The Royal Infirmary of Edinburgh

Edinburgh, the “Athens of the North,” was a hub of scientific and educational transformation in the second half of the 18th century. Edinburgh was a seat of medical development, perhaps best known for its anatomists (and grave robbers). In 1729, the Royal Infirmary of Edinburgh opened its doors. This facility soon became a cornerstone, in tandem with the university, of the international reputation of the city.

Within three years, the infirmary's case reports were analyzed and published for educational purposes. Formal educational courses began in 1748. Thus the hospital provided education as well as care for the “working poor” to increase productivity and avoid the need for public support. A formal teaching ward opened in 1750, and eventually the fees paid by students helped defray facility costs. The hospital was known for its “cleanliness, low mortality and pharmacy.” A unique feature of the infirmary was its attention to the details of documentation—not just of the patients, but of other administrative issues, including finance and census management. Metrics were very important, especially the number of admissions, outcomes, and mortality.

Patients were referred to the facility for admission with a standard “subscription letter” from a sponsor (typically a local doctor, businessman, or politician). It was required for all but emergency admissions. The infirmary established from the beginning that it was responsible for neither transport to and from the facility nor burial expenses. A very interesting part of this preadmission paperwork noted the sponsor's obligation to convey patients back to their original location postdischarge to avoid them being readmitted or becoming a burden on the city. Patients might come from long distances, but without a formal subscription letter they would not be hospitalized. The most generous sponsors had the best chance of having their referred patients accepted. Patients would arrive by foot or “sedan” and be directed to the admissions room. Like many modern hospitals, the facility had 228 beds, but the number of staffed beds was lower, depending on institutional funding, for an occupancy that averaged 70%. The standard charge was one guinea a day, but a few charity cases were also allowed.

At noon each day physicians and surgeons would round through the admissions room and decide who might be admitted. Did the patient have a subscription letter? If so, was the disease acute or chronic, was the patient's life in immediate danger, and did he or she have severe fractures or wounds? The question of curability always had to be considered. Admission was not encouraged for patients with tuberculosis or for elderly patients with palsy or dropsy (CVA and CHF). Palliative care admissions were allowed if it was believed the patient would benefit. Women patients with children had to find care for their offspring due to concern that they might end up wards of the hospital if their mothers did not survive. The poorest patients received hospital clothes, and with a physician order, might even receive a bath.

Treatments in the hospital included medications, procedures, and ancillary care. Among the medications were analgesics such as opium, emetics like ipecac, and mercury, obviously dangerous but especially popular on the venereal ward. Placebos were very popular as well and a way to allow extra time for diagnosis. Cutting-edge therapies included digitalis, popularized by William Withering in 1785. (See Newman's Notions in the March 2010 ACP Hospitalist for details.) Among the therapeutics were bloodletting (by leach or scalpel), cupping, blistering, bathing, electricity, paracentesis, bladder catheterization, and the setting of fractures and amputation. The complication rate was monitored and included weakness (debility), bedsores, diarrhea, and rashes.

When a patient was felt to be cured or to have improved as much as possible, it was time for discharge. Many patients resisted discharge due to poverty or fears of institutionalization. The discharge order carried an administrative category, including cured, relieved, by desire (AMA or elopement), dead, improper (psychiatric or incurable), irregular (nonadherent or malingering), and by advice (chronically ill). Readmission was not uncommon, even among patients who had been discharged as cured. The mortality rate was a surprisingly low 4% to 8%—higher in the teaching wards, which may have represented a selection bias toward sicker patients. It's likely there was an effort to “game” the metrics, as hospital data were key to fundraising.

Much like the medieval Byzantine hospital (described in Newman's Notions in the July 2017 ACP Hospitalist), we can see familiar themes for success in this Scottish hospital in the Age of Enlightenment. The staff was regulated, the administration was organized, metrics were monitored, treatments were cutting-edge, education was essential, and fundraising was king. As we sit here centuries later, it is easy to look back on the treatments and management of the past with a superior air. But the issues we face now, from admission criteria to discharge planning and readmission prevention, are not so different than those of our medical ancestors. (I do have several patients I might like to discharge for “irregularities.”)

Editor's Note: “Hospital Life in Enlightenment Scotland: Care and Teaching at the Royal Infirmary of Edinburgh,” by Guenter B. Risse (Cambridge: Cambridge University Press; 1986), served as reference material for this column.