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.)