USA > Massachusetts > Suffolk County > Boston > Fifty years of Boston; a memorial volume issued in commemoration of the tercentenary of 1930; 1880-1930, Pt. 2 > Part 3
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Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37 | Part 38 | Part 39 | Part 40 | Part 41 | Part 42 | Part 43 | Part 44 | Part 45 | Part 46 | Part 47
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Boston Lying-In Hospital.
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nurses and medical students, for the latter now do much of the work in study- ing the individual patient in preparation for a correct diagnosis and treatment. Physicians, nurses and medical students cannot so serve without acquiring thereby wider experience and more knowledge, and this is education. The careful study of individual patients accumulates data, which later can be correlated so as to advance the knowledge of medicine. Medical science brings to the care of the individual patient keener observation and the application of new methods of diagnosis and treatment, and at any time may result in new knowledge that will revolutionize the treatment of a given disease. Such, for example, was the case with pernicious anemia after the recent discovery in Boston by George R. Minot and his associates of the efficacy of liver or liver extract in its treatment, a discovery which has converted a practically always fatal into a curable disease. In these ways teaching and investigation in the hospital have become highly advantageous to the patients.
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The hospital of 1880 was hardly more than an aggregation of beds with facilities to feed and care for the patients there housed. Operating rooms existed, but they were simple in arrangement and their field of use was very limited, for relatively few conditions were amenable to surgical treatment. Now the hospital is a very complex organization. Operating rooms are more numerous and more complicated. Chemical, bacteriological and pathological laboratories occupy much space. Equipment for X-ray examinations and treatment fills a number of rooms. There are special diet kitchens. Arrange- ments for baking, massage and other forms of mechanotherapy, as well as heliotherapy and hydrotherapy, are found. The interviewing of patients seek- ing admission and of patients' friends, the collecting of fees, the management of the institution, etc., necessitate a complex administrative system administered by a superintendent with a corps of clerks and assistants. The training school for nurses adds further complexity. The professional staff is large and requires a variety of mechanical aids in its work. Typewriters hum. Social service workers come and go. Patients return for follow-up examinations. Rapidly mounting budgets are an index not only of the increased cost of living but of the ever-expanding functions of the hospital. Increasingly patients of all grades of social and economic standing seek the hospital when sick, and surgery is scarcely thought of outside the hospital. The rich and the poor come to the same institution, for modern medicine avails itself of a machinery possible only in large hospitals, and many citizens at present live in apartments and small houses poorly adapted for the care of the sick.
The organization of the hospital staff has changed much since 1880. Then visiting physicians and surgeons would be on duty three or four months out of the year; on each service there was a regular rotation of medical men in charge of the patients, each one often spending relatively little time per day in hospital work. This prevented continuity in the way things were done and greatly subdivided authority. Notwithstanding these very obvious disad- vantages, the condition continued unchanged until the early years of 1900, when at the Carney Hospital in 1903 John C. Munro was made surgeon-in-chief and in 1907 Henry A. Christian was made physician-in-chief, each with con- tinuous service and responsible for the work of all those on the surgical and
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medical services, respectively. It was some years before this plan was adopted by other Boston hospitals, although now the plan is in universal use except in smaller, semiprivate hospitals.
Year by year the hospital staff has grown in size, each member giving an increased amount of his time to hospital duties, until now large groups of physi- cians, surgeons and specialists serve each of the larger hospitals. Especially marked has been the change in the out-patient departments. In 1880, as the figures on an earlier page indicate, relatively few visits were made by ambula- tory patients as contrasted with those of the present day, and some hospitals had no out-patient department. Such patients as came could be seen in a short space of time, for often little more than a brief questioning and the writing of a prescription constituted the doctor's care of the case; or, perhaps, an infec- tion was incised speedily or dressings were quickly placed. However, patients gradually were examined far more thoroughly, and this required considerable time and necessitated having more doctors on duty longer hours each day. Unfortunately, under the best of conditions, doctors were hurried, and patients must spend long hours awaiting their turn to be seen. Only within the last year or two has this been corrected by the adoption of the appointment system, under which the patient has a definite period of time assigned on a given day for his examination and treatment. This keeps the patient from long waits and gives the doctors sufficient time to care well for each patient. All of the Boston hospitals now follow this appointment plan.
In 1880 little attention was given to what happened to the patients outside of the walls of the hospital. They went home to carry out, as best they might, certain directions, which might have been, and often were, completely mis- understood. No follow-up of these patients was attempted. Much energy was wasted in this way by the hospital staff, and patients failed to get the advan- tage that might have come from treatment properly carried out at home. It came, too, to be realized more and more that social and economic factors often were all-important causes of distress and disease and that frequently patients needed medicines least of all. This realization led to the development of social service work. At the Massachusetts General Hospital in 1905 Richard C. Cabot directed the development of the first Social Service Department to meet the deficiencies of hospital work as just noted. In a surprisingly short time this movement spread far and near, until now practically every hospital in the United States has social service workers, who interpret to the patients the doctor's directions and follow them into their homes and investigate their social and economic background. Without this work in the homes much of the good done by hospitals would be impossible.
In the early part of 1900 Amory A. Codman began his insistence on a plan for following up surgical patients to find out the final results of operations and soon the follow-up of hospital patients became generally practised. With these developments the hospital has come to have more and more contacts with the community, and already not alone the treatment of disease but the dissemination of the principles of good hygiene and the prevention of disease are among its generally recognized functions, and staff organization and institu- tions are being modeled to serve these ends.
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With this increase in the size of the visiting staff, there has arisen a need for a much larger resident staff on call throughout the twenty-four hours, since on these men devolves much of the work of examining the patients, recording their histories, making various laboratory studies and directing their treatment, all under the supervision of the visiting staff, co-ordinated in their various duties by the chief of staff. The resident staff is made up of house officers or internes, serving periods of time from twelve to twenty-four months; in many hospitals there are also assistant residents and residents, young medical men who have completed their terms of service as house officers and are spending from one to several additional years in hospital work. The system of residents and assistant residents was introduced into Boston at the Peter Bent Brigham Hospital when it was opened in 1913; subsequently it has been adopted very generally.
This system of having young medical graduates resident in the hospital and on call throughout the twenty-four hours makes possible a prompter care of unexpected emergencies than can happen when the patient must await the coming to the hospital from his home of the medical man in charge of the patient, and allows of much more careful study of the patients. Curiously enough, such a service was provided earliest for ward patients, while well-to-do private patients remained dependent on outside physicians, even though they were in hospitals. Even today in Boston more private patients in hospitals fail to have the services of any sort of a house officer or resident staff than get it, there still being no resident staff of medical graduates in such hospitals as the New England Deaconess Hospital, the Baptist Hospital, the Phillips House of the Massachusetts General Hospital and other smaller institutions much frequented by private patients.
Latterly medical students have been added as integral parts of the hospital staff, doing much of the work formerly devolving on house officers and at the same time receiving a practical training of great value in their education. This system had its beginning in Boston for a small group of Harvard students in 1905 on the service of Reginald Heber Fitz at the Massachusetts General Hospital under the supervision of Henry A. Christian and soon was extended to other hospitals. Now it is accepted generally that in those hospitals to which medical students are attached in this way patients receive better and more thorough service, and in Boston the various hospitals today are anxious to have these teaching relations with a medical school.
Some idea of the change that has taken place in surgery since 1880, may be had by recalling that at the Massachusetts General Hospital as late as July 23, 1882, there appeared in the minutes of the Medical Board in connection with the nomination of Dr. John Homans as visiting surgeon the words "pro- vided . he understands and desires to comply with the restrictive policy of the Hospital in relation to the practice there of specialties, particularly the specialty of ovariotomy." John Homans was one of the pioneers in develop- ing abdominal operations by successfully performing ovariotomies, his earlier work being done at the Carney Hospital. As late as 1882 the surgeons at the Massachusetts General Hospital disapproved of such work, as appears by the minute just referred to. It is difficult to realize today that so short a time ago
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opening the uninfected abdomen was regarded by the Massachusetts General Hospital as a procedure too dangerous to be permitted. As events have turned out, this attitude appears in the light of a very narrow conservatism which would have retarded surgieal progress, had not John Homans, though a member of the Massachusetts General Hospital staff, gone elsewhere to do abdominal work, and had not others dared, too, to open the uninfeeted abdomen.
Today one of the most eommon operations on the abdomen is for appendi- eitis, but it was not until 1886 that this eondition was described and named by Reginald Heber Fitz, then pathologist at the Massachusetts General Hospital, though later to become visiting physician. Soon his eolleague at the Massachusetts General Hospital, Mauriee H. Richardson, and others were removing diseased appendiees, and in a short time this beeame a very frequent surgieal procedure.
In 18SO antisepsis was being praetised in Boston as introdueed by Lister in the early 60's, and operations were done under a earbolie spray, but this was eumbersome, and not until the principles of asepsis were introduced in a later period could rapid progress in surgery be made. It is of historieal interest that Harold C. Ernst, who had returned from Europe eonversant with the recent advances in baeteriology and was then teaching bacteriology at Harvard, in the winter of 1887-88 devised a method for preparing sterile dressings for J. Collins Warren to use in operations at the Massachusetts General Hospital, but, in the words of Doetor Warren, "the next winter when I went on serviee, the apparatus had disappeared, and not one of my assistants knew how sterile dressings were prepared. Thus the Massachusetts General Hospital, which is inseparably eonneeted with the first use of ether anesthesia, probably lost the chanee of being the first hospital in the world to use aseptic surgery."
However, abdominal surgery did progress rapidly and methods developed in this field were soon applied more and more extensively, until now there is no part of the body but may be explored with safety. One of the more reeent developments has been in the field of brain surgery, in which a Boston surgeon, Harvey Cushing, at the Peter Bent Brigham Hospital, has been the leader. Lung surgery is being developed rapidly, and even the heart has been entered and attempts have been made with some slight suceess to widen narrowed valve orifiees. Elliott C. Cutler performed the first sueeessful operation of this kind at the Peter Bent Brigham Hospital in 1923.
Of the diseases with which the physician deals many eome in the group of infectious diseases. Several of these are caused by baeteria, yet in 1880 the bacterial eauses of almost all of these diseases remained unproved; there was no such thing as an antitoxin for their cure, and the only available measure of prevention was isolation of the patient. Sueh isolation was merely a blind procedure, for no one knew what eaused the disease or how it was transmitted from patient to patient. In a very short period, beginning with 1879, the definite baeterial eause of a number of diseases was demonstrated, such as gon- orrhea in 1879, leprosy in 1879, tubereulosis in 1882, glanders in 1882, erysipelas in 1883, diphtheria in 1883-84, boils in 1884, typhoid fever in 1884, loek-jaw (tetanus) in 1884, Asiatie cholera in 1884, pneumonia in 1885 and epidemie meningitis in 1887. Soon after this period the antitoxin for diphtheria was
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developed and later one for tetanus. It is difficult to realize that all of this knowledge is so comparatively recent.
Antitoxin for diphtheria was discovered in 1891 and in a relatively short time was used with striking results by Dr. John H. McCollom at the South Department of the Boston City Hospital. In more recent years bacteriological investigation has given us various sera to be used in the treatment and preven- tion of infectious diseases and has developed many serological and other methods of diagnosis without which the physician would be greatly hampered in his work. Now with a small amount of blood such diseases as typhoid fever, undulant fever, syphilis, etc., may be diagnosed with great accuracy, and by various technical methods causative bacteria may be isolated from the patient, thus proving the exact cause of the disease. All of this knowledge has been developed since 1880; its necessary consequence is that each hospital now must have well equipped bacteriological and serological laboratories. Boston has taken an active part in the practical application of bacteriological knowledge, though little of importance in this field has been discovered in Boston, probably because until comparatively recently facilities for medical investigation have been meager.
The first to prove the insect transmission of an infectious disease was Theobald Smith, who subsequently came to Harvard as professor of comparative pathology. This discovery has been of fundamental importance in the preven- tion of certain diseases, especially tropical diseases, making the tropics habitable to the white man and preventing epidemics, such as yellow fever, from visiting the temperate zone.
Another great advance in diagnosis came with the application of the X-ray to medicine. In 1895 Roentgen discovered the X-ray and in a short time Francis H. Williams at the Boston City Hospital and Walter J. Dodd at the Massachusetts General Hospital were using it in diagnosis. At first, fractures and other changes in bones constituted the chief field for its application in medicine. In 1897 Walter B. Cannon in the physiological laboratory of the Harvard Medical School gave animals a suspension of bismuth sub-nitrate, which is opaque to the X-ray, as a means of observing the motor function of the stomach. Such a substance, opaque to X-ray when it fills a hollow viscus, gives a silhouette of the viscus which changes in form with changes in the wall of the viscus and so serves to help in the recognition of changes and the diagnosis of their cause. Soon this method was used to study the gastro-intestinal tract in man and rapidly became of extreme usefulness in the diagnosis of all sorts of disturbances in that tract. Other hollow organs similarly can be outlined by injecting into them materials opaque to the X-ray.
Latterly it has been found that certain materials, opaque to the X-ray, may be injected into the blood stream to be excreted in a specific way by a certain body organ, and this will give an outline of the excretory channels from that organ. Within a few years substances have been developed that will be excreted by the liver and fill the gall bladder so that we can study its form, function and content. This is particularly useful in the diagnosis of gall stones. Within a year another substance has been discovered, which after intravenous injection is excreted by the kidneys and with the X-ray, to which it is opaque,
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gives the form of the pelvis of the kidney, the ureters and the bladder and thus furnishes another X-ray method of recognizing disease in these passages from the kidney to the external world, applicable when, for some reason, it is un- desirable to inject a substance opaque to the X-ray directly into the urinary tract.
Air, too, can be injected into various body cavities, including those of the brain, and as air is less opaque to the X-ray than the surrounding tissues, the form of these cavities may thus be studied, and this helps in recognizing certain forms of disease. Early in the development of the X-ray it was applied to the study of changes in the lung, and this field has been extended further by the injection of X-ray-opaque oils into the bronchi going to different parts of the lung. Similar oils may be injected into the Fallopian tubes to study their form, position and patency, or into the spinal canal to localize tumors obstructing the space about the spinal cord.
As a result of all this, the X-ray department has become a most active feature of all hospitals, and the X-ray is used in the examination of a very large percentage of patients entering our hospitals or coming to the out-patient departments. In Boston those directing X-ray departments have aided in a noteworthy manner in the perfecting of X-ray methods and their application to the study of disease in man.
Both X-rays and the rays from radium are of use in treating certain diseases and the influence of these different kinds of radiant energy is utilized daily by the hospitals as one method of therapy.
Another way in which diagnostic methods have been extended is by the chemical study of the blood and other body fluids. Numerous constituents of these fluids can be recognized and their quantity determined. These change in character and amount under the influence of disease, and this knowledge helps in the study of disease. Many of the methods applicable to very small amounts of blood and other body fluids now used in this field were devised by Otto Folin in the bio-chemical laboratory of the Harvard Medical School.
As a result of such developments as have been described, the modern hospital is equipped with large laboratories in which all sorts of diagnostic methods are carried out, to be applied in the care of patients and used for investigation. To provide for these, Boston hospital plants have been enlarged steadily, and it is gratifying to realize that these institutions everywhere are considered to be of the first rank and often have been leaders.
Like the hospitals, medical schools in Boston have developed enormously, especially in the last decade and a half, and Boston is considered to be a center of medical teaching of great importance. There are three medical schools in Boston of Grade A, the Harvard Medical School, founded in 1782, the Medical School of Boston University, founded in 1873, and the Tufts Medical School, founded in 1893.
In 1880 the Harvard Medical School occupied a rather small building . situated near the Massachusetts General Hospital. Up to then anatomy had been almost the sole subject in the medical curriculum needing anything of the nature of a laboratory for its study, and so not much space was required for a medical school. However, at about this time it became evident that these
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conditions would not continue, and soon larger quarters would be required for the medical school, especially to supply space for laboratories. As a result, plans were made for a new building and in 1883 the Harvard Medical School moved to the building which had been erected for it on the corner of Boylston and Exeter streets, a building where, in the words of President Eliot at its opening, "it has secured itself in the center of the city for many years to come." Soon, however, new subjects and new ways of teaching required more space, so that in 1890 a commodious wing was added to this building, the gift of Dr. Henry F. Sears; but for only a short space of time did it suffice, and in 1900 plans were laid for a new and far larger group of buildings.
By 1906 under the inspiring leadership of Henry P. Bowditch and J. Collins Warren the plans had been brought to fruition, and a group of five marble buildings had been completed for the use of the Harvard Medical School on a site on Longwood avenue at a cost of $2,917,938.
Twenty-six acres of land had been purchased originally. Eleven of these were used for the medical school and fifteen were eventually sold to the Peter Bent Brigham Hospital and the Children's Hospital, so that hospitals might be in close proximity to the medical school buildings and serve for clinical teaching in affiliation with the school. This idea has developed so that adjoin- ing or in close proximity to the Harvard Medical School buildings, as dedicated in 1906, there are now a very large number of institutions serving some function of medicine. The Harvard Dental School, the Harvard School of Public Health and Vanderbilt Hall, a students' dormitory, have been added to the original group of buildings. In addition to the Peter Bent Brigham Hospital and Children's Hospital, nearby are the Huntington Memorial Hospital, the Lying-In Hospital, the New England Deaconess Hospital, the Palmer Memorial Hospital, the Psychopathic Hospital, the Beth Israel Hospital, the House of the Good Samaritan and the Channing Home. Only a short distance away are the Free Hospital for Women, the New England Baptist Hospital, the Robert B. Brigham Hospital and a number of small institutions, constituting a veritable city of medicine. In 1929-30 the Harvard Medical School had 519 students in the courses leading to the degree of doctor of medicine and 495 graduates in medicine registered for special courses. In this year the expendi- ture of the Harvard Medical School was $848,246.20, that of the Harvard School of Public Health was $271,345.83 and that of the Harvard Dental School was $161,983.39. The total annual expenditure in 1929 of the hospitals men- tioned by name in this paragraph was $3,884,450.56, making a total of over five million dollars expended in a single year by this group of institutions devoted to medicine. Moreover, it is to be remembered that they form but one of several large groups of medical institutions that Boston possesses.
The Medical School of Boston University was founded in 1872 as a homeo- pathic institution. It was closely affiliated with the Massachusetts Homeo- pathic Hospital, but since 1918 it has ceased to be a sectarian medical school and in 1923 it completed an additional affiliation with the Boston City Hospital. In 1929 the Massachusetts Homeopathic Hospital changed its name to the Massachusetts Memorial Hospitals. In 1929 the Medical School of Boston University had two hundred and nineteen students in courses leading to the
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M. D. degree and expended $105,000 for their instruction, and in the same year the Massachusetts Memorial Hospitals had a budget of $750,000. These two institutions have perfected plans for a new and greatly enlarged plant to be erected on Commonwealth avenue, which will constitute eventually another great medical center for Boston. It is highly desirable that these plans be developed speedily.
The Tufts Medical School was founded in 1893 and now occupies com- modious quarters on Huntington avenue, where in 1929-30 four hundred and eighty-seven students of medicine were enrolled. As this is being written (in the summer of 1930) a campaign is under way for funds to create still another medical center on Bennet street. The Boston Dispensary, founded in 1796, is Boston's oldest medical institution. Its work chiefly is for ambulatory patients with visiting physicians and nurses who care for patients ill in their homes. However, it has now a small hospital for children. This work is to be expanded and new buildings are to be erected from the proceeds of the campaign. With the Boston Dispensary the former Floating Hospital for infants and small children will be affiliated, and the Tufts Medical School will have in the same group a building for clinical laboratory work and teaching. These institutions will be co-ordinated into a medical center in which the training of medical students for family practice will be chiefly stressed. It is particularly hoped that this movement may supply medical men now greatly needed in the smaller towns and country districts of New England. This will be an important further advance in Boston medicine.
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