In the early morning, The Massachusetts General Hospital was notified by Harvard University that some students, at that time occupying a university building in protest of ROTC, might be brought to the hospital for treatment of injuries after their forcible removal from the building. This occurred at 5 a.m., and although some fifty students were reportedly injured, none were brought to the MGH.
At 5:45 in the morning, the last of the emergency-ward residents got to bed, sleeping fully clothed, sprawled on a cot in one of the treatment rooms. Taped on the door to the room was a piece of paper on which he had written his name and "Wake at 6:30." Across the hall in another treatment room, two surgical residents were sleeping; in a third room, one of the interns.
Even without the Harvard students, it had been a busy night. Shortly before midnight, the EW had admitted two college students with pelvic fractures from motorcycle accidents, and both had been taken to surgery; later on, they had also admitted a forty-one-year-old man suffering from a heart attack, an eighty-year-old woman with congestive heart failure, and a thirty-six-year-old alcoholic with acute pancreatitis. An elderly man with meta-static carcinoma and renal failure had died at 3 a.m.
There had also been the usual number of patients with sore throats, coughs, abrasions, lacerations, foreign bodies inhaled or swallowed, bruises, concussions, dislocated shoulders, earaches, headaches, stomachaches, backaches, fractures, sprains, chest pains, and breathing difficulties.
At 6:30, some of the junior residents and interns were up, doing lab studies and checking on the patients who had been admitted for observation to the overnight ward, adjacent to the emergency ward. The ONW limited patients to a three-day stay; it was designed for patients who required a period of observation longer than a few hours, such as those with suspected gastrointestinal bleeding or those with severe concussions. However, in practice it was also used for patients who were severely ill but could not get a bed at the time they arrived, because the hospital was full.
At 7 a.m., surgical rounds were made in the ONW. Six patients were discussed during half an hour, but most of the time was given over to a fifty-four-year-old woman with a recurrence of bleeding ulcer. This was her second day in the hospital and her condition was now stable; she had received five units of blood the day before. Normally she would not be a surgical candidate, but on two previous admissions she had shown the same pattern of massive, unexpected bleeding, followed by stabilization in the hospital after transfusion. The residents were afraid that if this happened again, she might bleed to death before she got to the hospital.
The emergency-ward residents attended these rounds, for in the early morning the EW is least busy. A short distance away, however, the acute psychiatric service was in full swing. The APS always gets a group of patients in the morning; they are the people who, for one reason or another, have not been able to sleep the previous night.
In one of four interview rooms in the APS, a nineteen-year-old girl, separated from her husband, chain-smoked as she described her unsuccessful attempts to kill her three-year-old daughter: first by hanging, then by suffocation with a pillow, and finally by gas asphyxiation. She explained that she wanted to stop the child from crying; the crying was driving her crazy. She came to the APS, she said, because "I wanted to talk to somebody. I mean, it's not natural, is it? It's not natural-a kid that keeps crying that way."
In another room, a forty-year-old accountant was running down a list of eight reasons why he had to divorce his wife. He had written out the list so he would be sure to remember everything when he talked to the doctor.
In a third room, a college student living on Beacon Hill explained that she was depressed and troubled by a recurrent sensation that came to her during parties. She said she would have the impression that she was invisible and that she was watching the party from across the room, from a different viewpoint. She had attempted suicide two days before by swallowing a bottle of aspirin tablets, but she had vomited them up.
In the fourth room, a husky fifty-one-year-old construction worker discussed his fear that he was going to die suddenly. He knew the fear was groundless but he could not shake it, and his work was suffering, since he was afraid to exert himself and lift heavy objects. He was also bothered by sleeplessness, irritability, and bad headaches. On questioning it developed that his father had died of a stroke almost exactly six years before; the patient remembered his father as "a cold fish that I never liked."
In the lobby of the APS were three other people waiting to talk to the psychiatrists. One woman was crying softly; another stared vacantly out the window. A middle-aged man in a tuxedo and ruffled shirt smiled reassuringly at everyone else in the room.
At 8:30 in the morning, a sixty-year-old widow arrived in the EW and asked to have a doctor remove her hangnail. The administrators at the front desk shrugged and told her it would cost her fourteen dollars. She insisted it was sufficiently important to warrant the expense. But the triage officer flatly refused to do it and told her to cut it herself. Unsatisfied, she wandered around for another fifteen minutes until she finally cornered a resident. She linked her arm in his and demanded that, since he was such a nice young doctor, he please cut her hangnail. He did; she was billed.
Twenty minutes later, a thirty-five-year-old housewife was brought in by the police after she had collapsed in a subway station and suffered an epileptic fit. Soon thereafter, a desperately ill elderly man with disseminated colonic cancer was transferred in from a nursing home. He had a cardiac arrest in the emergency ward and died shortly before noon.
An eighteen-month-old infant with a skin rash was brought in by his mother at noon. The mother wanted to know if it was German measles; she was pregnant and had never contracted the disease. A diagnosis of German measles was made, but the mother, in her sixth month of pregnancy, was reassured that there was no danger to her.
At approximately the same time, an eighteen-year-old secretary arrived, accompanied by the head of personnel at the office where she worked. The girl had reportedly collapsed after lunch. At the time of her arrival she was conscious, but unwilling or unable to speak. She was placed under observation in a room where she lay curled up in bed, burrowing her head beneath the sheets. Medically, she appeared sound, and a psychiatrist was called. He diagnosed an acute psychotic break. By then, her family and some fellow workers had arrived. All regarded the episode as shocking in its suddenness and repeated the observation that she had never acted unusually in the past. The psychiatrist came away shaking his head.
By 1 p.m., a man with a deep laceration of his index finger had arrived; also a woman with a sore throat; another man with a dislocated finger (a taxi door had slammed on his hand); and an eight-year-old boy brought in by his mother. The child had fallen from his bicycle that morning and struck his head. The mother didn't know whether he had been unconscious or not, but she thought he was acting oddly, and noted that he had refused to eat lunch.
No patients more seriously ill arrived, and the atmosphere in the emergency ward during the afternoon was relaxed. The residents took the chance to take it easy, drink coffee in the doctors' room, and catch up on reports in the charts they had to write.
At 3:40, the atmosphere abruptly changed. The hospital's station at Logan Airport called to report that there had been an accident: a dozen construction workers had been injured and were on their way in police cars and ambulances. At least two of the injured were going to Boston City Hospital; as many as ten might come to the MGH. The extent of injuries was not known, but some might be very severe.
The emergency-ward administrator put out a disaster call, notifying the chiefs of all departments of the impending emergency and its nature. The chiefs in turn arranged for mobilization of all available hospital personnel from other wards. In a matter of minutes, interns, residents, and senior men began to appear in the EW. The nurses and staff were already clearing patients out of the treatment rooms; the corridors were cleared and supply carts checked. Privately, everyone agreed that it was fortunate the day had been a slow one, for there was practically no back-up.
Emergency-ward personnel are always concerned about back-up. The emergency ward is geared to treat a new patient every eight minutes, around the clock; the staff is prepared to admit to the hospital one out of every five of these emergency patients, or a new admission every forty minutes. This is a furious pace, but it is standard procedure for the hospital. And although patient flow through the EW is generally smooth, there is almost always a back-up. At any time-and this day was an exception-the emergency ward may have three to ten people in the lobby waiting to be seen; another six to ten in the various treatment rooms; another four or five in the back room waiting for X rays, orthopedic examinations, or sutures of minor lacerations. This is the back-up, and the residents keep an eye on it; when it begins to swell, everyone worries, because there is no way to predict when there will be a six-car automobile crash, or a fire, or some other disaster that will strain the hospital's facilities for emergency care.
It is a little like trying to direct traffic without ever knowing when rush hour will occur.
The first patient from Logan Airport to arrive was Thomas Savio, a twenty-seven-year-old bearded construction worker. He arrived in a state police ambulance and was wheeled in wrapped in a gray wool blanket. He was shivering and had severe facial lacerations.
"There's a worse one coming," one of the troopers said. Moments later, John Conamente arrived, groaning. As his stretcher came through the door, one of the residents asked him what hurt. He said it was his shoulder and his leg. Conamente was followed by Albert Sorono, also on a stretcher, complaining of severe pain in his chest and difficulty in breathing.
By now the waiting room was filled with troopers and policemen. The families of the injured men had not yet begun to arrive. Hospital personnel who had not been informed of the accident but had noticed the cluster of policemen stopped to inquire what was happening. At this time, no one really knew the nature of the accident and there was widespread confusion about it; most people thought a plane had crashed at Logan. An inquisitive crowd began to gather in the lobby. The EW administrators were busy trying to get identifying information on the patients and also attempting to keep the passageways from becoming clogged. "We got seven more coming," one of them said over and over.
A few minutes later, another ambulance pulled up and Ralph Orlando, a fifty-five-year-old father of four, was taken off. He had suffered a cardiac arrest on the way to the hospital and closed cardiac massage was being given by a nurse, the first person who happened to reach him as he was taken from the ambulance. Orlando was wheeled in at a dead run; the massage was taken over by a resident. The patient was taken to OR 1, where full re-suscitative procedures were begun.
The routine of cardiac resuscitation is now so standard that few people realize how recent it is. The basic principle of closed cardiac massage was first properly described in modern times in 1960. (It had been described in the nineteenth century but was not commonly practiced.) Prior to that time, a cardiac arrest was almost certainly fatal. The only treatment was thought to be open massage, in which the surgeon incised the chest and squeezed the heart directly with his fingers. Although frequently successful, open massage rarely produced long-term benefit; one study in 1951 indicated that of patients who underwent open massage, only 1 per cent survived to be discharged from the hospital. That figure still stands; open massage is now a last-ditch effort only.
Closed cardiac massage depends upon the anatomical fact that the heart is tightly packed in the chest between breastbone and backbone. Rhythmic pressure upon the breastbone will squeeze the heart enough to produce a pulse. Direct open massage is therefore not necessary, and the hazards of this surgery are avoided.
The purpose of cardiac massage is to maintain blood circulation which, in conjunction with artificial respiration, provides blood oxygenation for the brain. The brain is the organ most sensitive to lack of oxygen; under most circumstances brain damage will begin after three minutes of circulatory arrest. In contrast, the heart itself is much more durable and can resume beating after ten or more minutes. But by this time, unless resuscitation has already been begun, the brain will be irreversibly damaged.
In some situations, mere compression of the heart is enough to start it beating again, but the massage is generally accompanied by a variety of other maneuvers to correct metabolic changes from the arrest. This includes the injection of Adrenalin, calcium, and sodium bicarbonate. The experience of the last decade, utilizing these techniques, has demonstrated that cardiac arrest is reversible to an astonishing extent.
The procedure for Ralph Orlando was the standard one: closed massage and artificial ventilation, with simultaneous injection of substances to correct metabolic imbalance. This procedure failed to induce spontaneous contractions of the heart muscle. Electrical defibrillation was then begun.
No one had any idea how long it had been since Orlando had suffered his arrest; presumably whoever had ridden with him in the ambulance knew, but that person could not be found.
Initial electroshock therapy failed. Using a long needle, Adrenalin and calcium were now injected directly into the right heart ventricle, and further shocks were administered. It was now twelve minutes since his arrival.
While this was going on, the rest of the EW staff was organizing itself around the other patients. One resident was assigned to oversee the care of each injured man. In the operating room across from Orlando, John Conamente was also surrounded by people. He was simultaneously being examined by the orthopedic surgeons, having intravenous lines inserted in both arms, having blood samples drawn, being catheterized, and being questioned by the resident, who stood at his head and shouted in order to be heard over the noise of the people working around him. The resident conducted a typically stripped-down history and systems review, which under normal conditions might take ten or twenty minutes.
The resident asked, "What happened? Did it fall on you?" (At this time, most people still did not know the nature of the accident, except that something had fallen on a group of construction workers.)
"Yeah," John Conamente said.
"Where did it hit you?"
"My leg."
"Where else? Did it hit your shoulders?"
"Yeah."
"Did it hit your head?"
"No."
"Were you unconscious?"
"No."
"Does your left arm hurt?"
"Yes."
"Your other arm?"
"No."
"Your right leg hurt?"
"Yes."
"You have pain anywhere else?"
"No."
"Your chest hurt?"
"No."
"Breathe okay?"
"Yes."
"Pain in your belly?"
"No."
"Pain in your back?"
"No."
"You ever been in the hospital before?"
"No."
"You ever had an operation before?"
"No."
"Any heart trouble?"
"No."
"Any trouble with your kidneys?"
"No."
"You allergic to anything?"
"No."
"Can you see me all right?"
"Yes."
The resident held up his hand, fingers spread wide. "How many fingers?"
"Five. I'm thirsty. Can I have a drink?"
"Yes, but not now."
By now the orthopedists had concluded their examination. Conamente had fractures of his left arm and right leg.
Out in the hallway, another group was working on Thomas Savio, who complained of difficulty in breathing, pain in his chest, and pain in his lower abdomen. He had a large bruise over his right hip. There was a possibility of pelvic and rib fractures. A laceration on his forehead, while bleeding profusely, was superficial. He was wheeled off for X rays.
Meanwhile, in OR 1, attempts at resuscitation were discontinued on Ralph Orlando. Half an hour had passed since his arrival in the hospital. The resuscitation team filed out to help with the other patients, and the door to the room was closed, leaving behind two nurses to remove the intravenous lines and catheters and drape the body in a sheet.
Out in the lobby, John Lamonte, one of the workers, sat in a wheelchair and described what had happened. He was the least injured of all the men, though he had fallen from a height of thirty-five feet. "We were on a scaffolding," he said, "building an airplane hangar. There were three scaffoldings, all about thirty-five or forty feet up. One of them blew down in the wind. It came down real slow, like a dream. There were about twelve people on it, and some underneath." As he spoke, he gathered a crowd of listeners.
Across the room, one of the administrators was telephoning the City Hospital for a woman, to inquire about her brother-in-law. He had been taken there and not to the General. The woman bit her fingernails and watched the expression of the man telephoning. Finally he hung up and said, "He's fine. Just some lacerations on his hands and face. He's fine."
"Thank God," the woman said.
"If you want to get over there, there are cabs in front."
The woman shook her head. "My husband's here," she said, pointing down to the treatment rooms.
Ralph Orlando was then wheeled out on a stretcher. A woman who had just arrived in the EW for treatment of a rash on her elbows stared at the body. "Is he dead?" she asked. "Is he dead?"
Someone said yes, he was dead.
"Why do they cover up the face that way?" she asked, staring.
In another corner of the room, a woman who had been sitting stolidly with a young child got up and took her child out of the lobby while the body was wheeled out.
The emergency ward then received word that there would be no more people coming, that it would get no more than the six it already had. By now equilibrium was returning to the ward. People were no longer running and there was a sense that things were in control. The state troopers had for the most part gone, but the relatives were still arriving.
Mrs. Orlando, a stout woman accompanied by two teen-age children, was one of the many who immediately tried to leave the lobby and get back to the treatment rooms. All relatives were being prevented from doing this, because the area around the patients was already badly crowded with hospital personnel. Mrs. Orlando was insistent, however, and the more resistance she met, the more insistent she became. The EW administrators tried to coax her out of the lobby and into a more private waiting room. She demanded to see her husband immediately. She was then told that he was dead.
She seemed to shrink, her body curling down on itself, and then she screamed. Her daughter began to sob; her son tearfully swung at members of the staff, his arms arcing blindly. After a moment of this, he began to pound and kick the wall and then, following the example of his sister, he tried to comfort his mother. Mrs. Orlando was crying, "No, no, I won't let you say that." She allowed herself to be led into another room. There was a short silence, and then she cried loudly. Her sobs were heard in the lobby for the next hour.
An MIT undergraduate, working in the emergency ward on a computer study project, watched it all. "I don't know how anybody can stand to work here," he said.
Dr. Martin Nathan, a surgical resident who had also seen it, said to him, "There are good ways to find out, and there are bad ways to find out. That was a bad way."
"Are there any good ways?" the student asked.
"Yes," the resident said. "There are."
A few minutes later, a nurse went into the private room with sedation for Mrs. Orlando and her family. Soon thereafter, the emergency ward received confirmation that the remaining casualties had been treated at other hospitals. The five in the emergency ward were being cared for; three would go to surgery in the next hour. The extra personnel began to leave, in twos and threes, and things slowly returned to normal. One hour and ten minutes had passed since the first patient arrived.
At 6 p.m., a forty-six-year-old insurance salesman arrived after vomiting up blood; twenty minutes after that, a man came in with his sixty-one-year-old mother, who had suddenly lost her ability to speak and seemed to have trouble keeping her balance; then came a nineteen-year-old graduate student who had broken a glass while washing dishes and cut her ankle. At 7 p.m. a thirteen-year-old boy arrived who had been side-swiped by a car and had suffered a scalp laceration. At seven thirty, a child who had fallen out of bed and cut his forehead; at eight, a fifty-year-old man suffering from a heart attack; moments later, an unresponsive twenty-year-old girl who had swallowed a bottle of sleeping pills, brought in by her roommates; a two-year-old child who cried and tugged at his ear; a nineteen-year-old boy with appendicitis; a thirty-six-year-old woman who had driven her car into a telephone pole and was unconscious; a fifty-nine-year-old alcoholic who said he had been beaten by two sailors and had facial lacerations; a man who was thought to be in a diabetic coma; a linotype operator who had burned his left hand; an elderly man who had fallen and broken his hip; a forty-eight-year-old man with abdominal pain and rectal bleeding.
At midnight, a woman arrived complaining of squeezing chest pain; at 2 a.m., a sixty-two-year-old man with known cancer arrived with a high fever; at two thirty, a schoolteacher who had had abdominal surgery two months before was admitted with symptoms of small-bowel obstruction.
The last resident got to bed shortly before 5 a.m., lying fully dressed on a stretcher in one of the treatment rooms. On his door was tacked a sheet of paper which said "Wake me at 6:30."
"However great the kindness and the efficiency," wrote George Orwell, "in every hospital death there will be some cruel, squalid detail, something perhaps too small to be told but leaving terribly painful memories behind, arising out of the haste, the crowding, the impersonality of a place where every day people are dying among strangers."
That is a reasonable description of Ralph Orlando's death, and the unfortunate way his family learned of it. Yet one cannot imagine those events taking place anywhere in the hospital except in the emergency ward. The EW is the place where the haste, the crowding, and the impersonality are seen in their most exaggerated form. And in many ways, the EW is the place where one can see most clearly the work that the hospital performs, in all its positive and negative aspects; the EW is a kind of microcosm for the hospital as a whole. Its growth in recent years has been phenomenal. Its patient load has been increasing steadily at a rate of 10 per cent per year for nearly a decade. It now treats more than 65,000 patients a year. Half of all hospital admissions come through the emergency ward, and many aspects of hospital life are now arranged around that fact: for example, elective admissions in medicine and surgery may have to wait as long as twelve weeks for a free bed, because emergency cases receive priority. If an elective patient has, for example, surgically treatable cancer, the delay may be difficult for everyone to accept.
Yet the trend is clear. The hospital is oriented toward curative treatment of established disease at an advanced or critical stage. Increasingly, the hospital population tends to consist of patients with more and more acute illnesses, until even cancer must accept a somewhat secondary position. And there is no indication that the hospital has fallen into this role passively; on the contrary, this appears to be the logical outcome of many aspects of its evolution.
Massachusetts General Hospital now consists of twenty-one buildings along the banks of the Charles River. Included within this complex are the first structure, the Bulfinch Building, and the most recent, the Gray Building and Jackson Towers, still under construction. All together, the hospital has more than 1,000 beds, and is one of the largest hospitals in the United States.
Invisible is a complex of equal size, consisting of all the buildings that have been erected and then torn down during the last hundred and forty-six years-the isolation wards, the Building for Offensive Diseases, the laboratories and operating rooms that have come and gone as the demands of medical practice and the patterns of disease have shifted.
The hospital is now so large and so busy that it is difficult to grasp the magnitude of its activity. In 1961, it admitted 27,000 patients, performed 16,000 operations, treated 62,000 people in its emergency ward, examined 115,000 patients by X ray, saw 226,000 clinic patients, and dispensed 176,000 prescriptions from its pharmacy. These figures are so large as to be almost meaningless. A better way to look at the job the hospital does is to view it on the basis of a twenty-four-hour day, three hundred sixty-five days a year. On that basis, the hospital sees a new patient in the emergency ward every eight minutes. X rays are taken on a patient every five minutes. A new patient is admitted every twenty minutes. And a new operation is begun every thirty minutes.
The hospital's operating budget is some $35 million yearly. It has grown so expensive, in fact, that the initial sum of $140,000 that was used to build the hospital in 1821 now could not support its operation for a day and a half.
The growth in patient care has been equaled by a growth in teaching activity. From a handful of medical students following a senior man from patient to patient in 1821, the hospital's student population has grown to more than 800, including 250 medical students, 304 interns and residents, and 339 nursing students.
Added to these two traditional concerns- patient care and teaching-has been a third purpose: research. Here the growth has been both recent and phenomenal. As late as 1935, the MGH research budget was $44,000. By 1967, it was $10.5 million, with another $1.3 million for indirect costs of research. The research activities have transformed the very nature of the institution, making it, in combination with the medical school, a complete system for medical advance. Discoveries are made here; they are applied to patients; and new generations of physicians are trained in the new techniques.
It is this orientation toward innovation, and this commitment to scientific advancement, that the teaching hospital has contributed to the long history of hospitals. In other areas of its development, such as the emphasis on emergency care, the teaching hospital shares a trend evident among all hospitals everywhere, though it displays the trend in a more pronounced form.
The evolution of the hospital has been going on for more than two thousand years, beginning with the first system of hospitals about which much is known, the aesculapia of Greece. These first appeared around 350 b.c., taking the form of temples to Aesculapius, a deified physician who had lived nearly a thousand years earlier. (Homer insists that Aesculapius was a mortal, despite the fact that he was a pupil of the centaur Chiron.) The legendary fate of Aesculapius is ironic, for it represents the first statement that good medical care could lead to population problems. According to legend, Aesculapius was so successful as a healer that Hades became depopulated; Pluto complained to Zeus, who eliminated Aesculapius with a thunderbolt. The Aesculapian temples were not so much hospitals as religious institutions where patients came on pilgrimages, hoping to be cured by a visitation of the gods; the medical historian Henry Sigerist suggests Lourdes as the closest modern parallel.
Predictably, the most common cures were of people suffering from what would now be called hysterical or psychosomatic illness-headache, insomnia, indigestion, blindness caused by emotional trauma, and so on.
The hospital in a more modern sense began in late Roman times, and coincided with the spread of Christianity across Europe. The word "hospital" is derived from the Latin hospes, meaning host or guest; the same root has given us "hotel" and "hostel." Indeed, the first hospitals were little different from hotels and hostels. Essentially they were places where the sick could rest and be fed until they recuperated or died. All hospitals were run by the Church, and most were associated with monasteries. Medicine was practiced by monks and priests.
In theory, Sigerist notes, "Christianity gave the sick man a position in society that he had never had before, a preferential position. When Christianity became the official religion of the Roman Empire, society as such became responsible for the care of the sick."
But in practice, this preferential position had its drawbacks. Conditions in the medieval hospitals varied widely. Certain of them, well financed and well managed, were famous for their humane treatment and their cheerful, spacious surroundings. But most were essentially custodial institutions to keep troublesome and infectious people off the streets. In these places, crowding, filth, and high mortality among both patients and attendants were the rule.
All this soon led to the notion that one avoided a hospital if at all possible. Wealthier-and more worldly-patients were treated in their homes by apothecaries and barber surgeons; only the traveler, the very poor, and the hopelessly ill found their way into the hospitals, and for these people it was indeed "an antechamber to the tomb."
The Renaissance and Reformation loosened the Church's stronghold on both the hospital and the conduct of medical practice. New medical schools sprang up at Salerno, Bologna, Montpellier, and Oxford; in England, Henry VIII dissolved the monastery-hospital system altogether, and a network of private, nonprofit, voluntary hospitals was started to take its place.
A medical school was associated with St. Bartholomew's in 1622; it has thus been a teaching hospital for nearly three hundred and fifty years. Among its eminent surgeons and physicians have been William Harvey, the discoverer of the circulation of the blood; Percival Pott, who first described Pott's disease, tuberculosis of the spine; the brilliant and inventive surgeon John Abernethy; and Sir James Paget, the man who described Paget's disease.
During the seventeenth century, urban London was growing enormously, yet there were only two hospitals-St. Bartholomew's and St. Thomas's. The demands made upon these two institutions gradually resulted in an important change in function. Instead of caring for all patients, they shifted their emphasis to patients who could be cured, leaving the incurables to asylums and prisons. In 1700, St. Thomas's orders stated flatly: "No incurables are to be received"-a harsh order, but one with the encouraging implication that medicine was beginning to divide its clientele into those who could be helped, and those who could not. The situation was made more humane a few years later when a wealthy merchant, Sir Thomas Guy, financed one of the first private, voluntary hospitals to care for all patients, curable or not.
By now the hospital was becoming demonstra-bly more modern in purpose, but it remained a place to be feared and shunned. George Orwell notes that "if you look at almost any literature before the latter part of the nineteenth century, you find that a hospital is popularly regarded as much the same thing as a prison, and an old-fashioned, dungeon-like prison at that. A hospital is a place of filth, torture, and death, a sort of antechamber to the tomb. No one who was not more or less destitute would have thought of going into such a place for treatment."
Under the circumstances, it is not surprising that the first American colonists were in no hurry to build hospitals.
Although there was only one physician among the original passengers on the Mayflower, generally speaking the early immigrants to Massachusetts were remarkably well educated. According to one estimate, in 1640 there was an Oxford or Cambridge graduate for every two hundred and fifty colonists. This may have been the reason why Massachusetts had the first college (Harvard, 1636), the first printing press (in Cambridge, 1639), and the first newspaper in the Colonies (Boston, 1704). Massachusetts also contributed the first medical article written and published in the New World-"A Brief Rule to Guide the Common People of New England how to order themselves and theirs in the Small-Pocks, or MeaSels." It was written by Thomas Thacher, the first minister of the Old South Church. (Not all the energies of the colonists were directed toward intellectual pursuits, however, for Massachusetts also contributed the first epidemic of syphilis in the New World, in Boston, 1646.)
Nevertheless, Boston had no general hospital for two hundred years after the landing of the Pilgrims. During this time the city had been growing rapidly-from a population of 4,500 in 1680, to 11,000 in 1720, and finally to 32,896 in 1810. By now it was clear that an almshouse was inadequate for the population, a conclusion reached some years earlier in the larger cities of Philadelphia and New York.
Thus the Reverend John Bartlett, chaplain of the overcrowded almshouse, wrote a letter in 1811 to "fifteen or twenty-five of the wealthiest and most respected citizens of Boston," urging support of a general hospital. Shortly before, two professors of the newly formed Harvard Medical School had written a similar letter. Their emphasis was slightly different, for the medical school needed a hospital for clinical teaching, and every attempt to use the existing almshouse or to build a new hospital had been blocked by the local medical society, whose members feared the encroachment of the school on the conduct of medical practice.
Through these letters run a number of recurrent themes: that a hospital is indispensable for training young doctors; that existing facilities are inadequate; that the obligations of Christian charity demand support of a hospital; and that Boston has fallen behind Philadelphia and New York.
The appeal, on many levels, was certainly successful. When fund-raising began in 1816 (it was delayed by the War of 1812), $78,802 was collected in the first three days, and donations eventually exceeded $140,000.
The State was involved to the following extent: it granted a charter to incorporate the Massachusetts General Hospital; it contributed some real estate along the banks of the Charles River; it contributed granite for construction of the building; and it supplied convict labor to build it.
The designer of the building was Charles Bulfinch, Jr., a leading architect and son of a prominent physician. With its dome, the building was an architectural marvel of its time, and was considered the most beautiful structure in Boston for many years afterward. Organizationally, too, it was quite advanced; it was patterned upon the English urban teaching hospital as exemplified by Guy's Hospital in London.
The new institution was not, however, immediately popular with Boston citizenry. The first patient appeared on September 3, 1821, but no other applied until September 20, and the hospital never ran at full census until after 1850, when massive emigration from Ireland increased the city population fourfold.
This early reluctance to use the newly founded institution is frequently attributed to experiences with earlier hospitals, such as the military hospitals of the Revolution (which Benjamin Rush said "robbed the United States of more citizens than the sword"), the pesthouses, and the almshouses.
But in fact it is perfectly understandable if one considers the state of medical science when the hospital first opened its doors.
In 1821, the concept that cleanliness could prevent infection was unknown. There was little systematic attempt to keep the hospital clean; physicians went directly from the autopsy room to the bedside without washing their hands, and surgeons operated in whatever old street clothes were considered too shabby for other purposes.
In 1821, the stethoscope was a newfangled French gadget, invented four years before by Laennec. (It was a hollow tube, designed to break into two pieces so it could be carried inside a physician's top hat.) The syringe for injection was a novelty; the clinical thermometer would not be introduced for another forty years; and X-ray diagnosis was nearly a century off.
In 1821, the average physician's list of drugs contained many substances of doubtful value, including live worms, oil of ants, snakeskins, strychnine, bile, and human perspiration. Not so long previously, Governor John Winthrop had accepted powdered unicorn horn as a valuable addition to his pharmacopoeia. And if all this seems an exaggeration, it is worth remembering that as late as 1910 some doctors at the hospital still regarded strychnine as good treatment for pneumonia.
In 1821, there was no anesthesia, and consequently few operations. The post-operative infection rate was nearly 100 per cent. Surgical mortality was close to 80 per cent. In the first full year of service, the hospital treated 115 patients. Although records from that time are lost, the mortality for the hospital as a whole in its early years was a fairly constant 10 per cent.
Clearly, the hospital has undergone an astonishing growth in size and complexity since those days. That growth generally goes unquestioned; it is a peculiarity of the American mentality that the growth of almost anything is applauded. (Consider the mindless jubilation that accompanied the growth of our population to two hundred million.) One may ask whether there are any drawbacks to the size of today's MGH, and to its current emphasis on acute, curative medicine. The question is difficult to answer.
First there is size. For both patient and physician, the sheer size of the hospital can create problems. The patient may find it cold, enormous, impersonal; the doctor whose patients or consultations are widely scattered may find himself walking as much as a quarter of a mile from bed to bed. The intimate, supportive atmosphere that is possible in a smaller hospital cannot be achieved to the same extent here.
On the other hand, a large patient population permits active research on a range of less common diseases; and the hospital serves a genuine function as a place of expert management in such illnesses. Similarly, highly technical procedures, requiring trained personnel and expensive machinery, can be supported in a large hospital, and these procedures can be carried out with a high degree of expertise. Patients who require open-heart surgery or sophisticated radiotherapy find the expensive equipment for such procedures here-and, equally important, staff that carries out such procedures daily.
As for the emphasis on curative measures directed toward established organic illness, two points can be made. First, the hospital's ability to continue to care for the patient once he has left the hospital is not as good as anyone would like. The MGH founded the first social-service department in America, in 1905, to look after such follow-up care in areas not strictly medical. These departments are now standard in most large hospitals. Similarly, the out-patient clinics are designed to provide continuity of medical care to ambulatory patients. But many patients are "lost to follow-up," to use the hospital's expression; they don't answer the social worker's calls, or they don't keep their clinic appointment Nor can they be wholly faulted in this regard, for the hospital's out-patient services are, in general, quite time-consuming for the person who wants to use them. Not only does the patient spend hours in the clinic itself, but he must take the time to travel to and from the hospital on each visit.
Second, by definition the hospital has not done much in the area of preventive medicine. No hospital ever has. Since the aesculapia, hospitals have defined themselves as passive institutions, taking whoever comes to them but seeking no one out. There are some peculiar sidelights to this. For example, a high percentage of patients in the acute psychiatric service give a family history of severe psychiatric disturbance. In the case of the young girl who had tried to kill her child, her father was an alcoholic; her mother and younger brother had committed suicide; her twenty-year-old husband, a shoe salesman, had recently been admitted to a state hospital for an acute psychotic break.
It is possible to think of psychiatric illness as almost infectious, in the sense that these disorders are so frequently self-perpetuating. One is tempted to reflect that true infectious disease is best treated in the community, using direct preventive and therapeutic measures; indeed, the conquest of infectious disease-one of the triumphs of medicine in this century-is something for which the hospital, as an institution, can take no credit at all.
In the same way, it is in the hospital's approach to mental illness that its limitations as a curative institution, treating already established disease, are today most striking. If major inroads are to be made, they will not come from the hospital system as it is presently structured, any more than the old specialized hospitals for tuberculosis, leprosy, and smallpox had any real impact on the decline of those diseases.
Some of the ways the hospital is restructuring itself to meet these limitations will be discussed later. But the hospital is also revising its internal workings, and that is the subject of the next chapter.