Early 19th century reports of the Spedale Maggiore dell’ Ordine de SS. Maurizio e Lazzaro

By the end of the eighteenth century, the medical profession had come to appreciate the importance of statistical reviews of the patterns of disease in the community it services. These reviews included attempts at the nosological breakdown of the presenting disease state along with mortality rates. In the early 19^th century, the system in general use was based on the Synopsis nosologiae methodicae, published by William Cullen of Edinburgh in 1785. ¹ The practice of regularly analysing hospital admission information was quickly introduced to allow or better the assignment of resources. The present work reviews the hospital admission and nosological reports pertaining to the Spedale Maggiore della Sacra Religione ed Ordine Militare de SS. Maurizio e Lazzaro in Turin covering the period 1821-1844.

The Spedale Maggiore in Turin had originally been set up in 1573 on the initiative of Duke Emanuele Filiberto, grandmaster of the Military Order of Sts. Maurice and Lazarus. Throughout the centuries, extensions  to the edifice were carried out to better meet the needs of the community, the most significant being those performed in 1688 and 1780 that brought the hospital bed capacity to fourteen. In 1831, the Council of the Order approved a new significant extension that was carried out between 1837 and 1843. This 16^th century hospital continued to serve the needs of the city right through the centuries and was only closed down in 1885 when the medical services were transferred to a new edifice – Mauriziano Umberto I Hospital – constructed by King Umberto I. The 16^th century edifice was pulled down in 1888 leaving only the old pharmacy block.²

Primary Sources

In line with the increasingly adopted practice of maintaining management audits, the Turin hospital administrators, during the third and fourth decade of the nineteenth century, regularly drew up and published reports that included a nosological analysis giving an insight to the disease conditions managed by the institution. Six reports cover the period 1821-1844.

• Bernardino Bertini. Statistica Nosologica dal 1821 al 1833 e rendiconto medico per il 1834 del Venerando Spedale Maggiore della Sacra Religione ed Ordine Militare de SS. Maurizio e Lazzaro. Torino : Giuseppe Pomba, 1835.
• Bernardino Bertini, C. Serena. Rendiconto delle Malattie di Medicina curae nel Venerando Spedale Maggiore della Sacra Religione ed Ordine Militare de’ SS. Maurizio e Lazzaro durante il 1833. Torino : Chiro e Mina, 1834.
• Bernardino Bertini. Seconda Statistica Nosologica del Venerando Spedale Maggiore del Sacro Ordine Equestre de’ SS. Maurizio e Lazzaro dal 1833 al 1839. Torino : Alessandro Fontana, 1839.
• Carlo Francesco Bellingeri. Prospetto Clinico del Venerando Spedale Maggiore della Sacro Ordine Equestre dei SS. Maurizio e Lazzaro nel bienno 1839-40. Torino : Cassone e Marzorati, 1841.
• Bernardino Bertini. Terza Statistica Nosologica del Venerando Spedale Maggiore del Sacro Ordine Equestre dei Mauriziano per il bienno 1841-1842. Torino : Enrico Mussano, 1843.
• Carlo Francesco Bellingeri. Statistica Nosologica del Spedale Maggiore dell’ Ordine Mauriziano per il bienno 1843-44. Torino : Botta, (1845).

The authors

The majority of the reports are authored by Bernardino Bertini (b.1786; d.1857). Bertini is described as serving as dean emeritus and councillor of the College of Medicine of the Medical Faculty, president of the Societa Medico-Chirugica, senior doctor of the Spedale Maggiore della Sacro Ordine Equestre dei SS. Maurizio e Lazzaro, and doctor of the Judicial Prisons, of the R. Ergastolo and of the Corpo dei Carabinieri Reali. He was a corresponding member of the Reale Accademia d’Agricoltura, of the Direzione per l’Associazione Agraria dei R. Stati, and of a number of scientific European societies including Belgium, France, Germany, Italy and Switzerland. He served as one of the vice-presidents of the Section of Medicine in the Congresso scientifico di Lione in 1841, and first vice-president general of the Congresso Scientifico di Strasborgo in 1842. ³ Besides the four nosological hospital reports, he is the author of a number of at least seventeen other publications (Appendix 1a) including two works on the medicinal waters of the Kingdom of Sardinia and in Germany.

The second contributor to the series of nosological reports for the Turin hospital was Carlo Francesco Bellingeri (b.1789; d.1848). Bellingeri completed his medical studies at the University of Turin submitting his thesis on quinine substitutes. He subsequently was appointed professor of psychiatry at the Faculty of Medicine of the University of Turin, eventually being appointed dean of the Faculty. He served as a doctor and later consultant of the Spedale Maggiore della Sacro Ordine Equestre dei SS. Maurizio e Lazzaro. He was a member of the Accademia delle Scienze di Torino and corresponding member of numerous Italian and foreign scientific academies. In Italy, he is considered as one of the first scholars in neurology, publishing a number of scholarly works in the field. ⁴ Besides his two nosological hospital reports,  he is the author of at least twenty-one other publications (Appendix 1b) generally dealing with subjects related to neurology.⁵

Meteorological observations

In line with the belief that prevalent climatic conditions influenced the development of disease states, the reports detail the meteorological observations prevalent in Turin during the period, including observations related to temperature, barometric pressure, dominant wind direction, atmospheric conditions, and rainfall statistics. The importance given to climate conditions in relation to prevalent seasonal disease states by 19^th century medical practitioners has been previously discussed.⁶

Hospital admissions and mortality: 1821-1844

The average total number of admissions during the period was about 1038 cases annually. The hospital was reserved for individuals of the male gender and did not cater for women. There was however a gradual increase in the number admission throughout the period from an annual total of 599 cases in 1821 to a total of 1351 cases in 1844 (Table 1 / Figure 1). The figure suggests out-of-trend peaks in cases in 1834 and in 1840-1843.

Figure 1

Patient turnover: 1821-1844

The average number of patients who died after admission was about 49 cases annually. With the exception of the outlier high number of deaths in 1821, the deceased case number appeared to gradually increase throughout the period reflecting the increase in the number of admissions, ranging from 39 cases in 1822 to 58 cases in 1844 (Table 1). There was however a gradual decrease in mortality rate following the sharp drop in 1822 (Figure 2).

Figure 2

Mortality rate (% admissions): 1821-1844

The majority of admissions (31.3%) occurred in the third trimester (July-September) of the year; the other three trimesters of the year accounted for an average of about 22.9% each. The relative increase in admission during the third trimester was reflected by a markedly lower mortality rate at 3.80% when compared to the other three trimesters which averaged 5.53% (Table 2).

The age distribution of the medical cases over the period with the age-specific mortalities is outlined in Figure 3. The data, which excludes the cases admitted in 1839-1840 that are unrecorded in the respective reports, suggests that the majority (52.3%) of medical admissions were aged under 30 years. Only 7.3% were aged 60 years or more. The mortality rate from medical conditions increased progressively with increasing age from 3.2% in those aged <30 years to 26.5% in those aged 70 years or more (Figure 4).

Figure 3

Age-specific medical admissions and mortality

Figure 4

Age-specific medical case mortality rate

The majority of admissions (54.3%) to the institution over the period in question belonged to the working-class community of the population mainly manual and menial workers of all types. Admissions of individuals belonging to the white collar and middle-upper class professions accounted for only 1.3% of the total. Military personnel made up 8.6% of admissions. The remaining 35.6% of admissions were not specifically identified as to profession (Table 3). The occupation-specific mortality rate was highest at 12.3% of admissions in the ‘civil & ecclesiastical’ profession category.

Medical conditions requiring admission

A number of attempts had been made during the eighteenth century to produce a systematic classification of diseases. In the early 19^th century, the system in general use was that published by William Cullen in 1785. The authors of the nosological reports for the Turin Hospital apparently preferred a different classification of diseases when compiling their reports, preferring to follow the classification of disease developed by the German physician Giuseppe P. Frank who in 1828 published an Italian translation of his work entitled Epitome di Medicina Pratica in Naples [p.25-29]. ⁷

The majority of admissions (43.7%) involved cases related to febrile disease including intermittent, continuous or eruptive fevers. These overall were associated with a mortality rate of 0.94%. Inflammatory conditions accounted for another 41.1% of admissions with an overall mortality rate of 9.42%. The conditions associated with the highest mortality rates included those associated with oedema (34.53%) and cachexia (25.0%) (Table 4).

The reports further detail the noted pathological features as noted at autopsy of individuals succumbing to different disease conditions. The reports also describe the clinical features and treatment provided for the different disease conditions managed in the hospital.

Discussion

Statistical analysis of hospital activity is an essential part of good management practice allowing for accurate planning and correct allocation of available resources. The report published in 1835 for the Turin Hospital managed by the Order of Sts. Maurice and Lazarus appears to be the first published hospital activity report with the report further reviewing the statistics of the previous years. The publication of these reports was made obligatory by a regulation which came into effect of the 1^st March 1835. The retrospective data was recovered and compiled from the available hospital registers [p.15]. During the period 1821-1834, the hospital saw an augmentation in bed capacity and resources. This described augmentation in services was linked in the report to the noted increase in hospital admissions during the period. During the early part of the period 1821-1827, the maximum bed complement was forty – of these 20 beds were reserved for medical cases, 10 beds were reserved for the Guardie del Corpo di Sua Maestà (the latter never having been utilized), and five beds were reserved for incurable cases. In 1827, the medical beds were augmented to 25, while the surgical beds were augmented to 20. In 1832, the sixty beds in the large ward were equally designated to receive medical and surgical cases; while two other wards were reserved for the Guardie del Corpo di Sua Maestà and for persons with a civil status. Throughout the period, the hospital also improved and ameliorated its backup services [p.4-5].⁷ In 1834, an out-of-trend peak in cases managed in the hospital was noted. This was linked to the different meteorological conditions prevalent during that year [p.69]. No condition was identified as particularly contributing to the observed increased number of hospital admissions. There was however, during 1834, a smallpox epidemic affected the population causing ‘so many victims [to be] taken to the tomb in Piedmonte’ [p.76].⁷ The out-of-trend peak for the period 1840-1843 was attributed to the marked rise in both medical and surgical admissions from the total of 1015 in 1839 to 1326-1442 during the period is question. ‘The reason for this increase is that, following the opening of the new wing of the building on May 15, 1840, twenty beds were added in the infirmary, sixteen of which were intended for the treatment of surgical diseases’ [p.39].⁸

In Malta, the first evidence of an attempt at maintaining a record of disease patterns appears to have been made by Dr Joseph Demarco practicing in the latter part of the 18^th century (died 1793). ⁸ A similar register of medical certificates presented to the Health Authorities and the Gozo Law Courts during the period 1813-15 was kept by Dr Calcedonio Speranza.⁹ Statistical records for admissions to the Sacra Infermeria of the Order of St John in Malta have as yet not been identified. The Libri mortuorum volumes registering the deaths at the Sacra Infermeria during the period 1677-1855 did not include the cause of death other than those dying violent deaths. ¹⁰ A report about admissions and deaths in the Hôpital militaire (previously the Sacra Infermeria) for the period 1798-1801 was drawn up by Dr. Claude Robert.^11-12 Case histories and postmortem reports of cases admitted to the Lazaretto in Malta for quarantine during the period 1739-1801 have been described.¹³

The first hospital nosological report from the Maltese Islands was prepared and published by Dr Thomas Spencer Wells and pertains to the cases managed at Bighi Naval Hospital during the period 1842-1844.¹⁴ The regular maintenance of admission registers for the various Maltese Government Charitable Institutions was formalized by the 1851 Charitable Institutions regulations.¹⁵ Previous to these regulations, the Civil Hospitals had probably already adopted the practice of maintaining an admissions register that included a clinical diagnosis. The earliest example of such an early civil hospital register known to the author pertains to the Hospital of St John the Baptist at Rabat-Victoria, Gozo covering the period 31^st December 1841 to 31^st August 1851.¹⁶

References

1. Robert Hooper. The Physician’s Vade-mecum containing the Symptoms, Causes, Diagnosis, Prognosis and Treatment of Diseases accompanied by a select Collection of Formulae and a Glossary of Terms. London: John Murray, 1812, available at https://www.thornber.net/medicine/html/hooper.html
2. Chiara Devoti, Cristina Scalon, Erika Cristina. Documenti e immagini dell'Ospedale Mauriziano di Toprino a 440 anni dalla fondazione (1575) e a 130 dall'inaugurazione della nuova sede (1885). Torino: Fondazione Ordine Mauriziano, 2016.
3. Bernardino Bertini. Idrologia Minerale ossia descrizione di tutti le sorgenti d’Acqua Minerali note sinora negli stati di S. M. Il Re di Sardegna ..... 2nd edition, Torino : Enrico Mussano, 1843.
4. Mario Santoro. BELLINGERI, Carlo Francesco. In: Dizionario Biografico degli Italiani. Rome: Istituto della Enciclopedia Italiana, volume 7, 1970. https://www.treccani.it/enciclopedia/carlo-francesco-bellingeri_(Dizionario-Biografico)/
5. Bellingeri, Carlo Francesco, 1789-1848. Wellcome Collection Library Catalogue, London: Wellcome Collection, https://wellcomecollection.org/works?query=%22Bellingeri%2C%20Carlo%20Francesco%2C%201789-1848.%22
6. Charles Savona-Ventura. Medical observations on Meteorological associations in the Nineteenth Century. Malta Medical Journal, 2021, 33(1), 85-92.
7. Bernardino Bertini. Statistica Nosologica dal 1821 al 1833 e rendiconto medico per il 1834 del Venerando Spedale Maggiore della Sacra Religione ed Ordine Militare de SS. Maurizio e Lazzaro. Torino : Giuseppe Pomba, 1835.
8. Bernardino Bertini. Terza Statistica Nosologica del Venerando Spedale Maggiore del Sacro Ordine Equestre dei Mauriziano per il bienno 1841-1842. Torino : Enrico Mussano, 1843
9. Horatio C.R. Vella. Introduction: Joseph Demarco – On the passage of air from the lungs into the blood system, Montpellier, 1746. Malta: University press, 1999, xxii-xli.
10. Paul Cassar. The practice of a surgeon in Gozo in 1813-1815. It-Tabib tal-familja - Journal of the Malta College of Family Doctors, 1996, 10:5-8.
11. Paul Cassar. A note on three Libri Mortuorum of the Holy Infirmary, the Civil Hospital of Valletta and the Central Hospital of Floriana (1677-1885). Proceedings of History Week 1981 (ed. Mario Buhagiar). Malta : Historical Society, 1982, 86-93.
12. (Claude) Robert. Mémoire sur la topographie physique et médicale de Malte suivi de l'histoire des maladies qui ont régné dans cette ville parmi les troupes françaises , sur la fin de l'an 6 , et pendant les années 7 et 8. Paris : P. Didot l'aîné, 1802.
13. Charles Savona-Ventura. Human suffering during the Maltese insurrection of 1798. Storja ’98 (ed. Henry Frendo). Malta : University Historical Society, 1998, p.48-65
14. Paul Cassar. Clinical case histories and post-mortem reports from the Malta Lazzaretto in the 18th century. Medi-scope, 1989, 13:9-13.
15. Charles Savona-Ventura. The naval career of Sir Thomas Spencer Wells in the Mediterranean: 1842-1853. Maltese Medical Journal, 1998, 10(2): 41-46.
16. Establishments of the Government Charitable Institutions of the Islands of Malta and Gozo. Malta : Government Printing Office, 1851, p.10.
17. Charles Savona-Ventura. History of Medical Data collection in the Maltese Islands. It-Tabib tal-familja - Journal of the Malta College of Family Doctors, 2000, 18:13-17.

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