. complex interplay of military and aid skills. Army service provided an War technology affects the nature medical technology than World and volume of the care that must War I. During this war, the machine be delivered at the battlefield. gun, poison gas, bombs, and aircraft The changing weaponry of the carriers affected the numbers nineteenth century brought with it and types of wounds suffered by new and graver types of . soldiers. These weapons as well as During the War of 1812 (1812- dispersing battle to a wider spread 1815) and the Napoleonic Wars of locations. Influenza and sexually (1803–1815), early amputation, transmitted infections contributed even at the front, was common. to much morbidity and mortality However, heavier rifle shot among soldiers. Conversely, introduced during the American however, the war served to Civil War (1861-1865) meant that facilitate the refinement and dis- wound shock was more likely. semination of wound debridement

Fig. 24 (Opposite page): Union Soldiers in a Hospital during the Civil War. Fig. 25: Florence Nightingale with her candle making the night round of the wards at Scutari hospital during the Crimean War, 1855.

Hospitals 21 techniques, topical antiseptics, transported to more centralized and become increasingly decentralized and imaging technologies like the better-equipped military hospitals and noncombatants less protected, roentgenogram. for treatment. the role of medical personnel has Developments in medical The popular image of the field changed. According to a report on therapeutics can have a profound hospital was indelibly shaped by the the website of Doctors Without impact on the health and survival 1968 novel M*A*S*H by Richard Borders, clandestine facilities in of soldiers. The availability of Hooker, which was later adapted Syria, for example, have been set up antibiotics and the enforcement of into a movie and a sitcom. By in caves, homes, farms, and bunkers. hygienic procedures like handwash- placing care in tents rather than in Tunnels, like those used by both ing lowered the ratio of soldiers buildings, Mobile Army Surgical sides during the Vietnam War, are dying from infectious disease from Hospitals, were designed to bring being used to transport supplies. [22] 1 in 4 during to 1 in physicians, surgeons, and nurses 10 during World War II. [21] Faster closer to the front lines than they modes of transportation also had been during World War II. meant that more soldiers could be As present-day warfare has – Contribution by Lisa Stern

Fig. 26: Nurses work with veterans at Walter Reed Army Hospital following World War I. Image courtesy the National Library of Medicine.

22 Medical History for Medical Students The Veterans Affairs Hospitals

Throughout the twentieth century, each successive war that the U.S. has fought has resulted in fewer deaths among American soldiers. However a relative increase has occurred in the amount of soldiers living with physical and mental trauma. War creates disability, and the management of these patients has long been closely bound to how the state has organized medical care. Stemming back to the American war of independence, the Continental Congress encouraged enlistment in the military by creat- Fig. 27: Korean War veterans receiving Purple Heart medals, 1950 ing the nation’s first pension law. The first Federal pension legislation care for him who shall have borne archive, “Hawley led the formation was passed when the Constitution the battle and for his widow, and his of a separate department of was ratified in 1789. With little orphan.” This was later adopted as medicine, outpatient treatment for money to provide wounded soldiers, the VA’s motto. The pension acts veterans with disabilities not related but with vast stretches of land at saw a series of reforms over the to military service, and the creation their disposal, the government following decades, as the amount of of resident and teaching fellowships offered free allotments. However, veterans increased, and more wars in VA hospitals. He also established for soldiers fighting for the Union waged. a policy of affiliating new VA hos- during the Civil War, which started In 1930, President Hoover signed pitals with medical schools. In 1946, in 1861, the first significant changes the executive order creating the Hines Hospital in Chicago was to veterans’ policy were seen. Veterans Administration, consol- the first VA facility to affiliate with The General Pension Act, which idating three preexisting Bureaus medical schools, signing up with provided payments according to – Veterans’ Bureau, the Bureau of Northwestern and the University a soldier’s rank and disability, the Pensions and the National Homes of Illinois. The appointment of VA Homestead Act, which made land for Disabled Volunteer Soldiers. medical staffs was removed from available for $1.25 an acre, and the In 1945, at the end of World War civil service rules in an effort to National Cemetery System, were all II, Major General Paul Hawley, attract doctors and other profes- established in 1862. In his second chief for the European sionals in larger numbers. It was inaugural address in 1865, President Theater, was appointed to direct VA under Hawley’s direction that VA’s Lincoln called upon Congress “to medicine. As stated within the VA’s hospital-based research program

Hospitals 23 As evidenced by veterans’ lobby groups, fighting for better health- care, the dual identity as soldier and patient is both politically and socially charged. As explained by historian David Gerber:

Disabled veterans have simulta- neously realized the dangers of accepting state paternalism. They have been held up to society as heroes, and a welfare system has been established in their behalf. While disabled veterans recognize the benefits conferred by both of Fig. 28: Cartoon lampooning VA wait times. Rick McKee, The Augusta these sources of special status, they Chronicle see a downside as well. Like most people with disabilities, what disabled veterans have most aspired to is was begun.” [23] At this time, Vietnam during the Vietnam Era. socioeconomic independence and the VA was operating 97 hospitals In July 1993 the VA announced a self-determined life bounded by with a total bed capacity of 82,241 that Vietnam veterans suffering personal relations and work. Being a patients. Within two years, 29 new from Hodgkin’s disease and por- ward of the state is at odds with that hospitals were opened. In 1950, phyria cutanea tarda (a liver disease) aspiration, especially in a society that when the “Korean Conflict” began, would be entitled to disability promotes the values of self-help and the number of VA hospitals was payments based on their presumed personal autonomy. [24] 151, with 128,000 veterans receiving exposure to Agent Orange and medical care daily. other herbicides. This decision The continuing surge in the number Chemical warfare during the followed the release of a National of veterans needing care at VA Vietnam War created the need Academy of Sciences study which hospitals and the challenges recruit- for special access to medical care. concluded that sufficient evidence ing physicians to staff the hospitals At first, the only allowable claims existed establishing an association has resulted in much press about related to Agent Orange were between herbicide exposure and unacceptable delays and disparities for a skin rash, chloracne. The five specific conditions. in access to care. However, has this VA in 1991 recognized two other This instance, as well as others one example suggests, healthcare in ailments, soft-tissue sarcoma and cited by disability studies scholars, organizations like this raises many non-Hodgkin’s lymphoma. The points to a troubled relationship other complicated social, political, Agent Orange Act of 1991 pro- between patients bound to govern- and personal issues that impact the vided care for disabilities resulting ment care by virtue of the service wellbeing of the patients. from exposure to herbicides used in they provided to the government.

24 Medical History for Medical Students The american hospital

Fig. 29: Johns Hopkins Hospital, 1890

wo Edinburgh graduates founded the first medical school in America at the College of Philadelphia in 1765. Two years Tlater the second medical school was established – in New York City – and in 1782 Harvard set up its medical college. By 1900, 151 medical schools were founded in America (there are 134 today). [25]

Hospitals 25 Throughout the nineteenth of Baltimore was were founded through philanthropy century, American medical educa- established for low-income patients. as charitable hospitals along the tion was shaped strongly around Exactly one hundred years later, it lines discussed in Britain, the spread laboratory science—a sign of the became the now prestigious Johns of public hospitals was slow. During significance weighted to analytical Hopkins Hospital. the Great Depression, occupancy approaches to disease over clinical One of the challenges of placing rates rose while funding dwindled. observation. While from the very students in wards was the objection After World War II, the population beginning instruction included raised by patients. Medical schools spread to suburban areas, where clinical lectures at the Pennsylvania tried to work around this by having healthcare needs were addressed Hospital, until the mid-nineteenth students wear white coats and refer through smaller clinics, family century when the body that became to them as “young physicians.” practitioners, and private insurance. the American Medical Association [26] Yet for hospitals and medical It was not until the federal govern- established new curriculum schools alike, the incentive beyond ment provided funding support guidelines, it was possible to receive developing bedside skills was for hospital construction following a medical degree without every financial. The history of hospitals the passage of the Hill-Burton stepping foot inside a hospital. in America is a history of economic Construction Act in 1946 that hos- By 1921, however, every medical struggle. While hospitals such pitals, particularly in underserved college had an affiliation agreement as the New York Hospital and rural areas, was stimulated. [27] with a local hospital. In 1789 the Massachusetts General Hospital

Fig. 30: , New York City, ca. 1890

26 Medical History for Medical Students City and County Hospitals and the Hill-Burton Act

City hospitals in the nineteenth century largely served charity patients, “‘living specimens’ accustomed to being pushed, shoved, poked, and, fi nally, dissected,” to quote historian Charles Rosenberg. [28] Industrialization, immigration, and urbanization increased Americans’ contact with the institution of the hospital, and they contributed to the rising prominence of the city hospital around the turn of the century. After World War II, the county hospital experienced its greatest visibility due to an infl ux of state and fed- eral funding from the Hospital Survey and Construction Act, commonly known as the Hill-Burton Act, passed in 1946 and named for its sponsors, Lister Hill, Democratic senator from Alabama and Harold Burton, a Republican senator from Ohio. The legislation, administered through the U.S. Public Health Service, aimed to provide care to medically under-served populations, which were most often rural areas, by “fi lling the gaps rather than subsidizing the entire [healthcare] system.” [29] Just as a need for hospitals in urban areas prompted the creation of city hospitals, lack of care in rural areas fostered creation of county ones. Half of the new facilities built following the Hill-Burton Act were in the South where some 75% of the population was African-American, in what constituted over half the rural population of the United States in 1940; this was also the region with the highest rates of morbidity, mortality, and war-time draft rejection. [30] $3.7 billion in federal funding and $9.1 billion in matching state and local funds caused a boom in hospital construction that resulted in a massive increase in hospital admissions and Americans’ experience with the hospital system. [31] Despite the “separate-but-equal” clause that was included in the legislation, at least one historian considers Hill-Burton the fi rst successful act of the civil rights movement because it, “...both met the South’s immediate health needs and provided a transitional infrastructure to promote the acceptance of black patients and health professionals into the mainstream health care system until integra- tionists achieved their goals in the 1960s.” [32] The history of city and county hospitals allows historians of medicine to investigate larger questions about the history of health and health sciences in the United States. Differences between geographic regions, urban and rural areas, the professional elite and those outside of it, as well as the roles played by funding and policy decisions become apparent in investigating this topic. Moreover, it presents a unique lens with which to view many issues of race, class, and gender in medicine that remain underrepresented areas of scholarship.

Fig. 31: Unidentifi ed nurse, ca. 1960 – Contribution by Meg Vigil-Fowler

Hospitals 27 The history of hospitals reveals medical centers struggle with the It is worth remembering as themes that complement many intent to do no harm and provide one walks through the wards as a of the points we will see again care to all in need, yet the economic student on clinical rotations, learn- highlighting the intertwined exis- reality is that hospitals are often ing to apply physical exam skills tence of religious, philanthropic, constrained by the patient’s ability and collecting patient histories in economic, and professional interests to pay. Current debates, more hospital settings, that one is walking that impacted the evolution of political than medical or moral, in spaces that were carved out from ideas, practices, and institutions about Medicare provisions and thousands of years of concern of medicine. Since the time of reimbursement force hospitals to about health, illness, and education. Hippocrates, medicine was seen as a weigh the risks of incurring “bad The very function of hospitals and vocation, a calling to public service, debt” (losses for medical care the definition of patients – and like the priesthood itself. We see a to underinsured) against public how they are treated, ethically and moral dimension to healthcare— beneficence. But the essence of medically – has changed through sometimes articulated as acting in this concern is not new, nor is time, as has our understanding of the service of a god, or sometimes our reliance on the philanthropic their diseases or what brought them using a patient’s physical illness to conscience of donors, as much as to the hospital to begin with. encourage piety and moral probity. the state or the marketplace, to help What about money? Today, provide that care.

Fig. 32: Nurse standing in a corridor of the clinical study center at San Francisco General Hospital in 1964

28 Medical History for Medical Students References

1. Alice Walton, The cult of Asklepios (Cornell Studies Gynecology and Gender in England, 1800-1929 in Classical Philology III) (Ithaca: Ginn and (Cambridge: Cambridge University Press, 1990), p. Company, 1894). Google eBooks: http://books. 82. For the Foundling Hospital, see Ruth McClure, google.de/books?id=wc8NAAAAIAAJ&print- Coram’s Children: The London Foundling Hospital in the sec=frontcover&source=gbs_ge_summary_r&- Eighteenth Century (New Haven: Yale University Press, cad=0#v=onepage&q&f=false 1981). 2. Guenter Risse, Mending Bodies, Saving Souls: A 10. Dora Weiner, “The French Revolution, Napoleon, History of Hospitals (Oxford: Oxford University and the Nursing Profession,” Bulletin of the History of Press, 1999), pp. 25-26. Medicine 46 (1972), 274-305. 3. E. R. Dodds, The Greeks and Irrational (Berkeley: 11. Keir Waddington (op. cit.), p. 4. University of California Press, 1951), p. 116. 12. The Voluntary Hospitals Database (University of 4. Nigel Allan, “Hospice to Hospital in the Near Portsmouth): http://www.hospitalsdatabase.lshtm. East: An Instance of Continuity and Change in ac.uk/the-voluntary-hospitals-in-history.php Late Antiquity,” Bulletin of the 13. Steve Cherry, “Beyond National Health Insurance: 64 (1990), 446-462, pp. 446-447. the voluntary hospitals and hospital contributory 5. Quoted by William Osler, “The Evolution of schemes,” Social History of Medicine, 5, 1992, 455-82. Modern Medicine” (1913), pp. 58-59, typescript 14. Roy Porter, The Greatest Benefit to Mankind: A in Google books, http://books.google.com/ Medical History of Humanity from Antiquity to the Present books?id=lzO3zQ3dK0cC&printsec=frontcov- (London: HarperCollins, 1997), pp. 290-291. er#v=onepage&q&f=false. 15. Anne Digby, Making a Medical Living: Doctors and 6. Colin Jones, The Charitable Imperative: Hospitals Patients in the English Market for Medicine, 1720-1911 and Nursing in Ancien Regime and Revolutionary France (Cambridge: Cambridge University Press, 1994), pp. (London: Routledge, 1989). 19-22. 7. Brian Abel-Smith’s classic, The Hospitals 16. Susan Lawrence, Charitable Knowledge: Hospital 1800-1948: A Study in Social Administration in Pupils and Practitioners in Eighteenth-Century London England and Wales (London, 1964), for general (Cambridge: Cambridge University Press, 1996), p. 108. background; also Mary E. Fissell, Patients, power 17. Erwin Ackerknecht, Medicine at the Paris Hospital and poor in eighteenth century Bristol (Cambridge: 1794-1848 (Baltimore: Johns Hopkins University Cambridge University Press, 1991). Keir Press, 1967), p. 15. Waddington, Charity and the London Hospitals, 18. Dorothy Porter and Roy Porter, Patient’s Progress: 1850-1989 (London: Boydell, 2000), p. 3. Doctors and Doctoring in Eighteenth-Century England 8. John Pickstone, Medicine and Industrial Society (Stanford: Stanford University Press, 1989); Ivan (Manchester: Manchester University Press, 1985). Waddington, “The Role of the Hospital in the 9. Ornella Moscucci, The Science of Woman: Development of Modern Medicine: A Sociological

Hospitals 29 Analysis,” Sociology 7 (1973), 211-224, p. 211. 19. The medical needs of sailors differ in important ways from those of soldiers serving on land, espe- cially regarding nutrition and access to supplies, and are not dealt with here. 20. Gunther Risse, Mending Bodies, Saving Souls: A History of Hospitals (New York: , 1999), 47. 21. Clinton K. Murray, Mary K. Hinkle, and Heather C. Yun, “History of Infections Associated With Combat-Related Injuries,” The Journal of Trauma Injury, Infection, and Critical Care 64 (2008): S221-S231. DOI: 10.1097/TA.0b013e318163c40b 22. Available at www.doctorswithoutborders.org/pub- lications/article.cfm?id=6669&cat=special-report. Accessed September 24, 2013. 23. Department of Veterans Affairs, “VA History in Brief,” http://www.va.gov/opa/publications/ archives/docs/history_in_brief.pdf, p. 5. 24. David Gerber, “Creating Group Identity: Disabled Fig. 33: Tabulated notes of fever cases Calcutta European Hospital (1904-1906) Veterans and American Government,” Organization of American Historians: Magazine of History 23 (2009), 23-28, p. 26. 25. Martin Kaufman, “American Medical Education,” Southerners, 1939-1960,” The Journal of Southern in Ron Numbers, ed., The Education of American History, 72:4 (November 2006): 826, accessed Physicians (Berkeley: University of California Press, September 24, 2013. 1980), 7-28, p. 8. 31. Thomas, 823 and Risse, 514. 26. N. P. Colwell, “The Hospital’s Function in Medical 32. Ibid., 870. Education,” JAMA 88 (March 12, 1927), 781-784, p. 33. Flurin Condrau, “‘Who is the Captain of all 781. these Men of Death’: The Social Structure of a 27. Rosemary Stevens, In Sickness and in Wealth: American Tuberculosis Sanatorium in Postwar Germany,” The Hospitals in the Twentieth Century (New York: Basic Journal of Interdisciplinary History 32 (2001), 243-262. Books, 1989), p. 399. 34. Sheila Rothman, Living in the Shadow of Death: 28. Charles Rosenberg, The Care of Strangers: The Rise Tuberculosis and the Social Experience of Illness in American of America’s Hospital System (New York: Basic Books, History (Baltimore: Johns Hopkins University Press, 1987) 167. 1995). 29. Ibid., 217. 35. Ornella Moscucci, The Science of Women: Gynecology and 30. Karen Kruse Thomas, “The Hill-Burton Act and Gender in England, 1800-1929 (Cambridge: Cambridge Civil Rights: Expanding Hospital Care for Black University Press, 1990)

30 Medical History for Medical Students Acknowledgments

We wish to thank the University of California Office of the President for generously supporting the activities of the UC Medical Humanities Consortium which funds the publications by the UC Medical Humanities Press and this digitial series. Grant ID: 141374.

Additional funding is also provided by the UCSF Center for Humanities and Health Sciences and we wish to thank Professor Dorothy Porter, Director, for supporting these initiatives.

The author wishes to thank Meg Vigil-Fowler, Sara Robertson, and Lisa Stern for their contributions to this tract.

Fig. 33: Tabulated notes of fever cases Calcutta European Hospital (1904-1906)

36. Lindsay Prior, “The Architecture of the Hospital: A Study of Spatial Organization and Medical Knowledge,” British J of Sociology 39 (1988).

Picture credits: Figures 2, 8, 11, 12, 14, 15, 16, 17, 20, 21, 22, 23, 25, 29, 30, 33 © Wellcome Library, London, licensed under Creative Commons Attribution 4.0. Figure 1 © Hospital di Santa Maria della Scala Figure 3 and 5 © Archaeological Museum of Epidaurus Figure 4 Google Earth Figures 6 & 7: © Wikipedia, licensed under Creative Commons Attribution 4.0. Figures 9 & 10: Museum Without Frontiers http://www.discoverislamicart.org/exhibitions/ISL/the_mam- luks%20/exhibition.php?theme=4&page=2 Figures 13, 24, 26, 27 © National Library of Medicine Figure 28 © Rick McKee, The Augusta Chronicle

Hospitals 31