Nation's First Hospital, 1751-2008

As commonly stated in medical history circles, the history of the Pennsylvania Hospital is the history of American medicine. The beautiful old original building, with additions attached, still stands where it did in 1755, a great credit to Samuel Rhoads the builder and designer of it. The colonial building on Pine Street stopped housing 150 patients around 1980, supposedly at the demand of the Fire Marshall, although its perpetual fire insurance policy still owes the hospital several thousand dollars a year as unspent premium dividend. There may have been one small fire during two centuries of use, but its true fire hazard would be difficult to assert. It was just out of date. The original patient areas consisted of long open wards, with forty or so beds lined up behind fluted columns, in four sections on two floors. The pharmacy was on the first floor, the lunatics in the basement, and the operating rooms on the third floor under a domed skylight. It was entirely serviceable in 1948, when I arrived as an intern doctor. Individual privacy was limited to what a curtain between the beds would provide, but on the other hand it was possible for one nurse to stand at the end of a ward and recognize any distress among forty patients immediately. In this trade-off between delicacy and utility, utility was certain to be the preference of the Quaker founders. Visitors were essentially excluded, and if a patient recovered enough to be unnaturally curious about other patients, well, he was probably well enough to go home.

Located between two large rivers, South Philadelphia up to ten blocks away was essentially a swamp until the Civil War. So, there were seasonal epidemics of malaria, yellow fever, typhoid and poliomyelitis at the hospital until the early twentieth century. Philadelphia was a port city, so sailors brought in cases of venereal disease, scurvy, even an occasional case of anthrax or leprosy. During the Industrial Revolution of the nineteenth century, tuberculosis, rheumatic fever and diphtheria were part of clinical practice. But underlying the ebb and flow of environmental effects, there was a steady population of illness which did not change a great deal from 1776 to 1948. These patients were all poor, because the rules in Benjamin Franklin's handwriting restricted service to the "sick poor, and only if there is room, for those who can pay." In 1948 there was a poor box for those who might feel grateful, but no credit manager or official payment office. The matter had been considered, but the cost of collection was considered greater than the likely revenue. When Mr. Daniel Gill was offered the position as the hospital's first credit manager, it was suggested that he be given a tenth of what he collected. To his lifelong regret, Dan Gill regretted that he refused the offer that he felt he could not afford to accept.

So, the wards were filled with victims of the diseases of poverty, punctuated by occasional epidemics of whatever was prevalent. And a second constant feature of the patients was their medical condition forced them to be housed in bed. For centuries, physicians dreaded the news that a new patient was being admitted with "dead legs". Mental and neurological diseases presented a second major imperative for admission; such patients either couldn't walk or couldn't be trusted to walk alone. Coma or raging fever was another category of mandatory admission.

Therefore, the roster of patients who were in the Pennsylvania Hospital on July 4, 1776 was not substantially different from those who were present on July 1, 1948. The turnover was greater, because antibiotics made it easier to treat the disabling diseases of the poor, but the causes of admission were essentially unchanged. Instead of treating five dead legs a month, a modern physician might treat twenty, but after you have seen and smelled one dead leg, you have seen and smelled them all. Under the circumstances one Pennsylvania Hospital surgeon, Dr. C. Alexander Hatfield, became an internationally famous expert on the management of this class of conditions. But although scientific rigor was much elevated in the meantime, both Benjamin Rush and his distant descendant Alexander Rush undoubtedly experienced the same sights and smells when dead leg patients were wheeled into that same ward. The nurses however almost seemed to welcome such cases. They had been told exactly how to spring into action, and within an hour the odor and slime had disappeared; the nurses were very visibly proud of their accomplishment. It was a miracle only they knew how to conjure up; you could tell from their beaming faces that they had accomplished a triumph. We today can be fairly sure the patients in the hospital paid scarcely any attention to the commotion in Independence Hall on July 4, 1776 four blocks away. Just as the patients in the same beds were later unaware and unconcerned about the explosion of an atom bomb in Hiroshima, their focus was much more pointed. What was surely overpowering to both groups was the unbearable summer heat in Philadelphia before air conditioning. Modern physicians are astonished to learn what was then a commonplace: during a heat wave, almost every patient runs a fever. No one was taking their temperature, but it seems possible the doctors and nurses were running a fever as well.

Venereal disease is a constant among the poor. At present, the most prevalent condition is HIV/AIDS, but syphilis was a regularly fatal condition until it disappeared within a few years of the introduction of penicillin. About a sixth of the patients in the old Pennsylvania were suffering from syphilis on the day the Declaration of Independence was nailed to a post. Two hundred years later, a survey of the Philadelphia General Hospital revealed one Wasserman test in six was positive. Prostitution was supposed to be the underlying source. One thing was more or less unique. Other hospitals serving the poor reported a great deal of drug addiction, now delicately called substance abuse, but Philadelphia had remarkably little of it. In another essay, we have speculated on the likely cause of this anomaly, although in more recent days there is far less reason to remark about it. Gunshot wounds, then and now, provided evidence of the interactions between criminals and police; these fierce combatants seem universally meek and humbled when the medical establishment gets to see them.

For two centuries, the more things changed, the more they stayed the same. And then, in 1965, the heavens opened and Lyndon Johnson rained money in all directions. It took a few years for a mistrustful system to adjust to the idea that things had changed forever. A doctor could really do anything he knew to do, without concern about cost. The nursing school, the heart of the hospital, was not only unnecessary as a source of free labor, but actually an impediment to full Federal reimbursement of costs. Not long afterward, the resident physicians were actually paid a reasonable wage, after two centuries of being paid nothing at all. The large open wards were eliminated and replaced with semi private rooms, as insurance regulations insisted. The definition of poverty was changed to include people whose circumstances would have been considered luxurious before Medicare, so there are still thought to be poor people in the hospital. But the diseases of poverty are hard to find among all those people who would once have been expected to be treated in their homes. The floor space tells a story. Up until 1965, patients would have occupied 90% of the floor space of the institution, now they scarcely occupy 15%. The presence of patients, the reason for the institution, is far less dominant; doctors and nurses are a comparatively small proportion of the thousands of employees. That makes a big psychological difference. At one time, there was hardly anyone present except patients, doctors and nurses. Today, the other members of the medical industry predominate within these walls. There are many more computers than patients. But what is ultimately most puzzling is that so much more money is being spent on so much less disease. Life expectancy has increased by thirty years, several dozen diseases have disappeared, the disorders of 1776 which took months to treat are now cured in three days. It's all a very good thing, but it is puzzling.

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