Many diseases were associated with tell-tale scents. From the medieval period, practitioners had developed complex diagnostic procedures determined by slight variations in scent, distinguishing putrid ulcers and cancer from ordinary wounds for example (Reinarz, 2014: 161). Plague, according to Francis Bacon, smelled of ‘mellow apple’. Like the skin disease known as favus, typhoid reputedly smelled of mice (Risse, 1999: 414), while typhus had a ‘close mawkish’ odour. Fever nurses were also adept at recognising diseases by the sweet smell of a patient’s breath (Currie, 2005: 211), some claiming to have distinguished diphtheria from scarlet fever and tonsillitis by smell alone (Currie, 2005: 105). Acute rheumatism had an acid smell, while nephritis was accompanied by the smell of chaff (Reinarz, 2014: 161). By the nineteenth century, more sophisticated clinical tests were developed to confirm initial diagnoses determined by scent, but occasionally a particular text would collect and publicise an extensive list of odours, which no doubt continued to guide practitioners in various fields. The work of Berlin-based chemist Johann Franz Simon (1807-1843) is a good example, his two-volume text on Animal Chemistry noting:

'The sweat of persons with the itch is said to have a mouldy odour while that of syphilitic patients is said to smell sweet. The sweat of rheumatic and gouty persons has an acid smell while in putrid fever and scurvy it has a putrid odour. In jaundice it is said to resemble musk in its smell. In Stark's 'General Pathology,' (p 1126), we find it stated that the odour of the sweat in scrofula resembles that of sour beer while in intermittent fever it smells like fresh baked brown bread.' (Simon, 1846, II: 108). Some of Simon’s observations were presumably made during his time as a pharmacist at Berlin’s Charité Hospital. 

Usually, ‘violent’ odours, such as gunpowder, quicklime and ammonia were used to neutralise disease-causing vapours at early hospitals (Reinarz, 2014: 160). L     ike the smelling bottles carried into hospitals by wary visitors, goats were kept at or near hospitals during times of plague to fill the air with a strong capric scent which was thought to neutralise or dilute dangerous pestilential odours (Cranshaw, 2016: 135).  More common at most hospitals were piggeries, the waste-disposal benefits of which were often seen to outweigh the scents generated. Many provincial hospitals continued to have piggeries attached to them into the twentieth century, the smell of some provoking complaints from nearby residents (Derry Journal, 1937). 

Besides medical sites, hospitals in Renaissance Florence were a stage on which religious services were daily enacted. The religious dimensions of the hospital during the last centuries ran alongside its medical role. Life on the ward was regularly punctuated by religious services, and leading the air and textiles in the building to be suffused with the scent of incense. Religious services might equally be conducted for the patrons of hospitals, such as the donor of a single bed, commemorative Masses being held regularly for their souls (Henderson, 2006: 135). Religion and medicine played complementary roles in the healing of bodies. 

Just as mentally ill patients were regularly segregated because of their potential to disrupt the wards through noise and violence, certain cases were separated from the general wards given their potential to offend other patients and staff through their smells. This was often the case with those afflicted with venereal disease, who might be removed to an attic ward and the space modified through the drilling of additional holes in the walls to improve ventilation. At the Edinburgh General Infirmary, burns patients were similarly removed from the general wards in the 1840s and isolated with infectious cases in a special ward, due to the way in which they stank and offended the other patients (Simpson and Wallace, 1956: 136). At most general hospitals, medical and surgical cases were separated around the same time, in order to spare the medical patients the ‘daily sight and smells of malignant ulcers and wounds’ (Webb, 2002: 152). 

Besides diagnosing diseases by scents, many medical practitioners smelled their patients for signs of drunkenness, whether indicated by the scent of alcohol or vomit, especially following accidents or when individuals were brought into the hospital unconscious. Numerous mistakes and scandals occurred as a result, patients with fractures being sent to prisons to sober up instead of receiving treatment. Those who did not bar drunken patients, isolated these cases in a designated room for ‘noisy or drunken patients’, as in Newcastle in the 1890s (Newcastle Daily Chronicle, 1899). At most hospitals, convalescing patients were often permitted out of hospital during the day, but were often smelled when returning in order to determine if they were drunk or were carrying alcohol back into the building. Staff might search wards and beds using scent to locate drink and other banned foods. 

At certain times, particular foods dominated the diets at hospitals. For much of history, beer (in northern Europe), wine (in southern Europe), bread and meat characterised the standard hospital diet, the preparation and distribution of which would have scented hospital wards. In the nineteenth century, specialised diets, such as that rich in milk, were also developed. Liebig’s beef tea was regarded as the best food to restore the tissues of the sick, and when St Thomas’s Hospital purchased 12,000 large jars in a single year in the 1860s (Halliday, 2009), the air of its wards was dominated by the broth’s scent. Treatises on hospital design by this time had begun to condemn the proximity of kitchens near the wards, for ‘nothing is so nauseous to a sick person as the constant smell of cooking’ (Burdett, 1896: 157). At Moorfield’s Eye Hospital in London at the end of the nineteenth century, all disagreeable smells from food had been avoided by moving the kitchen to the hospital’s top floor (Treacher Collins, 1929: 183). Most hospital kitchens were confined to basements or separate outbuildings given similar concerns.

Historically, hospitals were cleaned ritualistically. Early cleaning might simply involve sweeping floors, and dry rubbing or waxing floors, and not allowing them to get too damp. An annual cleaning might involve whitewashing walls, usually prior to an annual meeting or visit by local or national dignitaries; at such official visits, the hospital might be at its cleanest state annually. In the nineteenth century, various disinfectants were introduced to cleaning rounds, and many hospitals took on these new scents. Carbolic acid, often associated with Joseph Lister, was sprayed in operating theatres during operations and used for cleaning, sterilisation and also as a bandage dressing (Ellis, 2001: 93). In the 1870s, regular cleaning was so effective at some provincial hospitals that they were said to have lost the smell once thought peculiar to hospitals (Jacob, 1951: 143). 

Laundries have since the earliest times been an activity essential to the running of hospitals. In the early modern period, hospitals might have laundries, but during epidemics most clothing worn by patients might be either burned or sent with other contaminated sheets, blankets and mattresses to special facilities outside the institution to be washed or purified (Risse, 1999: 206). Facilities associated with smells, like kitchens, laundries and morgues, were often moved to basements in the eighteenth and nineteenth centuries, to avoid pungent smells from infiltrating spaces reserved for patients and treatment (Risse, 1999: 346). Many hospital laundries were industrialised and became steam laundries by the end of the nineteenth century, often situated in an outbuilding (Burdett, 1896: 165). It was common in German hospitals to place kitchens and laundries in one separate ‘housekeeping’ block, as in Nuremberg, Dusseldorf and Dresden maternity hospital (Milburn, 1912: 129) Disinfector blocks were also built at many institutions in the early twentieth century, and disinfecting work was undertaken in many provincial hospitals for local towns and regions (Webb, 2002: 144). 

The smell of smoke would have been perceptible on the wards of hospitals, with many being heated by open fires in the early modern and modern periods. Florence Nightingale encouraged the use of chimneys in her hospital designs to aid ventilation (Nightingale, 1863: 79). The smell of cigarettes would have been perceptible on the wards when some medical practitioners made their rounds, though most would have restricted patients from indulging in this habit. Occasionally, during wartime, especially the First World War, rules prohibiting smoking would have been relaxed in certain military hospitals and the smell of tobacco would for a time have been more common, especially with many locals and hospital visitors gifting tobacco to wounded soldiers in efforts to maintain morale (Carden-Coyne, 2014: 159, 220). 

Most early hospitals were initially built in towns and cities on what were often the outskirts of towns and cities overlooking gardens, fields, meadows and woodlands, so as to provide the sick with a healthy, well-ventilated place to recover from illness. Disease-causing miasmas were thought to be synonymous with bad smells, and the location of noxious agricultural and manufacturing processes, especially tanning, were also minimised or strictly controlled around hospitals. Their location on main arterial roads however ensured that most hospitals soon found themselves incorporated into expanding towns and cities and overwhelmed by urban smells (Henderson, 2006: 41).

Throughout the early modern period, hospital officials or visitors often attempted to protect their body from the noxious bodily smells that collected in hospitals through the use of smelling bottles, often filled with vinegar or perfumes. Official hospital visitors, or House Visitors, often confined their observations to the state of the hospitals’ privies and drains in a cycle of complaints that would be replayed in nineteenth-century sanitary campaigns (Reinarz, 2012: 510). The noted prisoner reformer John Howard never entered a prison or lazaretto without his trusted bottle of vinegar, and he usually aired his clothes and notebook after the foulest institutional inspections (Siena, 2019: 181). The governess who showed the prison and hospital reformer around a women’s hospital on a visit in Malta tourrelied on similar prophylaxis: ‘The governess attended me through every ward, and was constantly using her smelling bottle; in which she judged very properly, for a more offensive and dirty hospital for women I never visited’ (Howard, 1789: 60). His tour of European hospitals was perhaps the most comprehensive of the early modern period, and he often reserved negative olfactory observations for the most poorly managed hospitals he visited. On his travels, Howard occasionally found himself quarantined in a lazaretto and, on such longer visits, more than a smelling bottle was required on those occasions to make his accommodation tolerable. After being placed in an apartment in Venice’s Old Lazaretto, Howard described the active measures taken to provide himself with a ‘agreeable and wholesome’ room.

‘The walls of my chamber, not having been cleaned probably for half a century, were saturated with infection. I got them washed repeatedly with boiling water, to remove the offensive smell, but without any effect. My appetite failed, and I concluded I was in danger of the slow hospital fever. I proposed white-washing my room with lime slacked in boiling water, but was opposed by strong prejudices. I got, however, this done one morning through the assistance of the British consul, who was so good as to supply me with a quarter of a bushel of fresh lime for the purpose. And the consequence was, that my room was immediately rendered so sweet and fresh, that I was able to drink tea in it in the afternoon, and to lie in it the following night’ (Howard, 1789: 11). Howard soon recovered his appetite and no longer suffered from the headaches induced by the accumulation of such offensive odours. 

The early modern hospital pharmacopeia comprised a rich array of fragrant ingredients, perhaps more suited to a kitchen if sniffed seen from a modern perspective. Prepared and dispensed by hospital apothecaries, unguents and plasters for a fracture might contain honeysuckle, laurel oil, lavender, rose, turpentine, wax, pig fat and red wine. Pine resin was used specifically to treat inflammation, while incense, with its exotic origins was used to treat wounds; wax was often used to take away the strong smell of pork (Henderson, 2006: 316-17). It was through the taste and smell of medicine that many medical practitioners understood their virtues right into the modern period     . Popular nineteenth-century pharmacopoeia, such as that compiled by William Cullen, often divided materia medica into minerals, plants and animal products, by way of their scents, but no longer relied on smell alone in order to attest to their qualities. 

Less often commented up on than hospital pharmacies, are hospital bakeries and breweries. As in the earlier monastic tradition, the production of food was often situated on site at many early modern hospitals (Henderson: 56, 203). If poorly designed, the smell of baking and brewing often extended into the hospital wards, some governors situating these facilities further away from the main hospital building as a result of the smells they generated. The fragrance of fresh bread might equally extend outside the patients’ wards; the distribution of extra bread at some hospitals took place at the front gates of hospitals, where the scent of such products might concentrate during the distribution and possibly for some time afterwards (Henderson: 96). 

Many other hospitals were described by referring to unique odours. Although hospitals were established for the poor during most of the last five centuries, institutions for the destitute tended to smell of extreme poverty, neglect and less generous rations. As a result, the odours peculiar to workhouses tended to be stale bread (Higginbottom, 2012: 70) and incontinent old men (Doyle, 2002: 82), but those with a bonehouse, often suffered from high staff turnover due to the offensive odours on site (Longmate, 2003: 128). The London Homeopathic Hospital, in contrast, was noted for its absence of typical ‘hospital smells’, like carbolic, iodoform and other traditional medical odours (Shields Daily News, 1933). Nevertheless, homeopathic hospital dispensing guides made unusually detailed distinctions between diseases and smells, one guide distinguishing the smell of patients’ urine by comparing it to that of horses, cats, or even the smell of violets (Dewey, 1898: 221, 244, 245). Many other hospitals without large inpatient facilities were much easier to deodorise, or might smell more powerfully of materials regularly used in treatment, such as gutta percha at dental hospitals.

The admission process at most hospitals involved a form of ritual purification, most patients being bathed and provided with a clean set of bed clothes. While some patients would have been washed in common water, hygienic practices improved at many hospitals by the nineteenth century. Plunge baths in the basement of hospitals were replaced with bathrooms on each ward, if not portable baths, which brought the smells of bathing onto the wards themselves. Florence Nightingale recommended the use of sulphurous waters and medicated baths also became more common in the nineteenth century (Nightingale, 1863: 72).

The design of buildings was often to aid the removal of bad airs. The high vaulted ceilings of the Renaissance hospital in Italy for example would have enabled the ‘smells and fumes generated by disease and insanitary conditions’ to rise to the roof and away from the staff and patients (Henderson, 2006: 160-161). Inner courtyards of early modern hospitals were used to air mattresses, sheets and other materials. Hospital reformer Jacques Tenon, after a visit of the Hotel Dieu in Paris in the late eighteenth century, noted the lack of space which had led hospital officials to put as many beds in a room as possible and load these with multiple patients, mixing not only the sick and dead, but convalescents with the dying in rooms so narrow the air stagnates and it becomes charged with vapours (Ackernecht: 16). In the nineteenth century, Nightingale’s work took the olfactory-mitigating aspects of hospital design even further by extensively considering ventilation, as well as the materials used in hospitals, such as tiles, as well as cleaning practices (Nightingale, 1863). By the early twentieth century, however, most of the first voluntary hospitals were over a hundred years in age, and most had acquired ‘the odour of an old hospital’, an ‘all-pervading “close smell”’ caused by noxious matter suspended in the atmosphere, or even impregnating the walls, along with other defects (Taylor, 1997: 105).

Smell has often been relied on in diagnosis. It is a less obtrusive means of detection than touch, for example, and therefore less likely to cause harm or affect the doctor-patient relationship, except in cases of misdiagnosis. Just as smells could cause disease, under the humoral tradition, were used to treat disease, many odors carrying the qualities of the materials from which they originated, whether hot, cold, wet or dry (Palmer, 2004: 63). Cold smells included those of roses, violets, myrtle and camphor, and were effective in treating those patients inclined to heat. Warmer scents, like lemon, mint, aloes, amber and musk, were used to treat those with colder temperaments.

John Howard made a tour of the principle lazarettos of Europe and advised hospital managers and staff on how to improve the condition of wards. Most of his activities involved deodorising and disinfecting prisons and hospitals. In terms of hospitals, he regularly advised staff to remove patients’ ‘putrid discharges’ from the wards as soon as possible. When visiting the poor house in Birmingham, he found the ceilings in both the old and new parts of the workhouse to be too low to allow for the free flow of air (Howard, 1791: 159). At Guy’s Hospital in Southwark, London, he noted the use of ventilators in the ceiling which communicated with the chimneys of the wards over them, the fires drawing effectively drawing off the foul air in the wards (Howard, 1791: 135).

The post-mortem room, or hospital dead house, often involved a member of the hospital staff inspecting patients recently dead using their senses, including the sense of smell. Most often necropsy books or hospital post-mortem guides emphasise the importance or identifying foul odours when initially opening the head, chest or stomach, but, by the nineteenth and twentieth century, other tests were used to confirm what were originally olfactory ones attesting to putrid diseases. Some guides advised on minimising the ‘unpleasant smell’ of autopsy, given the speed of putrefaction, such as washing the corpse with terebene, or turpentine (Newth, 1878:132), or covering the hands with olive oil or lard, which prevent the ‘odour of the post-mortem’ from adhering to the hands (Harris, 1887, 75-76).

Originally built to treat the poor and catering primarily to this segment of the population until at least the late nineteenth century, hospital designs began to incorporate private rooms in the late nineteenth century. It was only at this later date that hospital smells were no longer associated with the working classes. While most hospitals were thought to smell foul, due to the accumulation of infectious patients, those institutions regarded to smell the worst had strong connections with sin and stigma, such as the lock hospital, where cases of venereal disease cases were treated (Siena, 2004: 187). The smells associated with lock hospitals reinforced the stigma to which its patients were subjected, and simultaneously made their the most ‘disreputable’ of diseases. On his visit to St Bartholomew’s Hospital, London, John Howard found the wards ‘clean and not offensive’, ‘except the men’s four foul wards, which are on the uppermost story, and had not one window open’ (Howard, 1791: 132). Interestingly, the women’s foul wards on this occasion were ‘fresh and clean’.

The mentally ill asylum patient was also regarded to carry a unique odor, which was described as ‘mousey’, a scent a Prussian psychiatrist claimed was the result of excessive perspiration (Wallis, 2017: 41). Others suggested the mentally ill gave off a smell reminiscent of henbane, otherwise known as ‘stinking nightshade’, though others would later suggest this odor, characteristic of many asylums was merely that caused by so many patients being doubly incontinent (Wise, 2012). Forbes Winslow in his publication, On the Incubation of Insanity (1846), argues that the lunatic’s skin has the appearance of having been rubbed with grease and ‘is accompanied by a peculiar fetid or cutaneous exhalation’ (Winslow, 1846: 19). This scent would gradually be attributed to the asylum and its level of hygiene, and greater efforts were taken to clean facilities for the mentally ill. In Haina, in northwest Hesse, for example, rooms were lined with straw and fumigated with juniper to neutralise the bad air (Vanja, 1996: 123). Epileptic patients were often treated with thyme to prevent seizures (Reinarz, 2014: 162). Patients suffering from seizures from the late nineteenth century were more often given paraldehyde, an anticonvulsant, the sickening smell of which remained on the breath for hours (Cherry, 2003: 195). Though less spoken of than hearing voices, unpleasant smells are often reported by delusional patients and linked to traumatic memories (Boschma, 2003: 136).

Certain hospitals were directly associated with specific national and religious identities, for example, a Catholic or Jewish hospital or a German hospital in a city or region other than a German nation, such as existed in the east end of London in the nineteenth century.  The primary scents that would have conveyed a particular identity would have been those associated with a specific national diet, or religious ceremonies. 

Within the hospital there was a clear distinction between physicians’ and surgeons’ noses, the latter being associated with trade and more direct contact with patients. That said, the senses were placed squarely at the heart of theories of knowledge, like that expounded by the physician-philosopher John Locke (Bynum and Porter, 1999: 1), and both physicians and surgeons relied on smell to diagnose diseases to guide their therapeutic recommendations. The early modern practitioner of humoral medicine was prepared to use all of the senses in order to make a diagnosis (Bylebyl, 1999: 47). Given the way in which smell was understood at the time, the brain, its front ventricles, or ‘olfactory breasts’, were the organ of smell (Palmer, 1999: 62-63). Smells, in way of thinking, had increased potential for both causing disease and therapy. Although ancient doctors tended to recognise two kinds of smell, good and bad, many more kinds were recognised by the Renaissance period, but scents characteristic of particular diseases did not emerge until the eighteenth century (Palmer, 1999: 67). Physicians, as learned gentlemen who used their heads to diagnose, also gradually expressed greater reluctance to smell their patients than surgeons. However, observations at the bedside remained central to clinical medicine throughout this period, the English physician and researcher into kidney disease Richard Bright reminding fellow members of Guy’s Hospital Clinical Society in 1840 that ‘every sense plays its part in the successful prosecution of Medicine’, spelling out the importance of sight, hearing, taste, touch, as well as smell (Warner, 2003: 226).

Although hospital cooks undoubtedly used their noses when purchasing food and drink, there are few sources which discuss the ways in which they assessed smells in this way. Numerous sources, from hospital pharmacopoeia and dispensatories, documenting the way in which hospital pharmacists used their noses to in their work. Several dispensing guides list the ingredients used to compile medicine and their characteristic odours, and variations, as well as the storage so as to preserve these properties, although many such texts are little more than recipe books with little commentary on individual ingredients, which are frequently listed in Latin before the mid-nineteenth century. Most often, pharmacopoeias comment on the odour of urine or sputum, or strong-smelling medicines. Among the most pungent were sulphur unguents for treating the ‘Itch’, which was used with reluctance due to its ‘offensive smell’ (Anon., 1827: 168). The powerful smell of ammonia salts was particularly useful in the treatment of obstinate sneezing, as found in cases of hay fever and influenza (Mackenzie, 1873: 79). Interestingly, one of the most famous set of lecture notes on materia medica, those of Edinburgh Professor William Cullen, warned hospital pharmacists against relying on smell for a knowledge of medicine (Cullen, 1772: 2).

Hospital pathologists were regularly advised to use their noses in order to identify foul-smelling fluids or other olfactory observations made when investigating patients post-mortem. In general, many guides written to assist in the conduct of the post-mortem or necropsy in hospital suggested that ‘any abnormal smell should be noted’ (Shennan, 1912: 400). While these might be described as offensive, putrid or fetid, by the twentieth century, such texts often referred to such ‘bad smells’, usually associated with tuberculosis or syphilis, as ‘ozaena’ (Shennan, 1912: 400). Rudolf Virchow, in his hospital post-mortems, often commented on either the absence or presence of a ‘cadaveric’ odour (Virchow, 1876: 56, 72). Commenting on the absence of smell in many similar guides, Virchow wrote ‘I will say nothing about the sense of smell though it is a great puzzle to me how it is that some persons, when making autopsies, seem to have completely lost the sense’ (Virchow, 1876: 19). In 1903, American pathologist, Henry Cattell, surmised that ‘more attention will be devoted to odour in future’ given that the organ of smell is poorly developed and ‘varies in different individuals and in the same individual at different times’ (Cattell, 1903: 17).  

The nurse’s nose gainedgains importance in the nineteenth century with improvements in training, but also the recruitment of women from the lower middle classes. In Nightingale’s Notes of Nursing, there are many references to the nurse’s nose being relied upon to ensure the cleanliness of the wards, but even to smell medicines in order to ensure the accurate distribution of prescriptions on the wards (Nightingale, 1860: 199). Nurses were to be vigilant in the detection of the worsening condition of the patients, especially surgical ones, to which the accumulation of foul air could be fatal (Nightingale, 1860: 184); Although the greater part of nursing consisted of preserving cleanliness, there were new rules to cleaning. Nightingale warned nurses against washing hospital floors, dry dust having been regarded as harmless, but wet dirt becomes dangerous, as made clear by the exhalations of the organic matter therein (Nightingale, 1860: 126-127); neither were nurses to rely on disinfections and fumigations to clean rooms, but thorough ventilation and the airing of carpets and curtains outdoors to remove the distinctive ‘close smell’ that characterised an improperly cleaned room. Many of such observations would have been made by hospital cleaners, but sources documenting their use of smell in their work are extremely rare.

Much of the emotional response to the smells of early hospitals appears to have come from medical staff and governors who feared that the stenches that collected in hospital wards would transmit disease in institutions. What is less captured in records is the response of patients to noxious smells that either accumulated in wards, or were even at times noticeably absent. That said, religious scents in early modern hospitals might have both neutralised odours regarded to be harmful and smoothed anxious patients who were close to death.  The smell of familiar foods could be as comforting as religious smells to patients in hospital, especially in hospitals associated with specific national or ethnic groups, such as the German Hospital in London, or Jewish hospitals throughout Europe. The use of disinfecting or deodorising materials in nineteenth and twentieth centuries, including chloride of lime, carbolic acid or iodoform, might equally have elicited reactions of fear because they drew attention to the smells they were intended to cover up.

The association of hospital stenches with the poor and poverty for much of the period from the seventeenth century to the early twentieth century would have resulted in the humiliation of patients, especially if the clothes in which they came to hospital were disinfected or destroyed because they were found to be contaminated. Bad smells, regardless of their origins, would also have been particularly stigmatising when associated with venereal, or lock, institutions.