Five Patients

Michael Crichton
Michael Crichton

Five Patients
 Health, as a vast societal enterprise, is too important to be solely the concern of the providers of
services.
William L. Kissick, M.D.
 Author's Note 1994
Twenty-five years have passed since I wrote Five Patients. When I
reread the book recently, I was struck by how much in medicine has
changed-and also, by how much has not changed. Eventually I decided not
to revise the text, but to let it stand as a statement of what medical practice
was like in the late 1960s, and how issues in health care were perceived at
that time.
By design, the book is highly selective, and some of the most dramatic
social changes in medicine were not anticipated in its discussions. This
book was written before the great government interventions of Medicare
and Medicaid; before the onslaught of malpractice litigation, which
transformed medical practice; before the rise of group practices and HMOs;
and before the entry of large numbers of women into the profession as
physicians. At the time this book was written, abortion was illegal; patient
rights were barely discussed; the right to die was only beginning to emerge
as an issue for the future; and genetic testing was still an exotic,
experimental procedure.
At the same time, the description in Five Patients of life in the
emergency room seems little different from the present day; the training of
new doctors is largely unchanged; the influence of medical history on
present attitudes remains as important now as it was then; and the struggle
to master new technologies, and to mount new surgical techniques, seems
entirely contemporary.
Much of the book focuses on emerging technologies, and it is
interesting to see how cutting-edge technologies in the 1960s have fulfilled,
or failed to fulfill, their promises. The use of closed-circuit television for
"remote doctoring" has not found wide application, but some observers
think that this is because the technology is still emerging, and will reach
fruition when a combination of robotics and virtual reality allow surgery to
be performed by a surgeon thousands of miles away.
Similarly, I was fascinated by the idea that the computer might provide
a powerful diagnostic tool, but diagnostic computer systems have found
little acceptance in medicine. Doctors don't trust them and patients don't
like them; they would rather give case histories to a paramedic or aide. On
the other hand, everyone accepts automated lab tests, which are quick,
accurate, and inexpensive. But overall, the effect of automation in medicine
has been mixed; for example, even the mundane use of computers for
hospital record-keeping has proven unexpectedly problematic, as our
society struggles with issues of accuracy and privacy in the era of electronic
data.
What was not foreseen by me, or by anyone else in the late 1960s, was
that computers would soon become almost unimaginably cheap. A
computer that cost ten million dollars in 1970 cost only a few thousand
dollars in 1980, and only a few hundred dollars in 1990. Ubiquitous, cheap
computer power has made possible a variety of non-invasive imaging
procedures-computer assisted tomography, magnetic resonance imaging,
and sonography- which have transformed the daily practice of medicine,
and which seem, to someone from that era, almost magical in their results.
As medical technology has proliferated we have gained more
sophisticated understanding of its limitations. Indeed, one trend in medicine
has turned away from technology altogether. The long-term improvement in
statistics for heart disease is primarily credited to life-style changes in the
population. Diet, exercise, and meditation are now solemnly prescribed
where once they were laughed at. And the growing interest in psychoimmu-
nology, the interaction of mind and disease, is shared by patients and
physicians alike. (When I wrote Five Patients, the most famous doctor in
America was probably Michael DeBakey, the Houston cardiac surgeon.
Now, he may very well be Deepak Chopra.)
It's also true that events in the larger world have upset the confident
expectations for continuously improved health. Smallpox has been banished
forever, but the appearance of Legionnaire's Disease, Lyme Disease, and
particularly AIDS reminds us that new illnesses have always arisen
throughout human history. During this past quarter century, we have come
to know even more horrific pathogens, such as Eboli virus, which
fortunately have not taken hold in Western societies. But the threat remains.
Skyrocketing medical costs were an issue in the late 1960s, as they are
today, although our concern about expenditures in that era now seems
quaint. Back then, the United States spent 6 percent of our GDP on health
care-about 50 billion dollars annually. I predicted that figure would reach
more than 100 billion by 1975. (In fact, it was 132 billion in that year.)
 But no one back in 1969 would have foreseen the present astronomical
level of expenditure: more than 800 billion dollars a year on health, more
than 14 percent of our GDP, with no end in spending growth in sight. The
reason was that, back then, nearly everyone imagined that the country
would have long since moved to a national health plan, if only to contain
costs. Our failure to do so has produced all sorts of unhappy consequences
for our nation, ranging from diminished global economic competitiveness
to new individual fears in the workplace. Half of all personal bankruptcies
in America now result from health costs, and the need to maintain insurance
coverage has transformed the work decisions of all Americans, greatly
diminishing our once-prized personal mobility.
When I wrote Five Patients, a room at the Massachusetts General
Hospital cost $70 a day. Now it costs more than $700. The hospital's annual
operating budget was then $35 million a year. Now it is $732 million, far
exceeding the rate of inflation for that period.
The need to control costs, while ensuring health care for all Americans,
now dominates every discussion about the future shape of medicine in
America. This country must finally adopt some form of national health
insurance, as every other industrial country in the world has long since
done. It is a complex and a difficult issue, even without its political
dimension, which often seems to render it almost insoluble.
But while the systems of other countries are not without their problems,
the fact is that other industrialized nations spend less on health care and get
more for their money. At the moment, our national debate on health care is
in the phase of blame and recrimination. We are told that doctors are paid
too much, or that lawyers and litigation cost too much, that pharmaceutical
companies charge too much, and so on. But the truth is that everyone works
within the constraints of the present system-and it is the system itself that
must be changed.
One can draw an analogy to the earlier complaints about the cost and
quality of American automobiles, which at one time were blamed on
American workers. But the reality is that workers on the assembly line are
prisoners of a system designed by others. Individual effort cannot
significantly affect the outcome of the system. Only by changing the
assembly line itself-by changing the way cars are designed and made-can a
better product result. And given a better process, American workers have
proven that they are as productive and efficient as anyone else.
 Similarly, American medicine has grown up as an unplanned
entrepreneurial system of individual providers. The current system does
many things well, but at high cost. A growing proportion of that cost
derives from legislation passed by American politicians, who are not
accountable for costs they impose. Indeed, freedom from political
accountability is one of the worst features of the present American system.
Changing the American system will confront us with far more difficult
decisions than how much doctors or lawyers or drug companies are paid.
The real battleground will be over coverage-what treatments the system will
pay for, and under what circumstances. This in turn will bring to the fore all
the ethical issues created by modern medicine in this century. Here
especially we will need the expertise of physicians. It is unfortunate that the
most recent tendency among politicians has been to exclude physicians and
other health-care workers from planning the new system. One can only
imagine this is a temporary phase, similar to the temporary phase when
Detroit tried to design better cars without the help of workers on the line.
That didn't succeed for automobiles, and it is unlikely that the current
strategies in Washington will succeed any better for health care. There are
signs that the public is disenchanted with politicians, and as our national
debate continues, we can at least hope for a system that controls costs while
preserving the innovation, vitality, and excitement that has always
characterized American medicine.

M.C.
 Foreword
there has recently been a lot of fool-ish talk about something called "the
new medicine." To the extent that it implies a distinction from some form of
old medicine, the phrase has no meaning at all. Medicine has crossed no
watershed; there has been no triumphant breakthrough, no quantum jump in
science or technology or social application.
Yet there is, within medicine itself, a sense that things are different. It is
difficult to define, for it is not the consequence of change, but rather the fact
of change itself.
The first time I began to look at the Massachusetts General Hospital in
the spring of 1969 I had the uneasy feeling there was too much flux, too
much instability in the system. I felt a little like an interviewer who has
come upon his subject at a bad time. Only later did I realize that there
would never be a "good" time, and that change is a constant feature of the
hospital environment. The true figurehead of modern medicine is not
Hippocrates but Heraclitus.
To trace a history of change, one must go back about fifty years, to the
time when organized research began to produce major new scientific and
technological advances. Medicine has been revolutionized by those
advances, but they have not stopped. Indeed, the pace of change has
increased. Within the past ten years, social pressures have been added to
those of science and technology, producing a demand for a new concept of
medical care, a new ethic of responsibility for the doctor, and a new
structuring of institutions to deliver broader and better care.
As a result, medicine has become not a changed profession but a
perpetually changing one. There is no longer a sense that one can make a
few adjustments and then return to a steady state, for the system will never
be stable again. There is nothing permanent except change itself.
From this standpoint, the experiences of five patients in a university
teaching hospital are most interesting. It should be stated at once that there
is nothing typical about either the patients described here or the hospital in
which they were treated. Rather, they are presented because their
experiences are indicative of some of the ways medicine is now changing.
 These five patients were selected from a larger group of twenty-three,
all admitted during the first seven months of 1969. In talking to these
patients and their families, I identified myself as a fourth-year medical
student writing a book about the hospital. As they are presented here, each
patient's name and other identifying characteristics have been changed.
I chose these five from the larger group because I thought their
experiences were in some way particularly interesting or relevant.
Accordingly, this is a highly selective and personal book, based on the
idiosyncratic observation of one medical student wandering around a large
institution, sticking his nose into this room or that, talking to some people
and watching others and trying to decide what, if anything, it all means.

M.C.
La Jolla, California
November 15, 1969
Acknowledgments
 I am greatly indebted to the employees and medical staff of the Massachusetts General Hospital
for a kindness and patience that went beyond any reasonable expectation.
I would also like to thank Drs. Robert Ebert, Hermann Lisco, Joseph Gardella, and Mr. Jerome
Pollock, all of the Harvard Medical School, for encouragement and advice in planning the book;
Drs. Howard Hiatt, Charles Huggins, Hugh Chandler, Ashby Moncure, James Feeney, Joel Alpert,
Edward Shapiro, Josef Fisher, Michael Soper, Jerry Grossman, and Miss Kathleen Dwyer for their
suggestions at various points in my work; Drs. Alexander Leaf, Martin Nathan, Jonas Salk, and Mr.
Martin Bander for their review of the manuscript at different points; Mr. Robert Gottlieb and Miss
Lynn Nesbit for ongoing, tireless work on the project; and finally Dr. John Knowles, whose influence
is everywhere in this book, as it is in the hospital he directs. With all this help, the book ought to be
flawless, and to the extent that it is not, I am to blame.

Acknowledgments
The late Alan Gregg once quoted a former teacher as saying, "Whenever you say anything
explicitly to anyone, you also say something else implicitly, namely, that you think you are the guy to
say it." Such sentiments trouble all but the most egotistical writers; the others recognize that their
sense of enfranchisement is a gift of the people around them, whom they can only hope not to
disappoint.
 Ralph Orlando. Now and Then
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.
 John O'Connor. The Cost of Cure
Until his admission, john o'connor, a fifty-year-old railroad dispatcher
from Charles-town, was in perfect health. He had never been sick a day in
his life.
On the morning of his admission, he awoke early, complaining of vague
abdominal pain. He vomited once, bringing up clear material, and had some
diarrhea. He went to see his family doctor, who said that he had no fever
and his white cell count was normal. He told Mr. O'Connor that it was
probably gastroenteritis, and advised him to rest and take paregoric to settle
his stomach.
In the afternoon, Mr. O'Connor began to feel warm. He then had two
shaking chills. His wife suggested he call his doctor once again, but when
Mr. O'Connor went to the phone, he collapsed. At 5 p.m. his wife brought
him to the MGH emergency ward, where he was noted to have a
temperature of 108°F. and a white count of 37,000 (normal count: 5,000-
10,000).
The patient was wildly delirious; it required ten people to hold him
down as he thrashed about. He spoke only nonsense words and groans, and
did not respond to his name. While in the emergency ward he had massive
diarrhea consisting of several quarts of watery fluid.
The patient was seen by the medical resident, John Minna, who
instituted immediate therapy consisting of aspirin, alcohol rubs, fans and a
refrigerating blanket to bring down his fever, which rapidly fell to 100°. He
was in shock with an initial blood pressure of 70/30 and a central venous
pressure of zero. Over the next three hours he received three quarts of
plasma and two quarts of salt water intravenously, to replace fluids lost
from sweating and diarrhea. He was also severely aci-dotic, so he was given
twelve ampoules of intravenous sodium bicarbonate as well as potassium
chloride to correct an electrolyte imbalance.
The patient could not give a history. His wife, upon questioning, denied
any history of malaria, distant travel, food exposure, infectious disease,
headache, neck stiffness, cough, sputum, sore throat, swollen glands,
arthritis, muscle aches, seizures, skin infection, drug ingestion, or past
suicide attempts.
 His past history, according to the wife, was unremarkable. He had never
been ill or hospitalized. His mother died at age fifty-five of leukemia; his
father at age fifty-nine, of pneumonia. The patient had no known allergies,
and did not smoke or drink.
Physical examination was normal except for a slightly distended
abdomen and a questionably enlarged liver, which could be felt below the
rib cage. Neurological examination was normal except for the patient's
stuporous, unresponsive mental state.
The patient was cultured "stem to stern," meaning that samples of
blood, urine, stool, sputum, and spinal fluid were sent for bacteriologic
analysis. He was also given heavy doses of antibiotics, including a gram of
chloramphenicol, a gram of oxacillin, two million units of penicillin; later
in the evening, kanamycin and colistin were added to the list.
X rays of the chest and abdomen were normal. Electrocardiogram was
normal. Hematocrit was normal. The white count was elevated at 37,000
with a preponderance of polymorphonuclear leukocytes, the cells which
increase in bacterial infections. Examination of the urine showed a few
white cells. Platelet count and prothrombin time were normal.
Measurements of blood sugar, serum amylase, serum acetone, bilirubin, and
blood urea nitrogen were normal. Lumbar puncture was normal.
An intravenous pyelogram (an X ray of the kidneys to check their
function while they excrete an opaque dye) showed that the left kidney was
normal, but the right kidney responded sluggishly. The excretory tubing on
the right side seemed dilated. A diagnosis of partial obstruction of the right
kidney system was suggested.
Because the abdomen was distended, six abdominal taps were
performed in different areas by the surgical residents, Drs. Robert Corry
and Jay Kaufman, in an attempt to obtain fluid from the abdominal cavity.
None was obtained.
Dr. Minna's diagnosis was septicemia, or generalized infection of the
bloodstream, from an unknown source. As possibilities he listed the urinary
tract, the gastrointestinal tract, the gall bladder, or the lining of the heart. He
felt that there was no good evidence for a central nervous system cause for
the fever, and no good history of drug inges-tion or thyroid problems to
account for the fever.
This was essentially the conclusion of the neurological consultants who
saw the patient later in the evening. They felt that Mr. O'Connor had
suffered a primary infectious process with sudden outpouring of bacteria
into the blood, and consequent fever and prostration. They felt the infection
was somewhere in the urinary or gastrointestinal system, or perhaps even in
a small area of the lungs. In their opinion, meningitis, encephalitis,
subarachnoid hemorrhage, or other central nervous problems were unlikely.
A formal surgical consult, also later in the evening, reported that in the
absence of muscle spasm or guarding of the abdomen, and in the presence
of six negative taps, an acute abdominal crisis was unlikely.
Genito-urinary consultants examined the patient that same evening and
reviewed his kidney X rays. They felt that there was a probable partial
obstruction of the right kidney, but they could not determine whether this
was a recent or a slowly developing change. They found no evidence of
infection of the prostate gland to explain the fever. Mr. O'Connor was
placed on the Danger List and transferred to the intensive-care unit of the
Bulfinch Building. At the end of his first twelve hours in the hospital, his
fever had been reduced, but was still unexplained.
Before continuing with Mr. O'Connor's hospital course, it is worth
pausing a moment to consider the patient's initial symptoms, and initial
therapy.
Mr. O'Connor was presented with high fever and shock. Classically, the
fever of unknown origin is a pediatric problem, and classically it is a
problem for the same reasons it was a problem with Mr. O'Connor-the
patient cannot tell you how he feels or what hurts. However, a high fever in
a child is less worrisome than it is in an adult, for children have a much
greater tolerance for fever. In adults, prolonged high fever is more likely to
result in permanent brain damage and death.
The most common cause of fever for anyone, child or adult, is infection;
the most common cause of fever of unknown origin is also infection. There
are some unusual causes occasionally seen, such as malignancies, bleeding
in the brain, drug ingestion, and outpouring of thyroid hormone, but, for the
most part, unexplained fevers are produced by unidentified infections.
It is now known that one can harbor an infection in a secluded part of
the body, and the body will make very little response to it; however, if the
infection spreads into the bloodstream, there may be a "shower" of bacteria,
and a subsequent rise in temperature. The shower is usually brief, lasting
minutes or hours, and often ends before the temperature rises. This makes
diagnosis difficult-if one wants to catch bacteria in the blood, one must
draw a sample before the temperature spike, and not during it or after it.
It was thought that Mr. O'Connor was suffering from precisely this sort
of situation: a sequestered infection producing episodic bursts of bacteria
into the blood, with episodic fever. However, his fever was threateningly
high. And thus a classic conflict in therapy as old as Hippocrates.
"For extreme diseases, extreme remedies," Hippocrates wrote. But he
also said: "For grave diseases, the most exact therapy is best." But,
obviously, an exact therapy depends upon a precise diagnosis, and here lies
the conflict.
What is a diagnosis? The question is not as simple-minded as it first
appears, for the notion of what constitutes an acceptable diagnosis has
radically changed through the years.
A diagnosis is drawn up on the basis of two kinds of knowledge: the
physician's concept of disease processes, and his available therapies.
Ideally, a diagnosis contains some sense of etiology- the cause of the
disease-but for most of medical history etiology was either ignored or
wrongly ascribed (as in "fever from excess of black bile").
In a modern sense, precise diagnosis is required because precise
therapies are available. Yet the need for precise diagnosis is older; in
Hippocratic time, this need was based on a prognostic, not a therapeutic,
concern. Physicians were unskilled at curing disease and therefore served
mostly to predict the course of an illness which they could not influence.
Robert Platt notes that "until quite recently… it did not matter whether your
diagnosis was right or wrong… Prognosis mattered rather more, especially
to the doctor's reputation."
Hippocrates was deeply concerned with the prestige of the physician as
related to prognostic acumen; much Hippocratic writing shows this
preoccupation with prognosis: "Sleep following upon delirium is a good
sign." "Those who swoon frequently without apparent cause are liable to die
suddenly." "Labored sleep in any disease is a bad sign." "Spasm
supervening upon a wound is dangerous." "Hardening of the liver in
jaundice is bad." "If a convalescent eats heartily, yet does not take on flesh,
it is a bad sign."
These observations are still valid today. But we demand something
further from diagnosis, as the range of therapies has increased. If a person
swoons, for example, it is important to know whether he has aortic stenosis-
and is likely to die suddenly-or whether he is hysterical, or diabetic, or has
some other reason for fainting. In short, we want more precise diagnoses
because we have more precise therapies.
Throughout medical history, physicians have felt that they had precise,
specific remedies, but few of these are still acceptable. As medical writer
Berton Roueche notes, only three eighteenth-century drugs are still
acceptable today: quinine for malaria, colchicine for gout, and foxglove
(digitalis) for heart failure. All the other "specifics," as well as what Holmes
termed the "peremptory drastics," have disappeared.
Even as recently as 1910, L. J. Henderson commented that "if the
average patient visited the average physician, he would have a fifty-fifty
chance of benefiting from the encounter." Much has happened since then-in
fact, nearly every diagnostic test and therapeutic procedure performed on
Mr. O'Connor during those first twelve hours has been developed since
1910. For clinically, diagnosis and therapy go hand in hand; increasing
sophistication in either one demands increased sophistication in the other.
The proliferation of tests and techniques in this century is staggering.
Consider the following list of tests performed on Mr. O'Connor, and the
dates those tests were first described in clinically practical terms:
X ray: chest and abdomen (1905-15)
White cell count (about 1895)
Serum acetone (1928)
Amylase (1948)
Calcium (1931)
Phosphorus (1925)
SCOT (1955)
LDH (1956)
CPK (1961)
John O'Connor 45
Aldolase (1949)
Lipase (1934)
CSF protein (1931)
CSF sugar (1932)
Blood sugar (1932)
Bilirubin (1937)
Serum albumin/globulin (1923-38)
Electrolytes (1941-6)
 Electrocardiogram (about 1915)
Prothrombin time (1940)
Blood pH (1924-57)
Blood gases (1957)
Protein-bound iodine (1948)
Alkaline phosphatase (1933)
Watson-Schwartz (1941)
Creatinine (1933)
Uric acid (1933)
If one were to graph these tests, and others commonly used, against the
total time course of medical history, one would see a flat line for more than
two thousand years, followed by a slight rise beginning about 1850, and
then an ever-sharper rise to the present time.
That is the meaning of technological innovation. It has struck medicine
like a thunderbolt: far more advances have occurred in medicine in the last
hundred years than occurred in the previous two thousand. There is no
mystery why this should be so. Most research scientists in history are alive
today; therefore most of the discoveries in history are being made today.
But the consequences of this vast outpouring of information and technology
have yet to be grasped. Major questions are raised in such widely diverse
subjects as medical education and euthanasia.
What makes the case of Mr. O'Connor so interesting is the way it
illustrates the vast web of technological advances that make diagnostic
techniques and treatment today so radically different from what they were
only thirty years ago.
Presumably, Mr. O'Connor had an infection. The treatment of infectious
disease is considered one of the triumphs of modern medicine, crowned by
the introduction of antibiotics. But as the bacteriologist Rene Dubos has
pointed out. "The decrease in mortality caused by infection began nearly a
century ago and has continued ever since at a fairly constant rate
irrespective of the use of any specific therapy." He says, further, that "these
triumphs of modern chemotherapy have transformed the practice of
medicine and are changing the very pattern of disease in the western world,
but there is no reason to believe that they spell the conquest of microbial
diseases."
In this light, consider Mr. O'Connor's antibiotic "cocktail," given shortly
after admission. It was later the subject of some heated discussion when,
during the first two or three days, he failed to improve.
The use of antibiotics is more sophisticated now than it was twenty
years ago, corresponding to a better appraisal of the benefits and limitations
of the drugs. Generally speaking, the antibiotic cocktail, a mixture of drugs
given before one has diagnosed the nature of the infection, is frowned upon.
The arguments against it are simple enough. For Mr. O'Connor, the mixture
of antibiotics might not eliminate the primary site of infection-but it would
certainly kill all free bacteria in the blood, thus making identification of the
organisms impossible. Without identification, one cannot treat specifically,
by matching the organism with the single most effective antibiotic. Further,
the inability to identify the organism deprives doctors of an important clue
to the location of the infection, since different organisms are more likely to
infect different parts of the body.
The arguments in favor of the cocktail are equally simple: that Mr.
O'Connor's fever was, in itself, dangerous and constituted a medical
emergency. The first duty of the EW residents, as they saw it, was to lower
that fever by every possible means, even if this hampered further diagnostic
efforts. As one resident said, "He could have died while we waited for the
cultures to grow out."
It all comes back to Hippocrates: Does one treat with a grave remedy, or
a specific one? The MGH chose a grave remedy, a strong antibiotic
cocktail. The residents did so with the full knowledge that it might impair
further work.
Let us now see what happened to Mr. O'Connor.

Day I

Mr. O'Connor survived the night. The following morning his blood
pressure was normal and his temperature was 99°, but he remained severely
agitated and unresponsive. He was sedated with morphine, continued on
intravenous fluids and electrolyte supplements. The oxygenation of his
blood had been poor from the start and he was continued on oxygen by face
mask.
At eight in the morning the genito-urinary consult saw him and felt that
he had peritonitis of the right abdomen, or infection of the sac-like
membrane which surrounds the abdominal contents. Evidence included
tenderness and muscle spasm on the right side, and tenderness when his
liver was tapped. Bowel sounds were decreased, suggestive of intra-
abdominal infection. There was tenderness to rectal examination, also
suggestive of such infection.
At nine, Dr. Minna examined the patient again and agreed that the
tenderness was impressive, particularly after a heavy dose of morphine. An
X-ray study of the gall bladder was planned. At eleven, he was seen by the
surgeons who agreed that gall-bladder infection was possible, even though
bilirubin and amylase tests were normal. They advised waiting on surgery,
however.
At noon, the gastrointestinal consult reviewed the barium enema, which
was normal. They concluded that "we remain in the dark regarding
diagnosis but would agree that bacterial sepsis secondary to a right
abdominal lesion is the best bet." They suggested, however, that perforated
small bowel, duodenal lesion, pancreatitis, and a number of other
possibilities remained, and advised an upper GI series of X rays.
At approximately the same time, the attending physician on the wards,
Dr. Kurt Bloch, noted that Mr. O'Connor presented "a very puzzling
problem," with some findings suggestive of right-upper-abdomen
pathology, but no clear indication of what it might be.
Later in the day the surgeons again saw Mr. O'Connor, but disagreed
with earlier interpretations. They felt his abdomen had no peritoneal signs,
and no localizing signs.
At eight in the evening, the neuromedical consult again evaluated Mr.
O'Connor, and concluded that his condition still gave no hint of central
nervous system disease. They felt that findings pointed to an abdominal
problem.
That same evening, more abnormal laboratory values came back from
the labs. They had been taken the day of admission, and included an
elevated uric acid level of 17.1 and an elevated alkaline phosphatase level
of 37.6. The alkaline phosphatase test was repeated, and was found to be
still higher, at 61.0. Two other enzymes were also slightly high: the serum
glutamic oxalocetic transaminase, or SGOT, was 123, and the lactic
dehydrogenase, or LDH, was 540. Blood samples were immediately drawn
for repeat determinations.
These two enzymes, SGOT and LDH, are measured as indexes of cell
destruction. Cells normally contain them; if the cells die, they rupture and
release their enzymes to the bloodstream. A rise in enzyme levels is thought
to correspond moderately well with the degree of cellular damage,
particularly when examined over several days. However, these enzymes are
found in many kinds of cells, and thus an enzyme rise does not pinpoint
precisely the area of destruction. For example, heart, skeletal muscle, brain,
liver, and kidneys all contain SGOT; damage to any of them will produce an
SGOT rise. In recent years, there has been a search for enzymes specific to
certain tissues. Cre-atinine phosphokinase, or CPK, is usually considered
more specific for heart damage.

Day 2

At 3:30 a.m., Michael Soper, a medical resident, got back the new set of
enzyme values. Everything was further increased: SGOT was now 640,
LDH 1250, and CPK very high, at 320. He wrote: "I've never seen a CPK
this high and don't know where it is coming from. Doubt it is solely of
cardiac origin. Electrocardiogram tonight is unchanged."
At 7 a.m., on morning rounds, Mr. O'Connor's abdomen was again
without localizing signs pointing to disease on the right side. All cultures
were back from the labs; all were negative. It was decided to continue only
penicillin and chloramphen-icol, and discontinue all other antibiotics.
Later in the morning, the patient was seen by the infectious-disease
consult, which concluded that the agitation and unresponsiveness were
almost certainly secondary to gastrointestinal disorders and metabolic
problems. The elevated enzymes could be the consequence of insufficient
oxygen and shock, present at admission. However, they noted that the
elevated alkaline phosphatase and elevated uric acid were unexplained.
They suggested the possibility, previously unconsidered, of staphylococcal
food poisoning.
Since no information could be obtained directly from the patient, his
wife was closely requestioned about symptoms of thyroid disease, or
longstanding diarrhea or other GI problems. The paregoric that the patient
had taken on the day of admission was brought into the hospital and
checked; it was, indeed, paregoric.
During this period the patient was examined by Dr. Alexander Leaf, the
chief of medicine, and Dr. Daniel Federman, the assistant chief, as well as
by a large number of other physicians, in an informal brainstorming session.
Every conceivable diagnosis, including mushroom poisoning and cholera,
was considered at this time.
The patient's condition remained unchanged.

Day 3

Continued problems with oxygenating the patient's bloodstream

produced a consultation by the respiratory unit, which advised drying the
lungs as much as possible, naso-tracheal suctioning, encouraging coughing,
and close monitoring by arterial blood gases. The patient improved
somewhat during the day, becoming less wild. That evening, for the first
time, he responded to his name.

Day 4

The patient was more alert. He was seen again by the surgeons, who
noted his abdomen was still soft, without any indications for surgery. His
dose of Valium, to contain his agitation, was reduced.

Day 5

He was seen in the morning by the neurological consults, who felt that
he was "still quite ob-tunded," confused and disoriented. Nonetheless his
progress since admission was striking. He could answer questions. When
asked where he was, he said, "the hospital," though he could not specify
which one. When asked his name, he said, "John." He could state his age.
He was taken off Valium entirely. His temperature continued to fluctuate in
the range of 99°-101°F. Dr. Minna wrote: "He is better in all ways."

Day 6

Lab values, back from the day before, continued to climb. CPK had now
gone to 2900, the highest in the history of the hospital. There was still no
explanation for these enzyme changes. The patient continued to improve in
alertness and responsiveness, though his mental function was far from
satisfactory. In answer to questions, he said that one plus one was "one,"
and two plus two was "five."
 Day 7

He was able to carry out verbal commands such as "Squeeze my hand"

and "Open your eyes." However, for the most part he lay in bed with his
eyes closed; he initiated little spontaneous activity, and never spoke except
in reply to questions.

Day 8

His Foley catheter was removed. He was able to urinate in the normal
manner. He was more active mentally, and remembered his last name, for
the first time.

Day 9

Blood cultures now revealed growth of a gram-negative bacillus,

identified as Bacteroides, probably of bowel origin. The patient was
sufficiently improved that he could be questioned about toxins, drugs,
mushrooms, work exposure, and possible ingestions of heavy metals; there
was no evidence for any of these. He was seen again by surgeons, who
concluded that his abdomen was soft, with normal bowel sounds.

Day 13

Barium enema was repeated, looking for diver-ticulitis or other sources

of infection. None was seen.

Day 10

He was seen by the neurological consults, who observed mild proximal

muscle weakness and suggested study of the electrical activity of the
muscles, by electromyography. He was also noted to have mushy swelling
of his extremities.

Day 14

Electromyography was normal. It was decided to discontinue his

chloramphenicol antibiotic and see if he remained without fever.
 Day 15

Chloramphenicol was stopped. The patient did well, taking liquids by

mouth.

Day 11

The patient's mental condition continued to improve. A repeat kidney X

ray was read as normal.

Day 16

On his second day off antibiotics, his temperature fluctuated in the

range of 1000-101°F.

Day 12

There was continued improvement. Enzymes had dropped to near-

normal levels. He had no fever.

Day 17

The patient had an upper gastrointestinal series of X rays, which were

normal. On his third day off antibiotics, the temperature began to spike
again, to 102°. Tenderness and guarding of the right-upper abdomen
reappeared.

Day 18

The surgeons concluded that the patient had cholecystitis, or infection

of the gall bladder, which had probably begun initially as cholangitis,
infection of the bile system. They also wondered, however, whether he
might have a liver abscess. The patient was put back on antibiotics.

Day 19

Mr. O'Connor was transferred from the medical service to the surgical
service as a pre-operative candidate for exploratory abdominal surgery. His
mental state continued to clear slowly.

Day 20

The neurological consult saw him and agreed his mental status was
improving. The surgeons, moreover, found that his abdominal tenderness
had disappeared with the antibiotics. X rays of the gall bladder showed no
filling of the bladder sac, but the films were of poor quality. Radioactive
scans of the liver and spleen were negative.

Day 21

The scheduled operation was canceled in order to allow time for further
pre-operative studies. A repeated gall bladder X ray definitely showed no
filling, although this time the films were of good quality. A celiac
angiogram was scheduled.

Day 22 and Day 23

The weekend. Specialized procedures such as celiac angiography could

not be done, and further work on the patient was postponed until Monday.

Day 24

Celiac angiography was performed. Under local anesthetic, a thin,

flexible catheter was passed up the femoral artery in the leg, to the aorta,
and finally to the celiac axis, a network of arteries coming off the aorta to
supply blood to all the upper-abdominal organs. A dye opaque to X rays
was injected, and the vessels studied. No space-occupying lesion (tumor)
was found and the vessels were normal in appearance. The patient made a
good recovery from the procedure.

Day 25

The abdomen was soft and non-tender. The patient felt well. He was
still on chloramphenicol. Enzymes were, by now, fully normal.

Day 26
 The patient had no fever and felt well. The surgical staff decided to stop
antibiotics and see if the fever and symptoms recurred. was now clear that
he was not an operative candidate. Plans were made for his discharge the
following day.

Day 27

He was taken off antibiotics. Temperature and white cell count

remained normal. The patient himself was in good spirits.

Day 28

There was no demonstrable worsening of the patient's condition on his

second day off antibiotics. His wife expressed the opinion that his mental
state was entirely normal once more.

Day 29

His condition remained stable on the third day. He said he felt well. He
had no fever and no elevation in white count.

Day 30

His condition was still good; his abdomen was soft without tenderness.
He said he felt well. It

Day 31

Discharged. His discharge diagnosis was fever of unknown origin with

bacteroides septicemia. The opinion of the house staff remained that this
patient had probably had a bile-collecting-system infection.
Five days after discharge, he was seen in the surgical clinic by Dr. Jack
Monchik, who scheduled another set of gall bladder X rays for the future,
and noted that if the patient had further trouble with infection, it would
probably be necessary to remove the gall bladder. For the moment,
however, the patient was fully well.
"To do nothing," said Hippocrates, "is sometimes a good remedy."
 On the surface, Mr. O'Connor's hospital course seems proof of this
ancient dictum of "watchful waiting." But this is not really so: had Mr.
O'Connor received no treatment, he would almost certainly have died
within twenty-four hours. He received vital symptomatic therapy (lowering
his fever) as well as acute support of vital functions (assisted respiration).
He was closely monitored by teams of physicians who were prepared to
intercede in his behalf, supplying more assistance should his body require
it.
He also received a vigorous diagnostic work-up, which did not produce
as much information as one might like. His therapy was successful, but no
physician at the hospital could claim, at discharge, that they really knew
what was going on in his case. A diagnosis of cholangitis and cholecystitis
was likely, but never demonstrated.
His hospital bill for a month of care was $6,172.55. This is just a few
dollars less than Mr. O'Connor's annual salary. But he did not have to worry
about it; unlike most patients with some form of health insurance, Mr.
O'Connor had coverage that was essentially complete. His personal bill
amounted to $357.00.
In this, as in many other things, Mr. O'Connor was a very lucky man.
The single most important problem facing modern hospitals is cost. This
cost can be analyzed in a variety of ways, most of them confusing and
unhelpful. But the following points are clear:
First, the cost of hospitalization has skyrocketed. The average MGH
patient today pays per hour what the average patient paid per day in 1925.
Even as recently as 1940, a private patient could have his room for $10.25
per day; by 1964, it cost $50.10 per day; by 1969, $72.00-$ 110.00 per day.
This staggering increase is continuing at the rate of 6 to 8 per cent per year.
Each year
1SUOD 10000 0
195*60 13510 D
One portion of Mr. O'Connor's 17-fooMong bflfc
for the past three, the MGH has had to raise its charges. Nor is the
teaching hospital unique in its financial squeeze. All American hospitals are
raising their charges at this same rate.
Second, hospitalization cost has increased much more rapidly than other
goods and services in the economy. Medical care is the fastest-rising item in
the consumer price index in recent years, and per day hospital cost accounts
for the largest proportion of this increase. [Physicians' fees have also been
rising faster than other items in the consumer price index. However,
hospital costs have been nearly doubled in the past decade, while
physicians' fees have increased 30 per cent].
Third, the individual contemplating hospitaliza-tion no longer worries
much, in a direct way, about cost. Third-party payment has led to public
apathy about hospital costs, and this is unwise-if for no other reason than
the fact that most people have only one fourth to one third of their costs
paid by insurance, a fact they discover late in the game.
Fourth, the often overlapping coverage of health insurance permits
some patients to make money from their hospitalization, while welfare
reimbursements are always less than the true costs of care. In this situation,
the hospital makes ends meet by overcharging private patients and their
insurance companies to cover the welfare deficit-in the case of the MGH,
roughly $10 a day overcharge.
Fifth, no single hospital stands alone in its financing problems, but
rather is influenced by the activity or decline of other hospitals in the area.
The decay of the Boston City Hospital, and its reduction in size to nearly
half its earlier patient capacity, has created great pressure upon other Boston
hospitals to take up the slack-by accepting precisely those patients on whom
the hospital loses money, namely, patients covered by welfare.
The decline of Boston's municipal, tax-supported hospital is similar to
the decline of other such institutions in other American cities. In each case,
the reasons behind the decline are political and financial, but the
consequences are always the same-to pass on costs to insured patients, and
make them augment insufficient tax funding for welfare. In the long run, of
course, it all works out to the same thing: one can either pay the money in
taxes or in higher health-insurance premiums. But in such a situation, it is
probably more efficient to choose one or the other-and the trend
unmistakably is toward universal health insurance in this country. Dr. John
Knowles notes that many Americans are required by law to arrange
insurance for their cars; why should they not also be required to arrange
health insurance for themselves?
Sixth, lest private health insurance seem a financial panacea, one should
note that private companies are often irrational in their payment procedures.
For example, for many years one could not collect for certain treatments-
such as the setting of fractures-unless one were admitted to the hospital, at
least overnight. Thus a person who might easily receive therapy in the EW
and be sent home had to be admitted in order to receive insurance coverage.
This unnecessary admission raised the total cost of health care, and
ultimately such increases are passed on to the consumer in the form of
higher premiums. Some of these odd payment procedures have been
changed, but not all.
Seventh, the American medical system in its full spectrum-from the
private specialist's office to the municipal hospital wards-has never been
able to structure the kind of competitive situation that encourages and
rewards economies. Nor has American medicine tried. The American
physician has been grossly irresponsible in nearly all matters relating to the
cost of medical care. One can trace this irresponsibility quite directly to the
American Medical Association.
For the past forty years, the American Medical Association has worked
to the detriment of the patient in nearly every way imaginable; it is a
peculiarity of this organization that it has worked to the detriment of
physicians, as well. Dr. James Howard Means has said: "Its ideology is very
like that of the big labor unions… it has now set up a continuing political
action committee quite like those of the fighting labor unions. Every
attempt that has been made by liberally minded groups to improve medical
care and make it more accessible… the AMA has attacked with ever
increasing trucu-lence… They forget perhaps that medicine is for the
people, not for the doctors. They need some enlightenment on this point."
The truculence of the AMA has been expensive. In terms of the
modern-day cost of medical care, we may cite the following points.
Beginning in 1930, it opposed voluntary health insurance, such as Blue
Cross. In 1932, it opposed prepaid group-practice clinics. In 1933, it began
a successful campaign to block the construction of new medical schools and
limit enrollment in those already in existence. We now have a shortage of
doctors. More recently, the AMA spent millions-probably no one knows
exactly how many millions-to fight Medicare, a program that resulted in
health benefits to 10 per cent of the population and vastly increased income
to physicians. (Indeed, a good gauge of the AMA's shortsightedness can be
gained by imagining the outcry from private doctors should anyone now try
to repeal Medicare.) Further, the AMA has failed to take any strong stand
on prescription pharmaceutical prices in this country, which nearly every
objective observer regards as grossly inflated. And more insidiously, the
AMA has permitted what may politely be called blind spots in health care.
The Journal of the American Medical Association refused to print a
government study of combination-antibiotic drugs which concluded that
many of these expensive medications are either worthless or dangerous; the
AMA has still failed to condemn cigarette smoking despite overwhelming
evidence that this habit, though profitable to certain industrial groups, is
directly responsible for much disease, suffering, and medical expenses in
this country.
One can only conclude that the American Medical Association has not
considered the interests of patients for forty years, or perhaps longer. On the
basis of its record, it is opposed to both better and cheaper medical care. Its
only commitment is to the doctor's bank account-and even then, it makes
astonishing errors in judgment.
In 1967, in his inaugural address, Milford O. Rouse, the incoming
president of the AMA, deplored the growing sentiment in this country that
medical care was a right, not a privilege. His opinion was not well received
by an angry public, and later presidents have been more circumspect in
voicing their views. Nonetheless, it is customary for AMA presidents to
travel about, speaking to groups of doctors, applauding what they call "the
phenomenal growth of the health industry."
That growth cannot be questioned. Personal consumption expenditures
for medical care rose from $7.5 billion in 1948 to over $27 billion in 1965,
and more than $50 billion in 1968. By 1975, it is expected to reach $100
billion or more. This is the sort of news to make a Wall Street broker squeal
with delight. But medicine is a service, not an industry, and one really ought
to look at it differently.
In fact, the United States spends more of its gross national product (6.2
per cent) on medical care than any other country in the world; it spends a
larger absolute sum than any other country in the world. Yet by most
objective standards of health- infant mortality, life expectancy, and so on-it
is far from the leader.
Other countries are doing better, and most of them have some form of
socialized medicine. The United States is extraordinarily backwards in this
respect. However, many clear-headed American observers have looked at
European socialized systems and have come away shaking their heads; and
there is a widespread doubt whether any European system can be adapted to
this country. Very likely, America will have to work out its own system. The
combination of group insurance with a group-practice system (essentially
the system at Kaiser and others) seems a feasible, economical, and practical
method, acceptable both to doctors and patients.
Without question, the notion of the doctor as a legitimate fee-for-service
entrepreneur, making his fortune from the misfortunes of his patients, is
old-fashioned, distasteful, and doomed. It is only a question of time.
Ultimately, however, it is not useful to lay blame, whether on
physicians, health-insurance administrators, politicians, or an apathetic
public. For they all seem to share a common blindness-a total failure to
understand why hospital costs are rising. In 1967, the average cost of a
hospital room in America increased 15 per cent. What is happening?
The per-day room charge is the largest single item in the hospital bill.
There are many ways to break down this charge-as many ways as there are
accountants-but the clearest is the following.
In 1969, the cost of a semi-private room at the MGH was $70.00.
Breaking this down, we find:

Per-Day Room Charge: $70.00

Utilities, housekeeping, maintenance,
plus business offices ("hotel expense") $ 6.96
Food and special diets 5.82
Nursing 18.42
Labs, records, house staff,
X rays, and pharmacy 28.80
Overcharge (to cover welfare debts) 10.00
Total $70.00

Now this breakdown contradicts one of the oldest complaints about

hospitals, as quoted in a national magazine: "My work puts me in contact
with hotels and hotel management and I know that a good hotel can give
you a beautiful room for $30.00 a day, with three meals, and make a profit
and pay taxes. And yet any hospital, which doesn't pay any taxes, operates
in the red for $65.00 a day. I say it must be poor administration."
If the analogy were true, the conclusion would be correct. But the
hospital is not a hotel-and in any case, its "hotel" costs are quite reasonable
at $6.96 a day; this is approximately half the cost of a decent motel room in
Boston. The charge of $5.82 for food, or approximately $1.95 a meal, is
equally reasonable, especially when one considers that as a restaurant the
hospital must provide an extraordinary range of services, including some
eighty special diets.
The true hospital costs-the expenses incurred in a hospital but not in a
hotel-are, on the other hand, very high. They account for 82 per cent of the
total per-day room charge. And the question, really, is whether these
charges are reducible. No sensible businessman would bother to try to get
his hotel and food costs below thirteen dollars a day; if there is to be a
decrease in costs, it must come from the non-hotel charges.
These in turn largely reflect the increased technological capacity of the
hospital. Mr. O'Connor's example is a case in point: most of the tests
performed on him were not available in 1925, when he could have had his
room for one twenty-fifth of what it cost him today. The maintenance of
this new technological capability costs money-and to a large extent, in
medicine as in education, law enforcement, sanitation, and a variety of
other services, you get what you pay for. If you are going to enter a high-
quality acute-care facility that has six employees (most of them non-
physicians) for every patient, and if you are going to pay these employees a
decent wage, then your care will be expensive [All this is sometimes easier
to see if it is taken out of the hospital setting. If a man had to hire six
secretaries for an eight-hour day, at $2.50 an hour, it would cost him
$120.00 a day. If a man had to hire two gardeners at $4.00 an hour, for a
single eight-hour day, it would still cost him $64.00 a day]. If you are going
to purchase technological hardware, maintain it, and keep it up to date, this
costs money. If you are going to keep the hospital in continuous operation
twenty-four hours a day, three hundred sixty-five days a year, this costs
money.
All this becomes clear in the instance of a simple procedure such as a
chest X ray. A private radiologist in his office will perform this for you at
one half or one third of what the hospital charges. His charge largely
reflects the fact that his unit can operate on an eight-hour day and a forty-
hour week; other costs, such as equipment and supplies, are the same. In
medicine today-as in every other industry-people are more expensive than
anything else. Sixty-three per cent of the hospital budget now goes to the
salaries and benefits of employees. And much of the rise in hospital costs is
directly attributable to the demand of these employees that they not be
personally forced to subsidize the health business by accepting wages
incommensurate with similar jobs in other industries. Their demands are
justified; most employees are still underpaid. Their salaries will increase in
the future.
One cannot, however, fairly claim that hospitals are superbly efficient.
Especially in a teaching hospital, attention to cost in the medical, non-hotel
sector is less central than one would like it to be. One can argue about
whether too many tests are ordered, and the argument can continue
endlessly. But certainly, when physicians who order these tests don't know
what patients are charged for them, eyebrows must go up. In general,
doctors tend to operate on a "spare no expense" philosophy which will,
eventually, need to be tempered.
But, more fundamentally, the present cost structure of the hospital
seems to lead to a rather old-fashioned conclusion: no one should go there
unless he absolutely has to.
If a diagnostic procedure can be done on an ambulatory, out-patient
basis, it should be; if a series of tests and X rays can be done outside the
hospital, they should be. No one should be admitted unless his care
absolutely depends upon being inside the hospital; no one should be
admitted unless he requires the hour-to-hour facilities of the house staff, the
nursing staff, and the laboratories.
For decades, admission to the hospital was necessary because there was
no other facility available. For a large segment of the population, care was
either given in the hospital, or not at all; and the hospital's clinic system was
a poor compromise, with hordes of patients being brought in to wait hours-
sometimes literally days-to have relatively brief tests performed.
There is hope that the satellite clinics will help solve the problem; one
study of a satellite clinic in Boston reported that there were fewer hospital
admissions as a result of the clinic's work.
In any case, alternative facilities must be found, because it is unlikely
that hospital costs will ever go down. The best anyone can hope to do in the
foreseeable future is to stabilize them somewhere in the neighborhood of
$100.00 a day. This makes the hospital an expensive place-but it has its
uses, and indeed will be an economically tolerable place, if it is used
appropriately.
 Peter Luchesi. Surgical Tradition
At 3:15 p.m., the emergency ward was notified that a patient was being
transferred in from an outlying hospital: a young man with a nearly severed
arm resulting from an industrial accident.
He arrived an hour later and was seen first by Dr. Hopkins, the triage
officer, who ordered him sent to OR 1. The surgical residents, Drs. Eugene
Appel and Terry Mixter, were called to examine the new patient.
He was twenty-two years old, of medium height and muscular build,
looked quite pale, and was speaking weakly. His left hand was bandaged
and splinted. An intravenous line had been inserted in his right arm, but it
had infiltrated. There was also a bandage over his chin. The bandages were
removed and a new intravenous line started. He had a moderately deep two-
inch laceration in his chin; the medical student, Sue Rosenthal, was called
to suture it. Meanwhile, Appel and Mixter turned their attention to the
injured arm.
Three inches above the left wrist the forearm had been mashed. Bones
stuck out at all angles; reddish areas of muscle with silver fascial coats were
exposed in many places. The entire arm above the injury was badly
swollen, but the hand was still normal size, although it looked shrunken and
atrophic in comparison. The color of the hand was deep blue-gray.
Carefully, Appel picked up the hand, which flopped loosely at the wrist.
He checked pulses and found none below the elbow. He touched the fingers
of the hand with a pin and asked if Luchesi could feel it; results were
confusing, but there appeared to be some loss of sensation. He asked if the
patient could move any of his fingers; he could not.
Meanwhile the orthopedic resident, Dr. Robert Hussey, arrived and
examined the hand. He concluded that both bones in the forearm, the radius
and ulna, were broken, and suggested the hand be elevated; he proceeded to
do this.
Outside the door to the room, one of the admitting men stopped Appel.
"Are you going to take it, or try to keep it?"
"Hell, we're going to keep it," Appel said. "That's a good hand."
The patient was started on two grams of cephalothin antibiotic
intravenously, and was given more tetanus toxoid. He had received pain
medication at the other hospital, and so far had not requested more.
As a workmen's compensation case, the operation would be done by
private surgeons: Dr. Hugh
Chandler for orthopedics, Dr. Ashby Moncure for general surgery. At
5:15, Moncure arrived and looked at the hand, satisfied himself that it was
indeed viable, and put the patient on call for the operating room. He also
called Chandler and summarized the case: "It's a circumferential crush
injury to the left hand with compound fracture of both radius and ulna.
Innervation and arterial supply look pretty good."
Meantime, the portable X-ray machine was brought in to take a chest
film, and two views of the injured hand. The medical student finished
suturing the chin laceration. Moncure came back to check that a sample had
been sent to the blood bank. He then went off to try to hasten scheduling for
the operating room.
At 5:30, the patient complained for the first time of pain in his hand.
The surgeons were debating what pain medication to give him when a nurse
came in to say the patient was on call to the OR and would get pre-
operative medication. He received atropine, Nembutal, and Demerol, which
settled the question of pain medication.
Dr. Hussey, looking at the now-elevated hand, concluded that it
appeared a little better; the color had improved. He wrapped the injured
area in soft gauze, and went off to the X-ray unit to examine the films. He
went directly to the residents' reading room, a cubicle with lighted, frosted
glass walls for examining X rays. The resident was busy reading other
films; Hussey went back into the developing room, past signs which
forbade him to do so, to get Luchesi's films. A female technician scolded
him; he said he was in a hurry.
He gave the films to the radiologic resident, who put them up and
dictated: "Unit number zero zero six, AP and lateral of the left forearm.
There is a transverse fracture of the radius in the distal third, as well as the
ulna, period. Numerous fragments of bone are scattered around the fracture
site, period. Considerable soft tissue swelling…" Here he stopped, realizing
Hussey was impatient. "Chest film normal," he dictated, and gave them all
to Hussey, who returned to the patient and supervised his transport to the
operating room on the third floor.
It was now six o'clock. The operation was scheduled for 6:15, at which
time on the OR blackboard was written:
 KM 7 PVT. SERVICE SEVERED ARM MONCURE/CHANDLER
In the operating room, Dr. Brian Dalton, the first of three anesthetists
who would work during the six-hour procedure, was administering an
axillary block, injecting lidocaine (a novocaine-like drug) deep into the
armpit, to dull, during the preparation, sensation in the nerves that ran out to
the hand. While this was being done, Moncure discussed the operation:
"What we're going to do here is stabilize his bones, and then deal with soft
tissues as need be. I think we'll find a lot of crush damage to muscle bellies,
particularly flexors, but intact vessels and nerves." He observed that while
clinically there was questionable nerve damage, a crush injury could
produce this without any actual cutting of nerve fibers; under such
circumstances the damage was probably fully reversible.
At 6:10, while the axillary block was being administered, Hugh
Chandler, the orthopedic surgeon, arrived and looked at the X rays. He said
that he would stabilize one bone, the radius, and worry about the other, the
ulna, later. Moncure was outside the OR, scrubbing according to the MGH
version of the ritual: three minutes of washing to the elbow with a hard
bristle brush, using orange sticks to clean under the nails, followed by a
dunking to the elbows in an alcohol-germicidal solution. When he finished
his scrub he came in, put on a pair of sterile rubber gloves, and began to
wash the arm with a safety soap and alcohol. The nerve block was
beginning to take effect, and it was possible to move the arm less gently
without hurting the patient.
The patient was still awake, but dazed. He stared at his arm curiously, as
if it did not belong to him. Moncure asked him how it had happened. Peter
Luchesi explained that he had been working in a private shipyard and a
boom had fallen on him. It weighed seven hundred pounds and it had struck
his shoulder glancingly, knocking him overboard. But as he fell, the boom
had somehow landed on his hand, leaving him dangling over the side, with
his hand pinned down. This was just after lunch. The other workmen were
not on the boat, so Luchesi had managed to get back up on the deck alone,
and attempted to lift the boom. He could not do it without help. Fifteen
minutes passed before the others arrived and were able to lift the boom.
He delivered the entire story in a monotone, while he stared at his hand.
Moncure asked him how it felt now, and he said it was beginning to hurt
again. As the surgeons began to drape the injured arm with sterile cloths,
which entailed considerable manipulation of the hand, he complained more.
The axillary block was not working well. With all preparation made, now
was the time to produce general anesthesia.
Dalton, the anesthetist, leaned over Luchesi and said: "I'm going to put
this mask over your face. You'll breathe only oxygen. Then I'll give you an
injection that will make you fall asleep. Don't worry about a thing, just
breathe and relax."
Luchesi nodded. The mask was put over his face and he breathed,
staring up at Dalton, who proceeded to inject pentathol intravenously.
Luchesi blinked once and closed his eyes. He was sleeping soundly, but
would continue to do so for only a few minutes. Then he would wake up,
unless more pentathol, or a different anesthetic, was administered.
Luchesi was fed pure oxygen for several moments, to be sure he was
fully oxygenated. Then Dalton injected succinylcholine, a substance that
paralyzes the entire body-including respiratory muscles-briefly. He removed
the mask, opened the mouth, squirted a jet of cocaine down the throat to
anesthetize the windpipe and prevent reflex coughing, and slipped a tube
down the mouth into the windpipe. This provided a direct channel from the
mouth into the windpipe and lungs, and prevented a major cause of death
from anesthesia, namely, vomiting up of food from the stomach and
blockage of the windpipe with this material.
The entire process of intubation took only a few seconds. Once
intubated, Luchesi was fed oxygen and nitrous oxide, a mild anesthetic.
Alone, nitrous oxide would not provide sufficiently deep anesthesia to
permit surgery, but the axillary block was also helping. When it wore off,
halothane, a more potent gas, would be added.
The operation began shortly before seven. There were seven people in
the operating room at that time. Five were scrubbed: Moncure and
Chandler, sitting on one side of the outstretched hand; Dr. Charles Brennan,
an orthopedic resident, and Steven Kroll, a medical student, on the other
side; and the scrub nurse, standing with two trays of instruments at her
fingertips. Also in the room but not scrubbed were the anesthetist and the
circulating nurse.
Around the hand, it was tight quarters. The scrub nurse first pinned
sterile towels across the backs of Moncure and Chandler; this was because
the upper-most portions of their backs, where the sterile gowns were tied,
were unsterile, and she did not want to touch them by accident.
 In general, the operating room is divided conceptually into "clean" and
"dirty" areas. The operative field, meaning the exposed area of skin which
has been shaved, scrubbed-and generally covered with plastic-is clean. The
rest of the patient, covered with sterile drapes, is dirty. The fronts of the
surgeons are clean; their backs are dirty. Anything above the level of the
table is clean; anything below is dirty, and surgeons never let their hands
fall to their sides. Hands, scrubbed and rubber-covered, are clean; faces,
capped and masked, are dirty, and it is poor form to get one's face too close
to the operative field or to touch one's mask with one's gloved hand.
The first incision was made over the underside of the wrist, just back
from the thumb. The object was to find and locate the radial artery in that
area. Moncure and Chandler discussed their procedure as they went, and
agreed to find and evaluate the principal structures first: the radial and ulnar
arteries, which run toward thumb and little finger respectively; the radial
and ulnar nerves, which run with the arteries; and the median nerve, which
enters the hand at mid-wrist.
As they began work, they found that the crush injury, with its
hemorrhage and swelling of tissues, made identification of structures
difficult. Five minutes into the operation, the radial artery was accidentally
nicked. A fine, thin stream of blood spurted up in a foot-long arc. This was
quickly clamped, and Moncure sewed it up with a small needle, perhaps no
larger than twice the size of a typewriter parenthesis mark, and the
operation proceeded. Moncure isolated the radial artery for a distance of
several inches through the wrist. Everyone commented on the fact that
pulsations through the artery were not as strong as they would like. The
artery was flushed with heparin to prevent clotting further along its course
in the hand.
At 7:20, Dr. Leslie Ottinger, another surgeon, entered the operating
room. He had been working next door in OR 8 for six hours, repairing a
crush injury to a man's thigh. Moncure, without looking up, said to
Ottinger: "Were your vessels intact?"
"No," Ottinger said. "The femoral artery and vein were completely
crushed. They were separated by three centimeters." "How's he doing
now?" "Fine," Ottinger said, "if he stays open." He watched the dissection
of the hand for some moments. "You find the radial artery yet?" "We nicked
it," Moncure said. "Well, that's a good way to find it," Ottinger said, and
left.
 As the operation progressed, Moncure noted that the surgical field was
more bloody. He felt the radial artery and concluded that it was pulsating
more fully now.
By eight o'clock, the contrast between the area of surgical dissection
and the area of crush injury was clear. One was clean and smooth, nicely
exposed, bleeding very little; the other was mashed and oozing blood.
Moncure, still working, glanced up at the clock and said: "Ottinger and I
had a squash game for eight o'clock. We both ended up here. That'll teach
us."
The operation itself proceeded slowly, impeded by the difficulty of
identifying structures within the injured area. When damaged, a tendon,
vein, and nerve can all look remarkably alike, but identification must be
made with certainty. Nearly any vein in the body can be cut without
consequence; to cut a tendon is an irritation, but not irreparable; to cut an
important nerve is a disaster of major proportions.
Eventually all the structures were identified. All were found to be intact
except for the ulnar artery, which was completely torn. The muscular coat
of the artery was in spasm, pinching it off; the ends were clipped for the
time being, and Chandler took over to begin work on the bones.
His first decision was to shorten the left arm by half an inch. This was
necessary because there was a fragment missing from the ulna, and both
radius and ulna had to be the same length. Also, shortening would make
repair of tendons easier. He pointed out that this shortening would not be
noticeable to the patient or anybody looking at him.
He began by filing the ends of the radius smooth and then joining them
together with a vitalium plate, made of an alloy of cobalt, chromium, and
molybdenum. It is electrically neutral and well tolerated by bone and the
tissues around it. Screwing the plate onto the bone was difficult; it was not
completed until 10:30.
Meanwhile, the anesthetist had been making some changes. "The
axillary block has worn off by now," he said. "So we're supplementing the
nitrous oxide with halothane in low concentrations. If he needs more for
pain, we'll raise the halo-thane." He indicated that he could judge the need
for anesthetic by watching the patient who, while not waking up, would
become restless and would breathe irregularly if he was "too light."
"The idea," he said, "is to give the minimal anesthetic necessary to do
the job, and to give it in such a way that the patient wakes up as soon as
possible after the operation."
After Chandler repaired the radius, Moncure resumed vascular and soft-
tissue reconstruction. He first re-examined the radial artery and decided it
was not flowing as well as it should, as judged by squeezing the artery wall
and feeling the pulsations. To make certain it was clear, he called for a
small Fogarty catheter. This is a small, flexible tube with an inflatable
rubber bulb at one tip. From the opposite end, water can be injected into the
tube, and the bulb will expand. Thus the catheter can be inserted down an
artery, and the bulb inflated within the artery. It can then be drawn back
while inflated, and in doing so, it will clean out the inner wall of the artery,
removing clots and other obstructions.
The Fogarty catheter is a relatively new device, named for its inventor, a
surgeon at Stanford Medical Center. The discussion that ensued is typical of
medicine in the modern day. So many developments and products are
becoming available that it is difficult for anyone to keep track.
Moncure: "Get me the smallest Fogarty you have."
The circulating nurse came back with one. "This is a number four."
Moncure: "Let's have a look at it." He removed it from its plastic
container; it looked too large. "Are you sure you haven't got something
smaller?"
Scrub nurse to circulating nurse: "I know we have a six, at least."
"But a six is larger than a four," the circulating nurse said. She said it
hesitantly, since numbers to designate sizes do not always run the same
way. For instance, urinary catheters and nasogastric tubes run in proportion
to size-a number fourteen is larger than a number twelve. But needles and
sutures run in the opposite direction: an eighteen is much larger than a
twenty-one needle. "Well, see if there's something smaller." It turned out
there wasn't. Moncure meantime had made a small cut in the artery wall,
and had found he could slip in the number four Fogarty without difficulty.
He inflated the bulb, drew back, and found that the subsequent pulse was
much improved. He sewed the cut shut, and felt the pulse. "Bounding now,"
he said.
He directed his attention to the ulnar artery, which had been completely
severed by the injury. The ulnar was smaller than the radial artery; it was
about the size of a pencil lead. As Moncure began to sew the ends together
with fine sutures, he said, "Microsurgery. Watchmaking." It was now 11:30.
He sewed it quite quickly, and the remainder of the operation, which dealt
with larger structures, went rapidly. The tendons that had been torn were
resewn. A heavy pin was run down the hollow interior of the ulna. By
12:30, the surgeons began to close.
It had been known from the outset that the wound area could not be
completely closed. The tissues were damaged and swollen; to pull the skin
tight across it would compress the arteries and cut off circulation to the
hand, negating all the efforts of surgery. The incision was therefore only
partially closed, with an area of the inner wrist left open. This area was
expected to close by itself, to a degree, and to scar over for the remainder;
after four or five days, they would reevaluate the area to consider skin
grafting. The surgeon's major concern was infection. It was decided to
continue the patient on cephalothin.
The operation was finished at one in the morning. The patient awoke in
the operating room and was taken to the recovery room. For the first
twenty-four hours, he was kept heavily sedated, but by the third day his
pain was considerably less. Two weeks later he was discharged from the
hospital. Two months later, on an office visit, Moncure found that the
patient had essentially full function and sensation in the nearly severed
hand.
The growth of modern surgery within the hospital is chiefly attributable
to three factors. The first is the discovery of anesthesia. The second is the
introduction of aseptic techniques. And the third, much more recent, is the
improved medical understanding of the patient, with attendant
improvements in pre-operative and, especially, postoperative care.
Consider anesthesia first. One hundred and three years before Peter
Luchesi's hand was sewn back on, John C. Warren wrote: "Surgery has
ceased to be the spectacular occupation it once was." It is impossible to
miss the regret in his words, but he did not mean it regretfully, for he was
talking about the difference anesthesia had made to surgery.
It is hard to imagine how ghastly, dangerous, and hasty surgery was
before anesthesia. In Warren's own recollection:
In the case of amputation, it was the custom to bring the patient into the
operating room and place him upon the table. [The surgeon] would stand
with his hands behind his back and would say to the patient, "Will you have
your leg off, or will you not have it off?" If the patient lost courage and said
"No," he was at once carried back to his bed in the ward. If, however, he
said "Yes," he was immediately taken firmly in hand by a number of strong
assistants and the operation went on regardless of whatever he might say
thereafter.
Relief from pain was not the only benefit of anesthesia. Equally
important was muscular relaxation, which prior to ether was produced as
follows: "In the case of a dislocated hip, where it was necessary to effect
complete muscular relaxation, an enema of tobacco was freely
administered, and while the victim was reduced to the last stages of collapse
from nicotine poisoning the dislocated femur was forced back into its
place."
One might expect this deplorable state of affairs would lead surgeons to
search for ways to kill pain and to be constantly alert for new drugs that
might accomplish the job. But in fact this did not happen: pain-killing drugs
were known for forty years before they were applied to surgery. If, as
Poincare says, discovery favors the prepared mind, doctors must be counted
strangely unprepared. Briefly, the story is this:
Nitrous oxide was isolated by the English chemist Joseph Priestly in
1772. Around 1800, another Englishman, Humphrey Davy, experimented
with the gas, noted its exhilarating and pain-killing properties and suggested
it might be used in surgery. The suggestion was ignored. Instead, "laughing
gas" became a popular form of amusement on both sides of the Atlantic. In
1818, ether was found to have the same effects as nitrous oxide. Soon
thereafter, "ether frolics" came into vogue, especially among medical
students and house officers-indeed, a whole generation of young doctors
toyed with immortality, but missed the point. The observation was
repeatedly made that one could bruise himself while under ether and have
no recollection of the cause later, but no one connected the phenomenon to
surgical applications. The blindness of these young men is sobering. (It also
makes one think more highly of Alexander Fleming, whose culture dishes,
contaminated with mold, might have been thrown out. One wonders how
many hundreds of researchers before him had seen penicillin-producing
molds, and had attached no significance to them.)
To make matters worse, when ether was finally used successfully in
surgery by two men in 1842-Crawford W. Long in Georgia and Elijah Pope
in New York-neither publicized his work widely, and their work had no
impact on future events.
In 1844, Horace Wells, a Hartford dentist, painlessly extracted a tooth
with nitrous oxide. He immediately communicated this news to a former
dentist, then a Harvard medical student, William T. G. Morton. Morton in
turn obtained permission for Wells to come to Boston and demonstrate
anesthesia before the class of Dr. John C. Warren at the MGH. Wells did
this soon after, but apparently did not obtain sufficiently deep anesthesia
with nitrous oxide (which is, in any case, not a powerful anesthetic). At the
crucial moment, the patient screamed; the students hissed; Wells slunk off
in disgrace.
The idea of painless operation was abandoned as hopeless fantasy by all
except Morton, who later met a chemist named Charles T. Jackson. Jackson
suggested the use of ether instead of nitrous oxide; Morton found that it
worked and himself approached Warren for a chance to demonstrate the
method publicly. It is to Warren's credit that, despite a resounding failure
only a short time before, he agreed to a second trial under his auspices. This
occurred on October 16, 1846, in the hospital amphitheater under the
Bulfinch Dome.
It must have been a strange scene. Morton arrived late, permitting some
jokes about a last minute failure of nerve. The patient, a man with a tumor
under the jaw, sat in a straight-backed chair, facing Warren and the
assembled students, all wearing frock coats. Also in the room were articles
then considered fit decoration for an operating theater: a skeleton, a large
marble statue of Apollo, and a mummy from Thebes. A photographer was
also present, but according to a newspaper account, "the sight of blood so
unnerved him that he was obliged to retire."
Apparently the photographer was the only person to experience pain
that day, for the patient underwent deep anesthesia, made no sound during
surgery, and when he awoke, reported that he had felt nothing. Dr. Warren,
then sixty-eight years old, turned with tears in his eyes to the audience and
said, "Gentlemen, this is no humbug." [Morton, who anesthetized Warren's
patient, attempted to exploit his discovery for financial gain. He labeled the
ether "letheon" and tried to disguise its characteristic smell with various
aromatic oils, hoping no one would discover it was only ether. The ploy
failed and even the name was dropped when Oliver Wendell Holmes
suggested that "anesthetic" would be a better word.]
News of the operation spread with extraordinary rapidity. The first
English ether operation was done some ten weeks later; it was performed by
the noted surgeon Robert Liston, who first announced skeptically, "We are
going to try a Yankee dodge to make men insensible." Although the
anesthetic worked, Liston operated with his customary speed, single-
handedly amputating the leg at the thigh in exactly twenty-eight seconds.
The first important effect of anesthesia was to increase the number of
operations performed. The Undaunted, Morton then petitioned Congress for
an award for his discovery. The sum of one hundred thousand dollars was
suggested, but he never received it; almost immediately a Southern senator
put forward a claim in the name of Crawford Long, and Charles Jackson,
the Boston chemist, entered one of his own. Debate raged until the outbreak
of the Civil War turned the attention of Congress to other matters.
The aftermath of all this is depressing. Horace Wells, the Hartford
dentist, went insane, was jailed for throwing acid at two girls, and
committed suicide while in prison. Charles Jackson also went insane and
died in an asylum. William Morton died a forgotten pauper on a park bench
at the age of forty-nine. second was to lengthen the time of operation: the
split-second showmanship of Liston and many others became obsolete
overnight, and new standards of meticulous skill sprang up.
But problems were far from ended. Difficulty with infection remained
for many years afterward, until Joseph Lister in Scotland formulated his
antiseptic methods.
Within the hospital, cross-infection was commonplace for all patients.
But surgical patients, in the absence of sterile operating techniques, were
particularly prone to infection, and one effect of increasing the duration of
operations was to increase the opportunity for bacterial contamination of
the wound. Thus, in the decades after the introduction of anesthesia, the
chief cause of surgical mortality was infection. [The great majority of
surgical incisions became infected afterward and surgeons spoke favorably
of "laudable pus" in the wound. But as Edward D. Churchill has said, 'To
intimate that surgeons before Lister expected all wounds to suppurate and
pour forth 'laudable pus' is to underestimate the intelligence of generations
of shrewd observers over the course of centuries… Hippocrates taught that
dead flesh in a wound must turn to pus, but Theodoric as well as
Mondeville [two medieval surgeons] expected incised wounds, in which
dead tissue is customarily minimal, to heal without suppuration as a matter
of course. In Lister's own century, at the Battle of Waterloo, it was generally
agreed among English surgeons that if the edges of clean-cut saber wounds
were drawn together by adhesive straps, healing would be accomplished
without suppuration. Listerism could not, nor did it pretend to, eliminate
suppuration arising in contaminated dead tissue… The principle of excision
of dead tissue (debridement) as the initial step in wound management
finally emerged in the 1914-1918 war."]
There was confusion about infection caused by crosscontamination,
from wound infection, and from decomposition of dead tissue within the
wound. In the absence of clear understanding, hospital infections-termed
"hospitalism"-were generally attributed to general environmental causes.
The location of the hospital was deemed crucial.
The Massachusetts General was built on reclaimed land. It was noted
that during the summer "the neighborhood was rendered offensive and
unwholesome by emenations from the flats and newly made land." In 1875,
the Board of Consultation recommended to hospital trustees that "no more
buildings should be erected upon the land adjacent to the present wards
because of improper (land) filling… At some future time, it will be for the
best interest of the hospital if the buildings should be given up and a new
site selected, one more fitted to the purposes of a hospital than the present
one is now or ever can be."
The date of this comment, 1875, is significant, for Listerian antisepsis
had been introduced six years before to the MGH by staff members who
had visited the Scottish innovator's hospital in Edinburgh. Antisepsis was
not widely accepted in this country, however, for nearly thirty years
afterward. Instead, environmental arguments continued-despite the fact that
Lister had halved infection rates in a hospital that was built on the site of a
makeshift cemetery in which thousands of cholera victims had been
shallowly buried only a decade previously.
It took less than three months for anesthesia to gain wide acceptance in
medicine. It took more than thirty years for antisepsis to be accepted. Why?
Both discoveries addressed themselves to equally important problems-if
anything, infection was an even greater problem than pain. And both
techniques, though primitive, certainly worked. What accounts for the
difference in speed of acceptance?
Scientific understanding is not part of it. At the time the two innovations
were proposed, neither could be explained. And though we now understand
antisepsis, we still cannot explain why anesthetic gases kill pain.
Nor is diffusion of information a problem. News of antisepsis spread as
quickly as news of anesthesia. Lister's techniques were widely and hotly
debated in every Western country.
 The answer seems to lie with medicine's capacity for dealing with
individuals rather than groups. Anesthesia was dramatic, it produced a
positive effect, and it could be seen working in the individual. On the other
hand, antisepsis was passive, not dramatic, and negative in the sense that it
tried to prevent an effect, not produce one. It was common in the early days
of antisepsis for a skeptical surgeon to half-heartedly try the lengthy,
exasperating techniques on one or two patients, find that the patients still
became infected, and generalize from this experience to conclude the
system was worthless. Nor can one really hold this against them, for a
modern understanding of individual and group effects-the notion, for
example, of a "controlled clinical trial" in all its statistical ramifications-is
very recent indeed.
Nonetheless, antisepsis eventually became accepted in principle and
thereafter followed a string of contributions to sterile operative technique.
William S. Halstead, the Johns Hopkins surgeon, is credited with
introducing rubber gloves for surgery in 1898. Special gowns to replace
street clothes came at the turn of the century. Masks were not common until
the late 1920's.
Ultimately, antibiotics provided the final powerful tool. Thus, in the
space of a century, surgical mortality, which was generally 80 per cent at the
time of the Civil War, was cut to 45 per cent by Listerian methods, and
slowly cut even further in ensuing years, until it is now about 3 per cent in
most hospitals.
Ways to reduce the percentage to zero are being explored. In recent
years, the evolved ritual of timed scrubs, sterile gowns, rubber gloves, and
masks has been criticized. Various studies have indicated that scrubbing
does not clean the skin, but just loosens the bacteria on the hands, making
them more mobile; that one quarter of all gloves have holes in them; that
modern gowns are permeable to bacteria, especially if they become wet (as
they often do in the course of operation); that doorways sealing off
operating rooms do not prevent spread of bacteria but serve as collecting
places for them. Such studies are too conflicting at present to see a clear
trend, but it is likely that the ritual will be strongly modified in coming
years.
Surgeons themselves tend to be almost complacent about the studies,
largely because postoperative infection is no longer a major problem. In
fact, the most common early, immediate, direct cause of death from surgery
is not the operation but the anesthesia.
One wonders why this was not always so, especially in view of early
methods for administering ether, by use of a cone-shaped sponge. J. C.
Warren recalls that during the Civil War period:
These men, many of whom had become inured both to fighting and to a
free use of alcohol, were not favorable subjects for the administration of
ether, and I have still a vivid recollection of my efforts as a student and a
house pupil at the hospital [1865-6] to etherize these patients. "Going under
ether" in those days was no trifling ordeal and often was suggestive of the
scrimmage of a football team rather than the quiet decorum which should
surround the operating table. No preliminary treatment was thought
necessary, except possibly to avoid the use of food for a certain time
previous to the adminstration. Patients came practically as they were to the
operating table and had to take their chances. They were usually etherized
at the top of the staircase on a little chair outside the operating theater, as
there was no room existing for this purpose at the time. In the struggle
which ensued, I can recall often being forced against the bannisters with
nothing but a thin rail to protect me from a fall down three flights. But
however powerful the patient might be, the man behind the sponge came
out victorious and the panting subject was carried triumphantly into the
operating room by the house pupil and attendant.
Although the method of induction was primitive, it was not very
dangerous. Profound anesthesia was difficult to accomplish and serious
complications, Warren says, "were not commonly encountered."
Thus in a sense surgery has come a full circle, from the time when
anesthesia opened new horizons to the time when anesthesia provides a
serious hazard to operation. It is the kind of ironic twist that one frequently
encounters in medical history.
A classic example of the full circle is the story of appendicitis. This is a
very old disease-Egyptian mummies have been found who died of it-but it
was never accurately described until 1886.
During most of the nineteenth century, surgeons were well aware of
diseases which produced pain and pus in the right lower quadrant of the
abdomen. Some attempts were even made to operate for the condition, by
draining the abscess. But results were not encouraging and in 1874 the
English surgeon Sir John Erickson said that the abdomen was "forever shut
from the intrusion of the wise and humane surgeon." Note that pain was not
a consideration here-surgical anesthesia was nearly thirty years old. Rather
it was the fact that pus collections in the abdomen were not understood and
did not appear to be helped by surgical intervention.
Twelve years later, an MGH pathologist named Reginald H. Fitz, who
had traveled in Europe and studied under the great German pathologist
Rudolf Virchow, published the results of an intensive study of 466 cases of
"typhlitis" and "perityphlitic abscess," as the disease processes were then
rather vaguely called. Fitz concluded that what the surgeon found at
operation-a large area of inflamed bowel and widespread pus in the
abdominal cavity-had resulted from an initial, small infection in the
appendix. By describing "appendicitis," he created, in effect, a new disease.
The new disease was not readily accepted by the medical profession.
Nor was Fitz's assertion that proper treatment required operation before
rupture, instead of afterward. Today the idea of "operative intervention" is
commonplace, but in Fitz's day surgery was generally the last resort, not the
first.
Even after his clinical description of appendicitis was accepted, the
surgical treatment remained a matter of dispute. In many hospitals,
appendectomy was considered a bizarre procedure of questionable value. In
1897, when Harvey Gushing was a house officer at Johns Hopkins (after
having interned at MGH and having seen several appendectomies
performed), he diagnosed appendicitis in himself. He had great difficulty
convincing his colleagues to operate; both Halsted and Osier advised
against it. Finally, however, the surgeons gave in and agreed to do the
procedure. Gushing did all the rest: he admitted himself to the hospital,
performed the admission physical examination on himself, diagrammed the
abdominal findings, wrote his own pre-operative and post-operative orders.
It was said that he would have performed the operation himself as well, had
he been able to devise a way to do so.
In the next few years, appendicitis became not only an acceptable but a
fashionable disease; in 1902, it was diagnosed in King Edward VII of
England, who was operated on for the condition. This signaled the onset of
a great vogue for diagnosis and surgical treatment of appendicitis.
As a reasonably safe, reasonably simple abdominal operation, it
encouraged surgeons to be more daring in exploring this body cavity. Their
encouragement was not without its drawbacks, however: surgeons were so
enthusiastic that nearly every bellyache was likely to receive an operation,
and there sprang up a vogue for removal of ovaries and tubes in women,
along with the appendix. The end result of this was the institution of
quality-control checks on surgical procedures, through the "tissue
committees" headed by pathologists.
Dr. Francis D. Moore has said: "[Fitz] was a student of pathology telling
the surgeons to do more operations… How ironical it was that within thirty
years it was to be the pathologists who applied the brakes to a surgical
profession that was running wild with the operation for appendicitis."
Remembering Mr. O'Connor's case, it may be well to go into some of
the differences, and some misconceptions, regarding the relationship of
surgeons and internists. The two groups have never been too congenial.
Traditionally, physicians have considered themselves more intellectual than
surgeons. Descendants of Hippocrates, they look down upon surgeons as
descendants of barbers. Surgeons, on the other hand, see themselves as
action-oriented and regard internists as procrastina-tors, unwilling and
unable to take action.
Temperamentally and philosophically, the two groups are at
loggerheads. At mealtimes in the doctors' dining room, medical and surgical
house officers can be heard berating each other about the care their
respective patients have received. The surgeons say that an internist will sit
hapless by the bedside and watch a patient die; the internists say that the
surgeon will cut anything that moves. Most of this talk represents a time-
honored outlet for black humor, but there is a long history of genuine
conflict.
Dr. Paul S. Russell quotes the surgeon Sir Heneage Ogilvie in a most
revealing passage:
A surgeon conducting a difficult case is like the skipper of an ocean-
going yacht. He knows the port he must make but he cannot foresee the
course of the journey… The physician's task is more comparable to that of
the golfer… If he judges the direction and the wind right, estimates each lie
correctly, finds the right club for each shot and uses it successfully, he will
get an eagle or a birdie. If he makes a mistake he will make a poor score but
he will get there in the end. The ground will not split beneath his feet, the
game will not change suddenly from golf to bullfighting.
That was written in 1948. Six hundred years earlier, the French surgeon
Henri de Mondeville set down his reasons for considering surgery superior
to medicine:
Surgery is undoubtedly superior to medicine for the following reasons:
1. Surgery cures more complicated maladies, toward which medicine is
helpless. 2. Surgery cures diseases that cannot be cured by any other means,
not by themselves, not by nature, nor by medicine. Medicine indeed never
cures a disease so evidently that one could say that the cure is due to
medicine. 3. The doings of surgery are visible and manifest, while those of
medicine are hidden, which is very fortunate for physicians. If they have
made a mistake, it is not apparent, and if they kill the patient, it will not be
done openly. But if the surgeon commits an error… this is seen by
everybody present and cannot be attributed to nature nor to the constitution
of the patient.
For hundreds of years, surgeons have been better paid than physicians.
Internists will not be surprised to know how ancient is the surgeon's
concern with fees. In medieval times, Mondeville was preoccupied with the
matter:
The surgeon who wants to treat his patient properly must settle the
matter of fee first of all. If he is not assured of his fee, he cannot
concentrate on the case. He will examine superficially, and will find
excuses and delays, but if he has received his fee, things are different.…
The surgeon must have five things in mind: first, his fee; second, to avoid
gossip; third, to operate cautiously; fourth, the malady; fifth, the strength of
the sick man. The surgeon must not be fooled by external appearance.
Wealthy people when they go to see a surgeon dress in poor clothes, or, if
they are richly dressed, will tell stories in order to reduce the surgeon's
salary… I have never found a man rich enough, or rather, honest enough to
pay what he promised without being compelled to do so.
On the other hand, enthusiasm for operation is not an ancient vice of
surgery, but a quite modern one. It was heralded by the development of
anesthesia and antisepsis, both less than one hundred fifty years old.
Operative restraint is still newer, a consequence of quality-control checks
that are less than forty years old.
Mr. O'Connor was in the hands of the surgeons for two weeks. He was
not operated upon; there was insufficient evidence of surgically treatable
disease and therefore he received essentially medical treatment on the
surgical wards. This is a far cry from the days when an MGH surgical chief
resident told his staff (perhaps apocryphally): "Every person has at least
three surgical diseases. All you have to do is find them." And it is a far cry
from the days when the medical residents could accurately claim that
surgeons didn't know how to read an electrocardiogram-and furthermore
didn't care. In fact, there is a great deal of evidence that surgery and internal
medicine are merging. It is a process that has taken several centuries, but
today the cardiologists and cardiac surgeons work hand in hand, as do the
immunologists and transplant surgeons; the tumor chemotherapists and the
tumor surgeons; one need only look at the number of surgical house officers
at the MGH who have done basic research in biochemistry and molecular
biology to recognize the trend.
Bertrand Russell once said that we describe the world in mathematical
terms because we are not clever enough to describe it in any more profound
way. Similarly, surgeons and internists have come to see that surgery and
medicine have the common goal of altering the functional status of tissues
within the body. However, altering tissues with a knife is a relatively crude
way of going about things; the finest surgeons are always the most reluctant
to operate.
This is not to say that the scalpel will become a museum piece in our
lifetime. Far from it. As surgery moves from a business of excision to a
business of repair and implantation, it will be ever more important to the
conduct of medicine. But the trend toward cooperation with internists,
rather than competition with them, is likely to be extended as time goes on.
Indeed, the dramatics of the operating room have obscured the fact that
most of the advances in surgery have taken place in terms of pre-operative
and post-operative care. Modern surgery is immensely more complex than
it was a century ago, but this complexity has more to do with electrolyte
balances than with ligature points.
One can argue that in the last twenty years surgical advance has been
largely dependent on para-surgical innovation, more involved with what
goes on outside the operating room than with what goes on inside it. The
paradoxical effect of this has been to increase the range and variety of
services directed toward the operating rooms. Vast areas of the hospital are
now given over to support and maintenance of a heavy surgical schedule,
involving more than 16,000 operations a year. Two clear examples are
Central Supply and the Blood Bank.
"Central Supply" consists of a single large room located one floor above
the operating rooms. As its name implies, it serves as the central supply
room for the hundreds of sterilized articles required for the operating
rooms, as well as the other floors, of the hospital. All sterilization is done
here; forty-three people are employed to keep the room in operation around
the clock, seven days a week. Its operating budget is more than $600,000 a
year.
Excluding operating instruments, Central Supply stocks nearly 500
separate items. These include 44 kinds of Foley catheters, 29 kinds of
drains, 10 kinds of needles, 15 kinds of sponges, and 55 kinds of "sets"-
prepackaged collections of equipment used in carrying out special
procedures. They range from alcohol nerve-block sets to arterial-oxygen
sets to liver-biopsy sets to suture sets and venous-pressure sets. Each set is
handed out, used, returned for re-sterilization and repackaging, and handed
out again.
Altogether, Central Supply hands out 12,000 items a day, or nearly 4.5
million items a year. The work of Central Supply has been increasing
markedly in recent years. For example:
1966 27,000 37,000 485,000
1968 38,000 61,000 1,208,000
Hospital Use Dressing sets Suture sets Thermometers
These are real figures, in the sense that they do not represent absorption
of work previously done by some other area in the last two years, but rather
a simple increased demand by the hospital for these items.
It should be stated at once that Central Supply does not handle all the
items now required by medical technology. For instance, the ten kinds of
needles it carries do not include needles for routine intramuscular and
intravenous use; these are purchased presterilized and are thrown away after
use. Rather, Central Supply stocks intracardiac needles, spinal needles,
sternal puncture needles, ventricular needles, and other similarly specialized
nondis-posable apparatus.
The question of whether Central Supply should be doing as much as it
does is the subject of debate. The cost of everything used in the hospital has
grown so enormously that even the simplest details of patient care have
undergone renewed scrutiny-revealing them, suddenly, as not so simple.
Consider the Great Thermometer Controversy.
Thermometers were first used clinically in 1890, when they were
delicate gadgets a foot long, but they are now a staple of modern care, and
the largest item of business for Central Supply, which hands out between
3,000 and 4,000 thermometers a day. The MGH employs a method of
reprocessing thermometers-unclean thermometers are returned to Central
Supply, washed, sterilized, spun dry, and repackaged for use again.
The hospital recently commissioned a cost analysis of thermometer
systems, which concluded that the average patient had 2.5 thermometer
readings a day, and a total of 32 readings during an average admission of 13
days. Within this framework, three possible systems were examined: the
reusable thermometer; a disposable probe used in conjunction with a
portable sensing unit; and a personal-thermometer system in which each
patient is given his own thermometer at admission, and keeps it at his
bedside throughout his stay.
The conclusions on cost per year were as follows:
Reprocessable, reusable $30,113.00
Probe and sensing unit $49,786.00
Personal thermometer $13,250.00
This does not tell the full story, however. There are some complicating
factors. First, the present MGH system is inefficient. Central Supply does
not get back all the thermometers it gives out; in 1968, it spent $30,000 to
replace lost thermometers, thus effectively doubling the cost of the present
system. Second, the probe and sensing unit has an important front-end cost,
namely the sensing units, which cost $190 each. Amortization has not been
figured into the above accounting. Neither has nursing time been assessed-
and the sensing units, unlike regular thermometers, are virtually
instantaneous.
The situation is further confused by fear that a personal-thermometer
system may not provide adequate patient safeguards. Some have envisioned
a situation in which a tuberculous patient is moved to a different room, and
a new patient put in his place, with the thermometer inadvertently
remaining at his bedside, to be popped into the mouth of the unsuspecting
new admission. The example is farfetched, but certainly any new system
deserves close scrutiny to assess its reliability and safety.
The upshot of all this is that it is difficult to be certain what is the best,
safest, and cheapest way to take a patient's temperature. The problems in
determining cost for this relatively simple matter are magnified many times
when one attempts to unravel the cost of a radiological unit or a chemistry
laboratory. Given the vagaries of accounting methods, and the uncertainty
of reliability with different systems, it becomes extraordinarily difficult to
decide which costs are justified and which are not.
The controversy rages on, but on balance the cost advantages are too
great, and the potential for danger too little, to permit the hospital to
disregard the personal-thermometer system. Converting to this system
would save the hospital only five hun-dredths of one per cent of its annual
budget. But one can see how a series of similar minor cost changes could
ultimately affect total hospitaliza-tion cost.
The Blood Bank is another large and expensive facility. The MGH now
has what is believed to be the largest single hospital blood bank and
transfusion service in the world. Located on two floors of the Gray
Building, it accounts for one fifth of all the blood used in the state of
Massachusetts. The great majority of the blood goes to surgical patients,
with a large proportion going to open-heart cases. At times as much as a
third of all hospital blood has gone to the cardiac surgical service. This
massive consumption, in turn, is largely the consequence of the heart-lung
machines, which require large amounts of blood to "prime" the pump.
Although the size of the Blood Bank is closely related to the increasing
demand of cardiac surgery, its growth preceded the development of open-
heart techniques. The MGH Blood Bank was begun in 1942, under the part-
time direction of Dr. Lamar Soutter. The hospital, skeptical of the need for
such a thing, contributed $5,000 in equipment and a basement room in one
of the buildings. Soutter recalls that "in the beginning everything went
wrong [but] the effort paid off with unexpected rapidity. In November of
1942 the Hospital was flooded with victims of the Cocoanut Grove [fire]
disaster. The Bank had more than enough plasma to give the patients
adequate care. This single episode swept away the last of the opposition to
the Bank and it became firmly established as a necessary part of the
Hospital."
The Bank has always operated in the black, though its operating budget
has grown from $5,000 in 1942 to $144,300 in 1951, and finally to more
than $1 million yearly at the present time. The staff has grown from one
nurse, one technician, and a part-time physician in 1942 to more than one
hundred technicians and nurses and secretaries at present.
By definition, an organ is a mass of specialized cells serving some
specific function. According to this definition, blood is an organ, though
one does not often think of it in this way.
 As a developing organ in the embryo, blood is formed from the same
tissue which also differentiates into cartilage, connective tissue, and bone.
This helps explain why, for example, blood is formed in bone marrow.
In the adult man, blood consists of five quarts of liquid, accounting for 7
per cent of adult body weight. This makes it, on a weight basis, a
respectably large organ-much larger than either the lungs (1 per cent) or the
liver (2 per cent). The functions of blood are suitably complex, ranging
from transport of oxygen and nutrients to defense of the body against
infection.
If blood is an organ, a blood transfusion is an organ transplantation. It is
not idle to think of transfusions in this way, for nearly all the problems of
modern organ transplantation were first met, and solved, in dealing with
blood transfusion. Only our familiarity with modern transfusion makes us
forget that it is, in fact, a transplant-a gift of vital cells from donor to
recipient.
No one knows when the first transfusion was performed, but it was
certainly a long time ago, for the efficacy of blood was highly regarded in
ancient times. In early accounts, it is not clear whether the blood was
transfused or drunk, since both methods were considered useful. Celsus, in
Roman times, refers to treatment of epilepsy by drinking the hot blood from
the cut throat of a gladiator. The Mongols, living in a horse culture, often
drank horse blood for sustenance.
The idea of intravenous injection is also old. Ovid relates that Jason was
helped by Medea with an injection of "succis" into his jugular vein.
Behind the early interest in transfusion was the quite logical notion that
an illness involving blood loss was best treated with blood replacement.
Early materials for this were primitive-needles made of quills and bone,
tubing formed from bladders or leather. In many cases, animal blood was
transfused to human beings, often with the addition of semen, urine, and
other substances thought to be invigorating.
It is not surprising that patients often died from this procedure. Donors
often died, as well. In a famous instance, Pope Innocent VIII received a
transfusion from three young boys in 1492. The donors as well as the
recipient expired within a few days.
In the eighteenth century, when better materials were available and
more careful observation the rule, it became clear that certain patients
benefited from transfusion but others did not. This early notion of the
"transfusion reaction" evolved slowly, culminating in Karl Landsteiner's
discovery in 1900 of A, B, and O blood groups. This represented the first
clear, unequivocal statement that all blood was not the same. For more than
a decade after Landsteiner's work, there was no practical clinical method of
differentiating blood groups. The search for such techniques is a direct
forerunner of modern tissue-typing methods for transplantation of other
organs.
Just as the matching of donor and recipient was a problem, so was
storage of the organ. Untreated, blood clots soon after it is drawn. It was not
until 1916 that blood could be kept refrigerated for two weeks in glass
bottles, with the addition of anti-coagulating substances. And it was not for
more than twenty years after that that clinical blood banking began on any
scale in this country. There was no important improvement in storage
techniques until 1952, when glass bottles were replaced by plastic bags,
which preserved blood elements much better.
More recently has come the ability to store frozen blood. This single
technical capability has solved several traditional banking problems, and
indeed is now integral to the MGH function: most open-heart cases are
done with frozen blood [Dr. Charles Huggins, an MGH surgeon, was one of
the pioneers in making frozen blood practical for clinical use].
Formerly, all blood had to be used within three weeks. Now it can be
stored at -120° F. for five years or more. In the past, patients had to be
matched to their own blood type. Now, the freezing-thawing process
washes out serum antibodies, which means that type O frozen blood can be
transfused to anyone, regardless of his blood type. The need for the bank to
stock many different blood types is therefore reduced.
And, finally, there is evidence that the risk of hepatitis, a traditional
problem with transfusions, is reduced when frozen blood is used.
There are, of course, some drawbacks to frozen blood. It is more
expensive at the present time. Also, some blood components, notably
platelets, which are important to clotting, are lost and must be supplied
separately. But there are easy techniques for this.
In fact, the products of the modern blood bank are increasingly
sophisticated. In 1942, the bank produced only two products-whole blood
and plasma (the liquid portion without the cells). But it is now possible to
give whole blood, or packed red cells without plasma, or platelets; it is
possible to give plasma, or only the protein from the plasma, or only
specific parts of the total protein without the others. Each of these
specialized blood bank products is becoming increasingly important to the
conduct of modern medicine.
What has all this meant to surgery? As it has become more scientific
and more complex, a certain amount of the drama and flair, the spectacle
that Warren remembered, has disappeared-or at least become muted, until it
is hardly recognizable.
On Saturday mornings at the hospital, surgical clinics are held for
students in which patients are presented pre-operatively and then the
students are invited to watch the procedures from the several overhead
viewing galleries. This teaching exercise is the last remnant of a proud
tradition of surgical spectacle. Dr. E. D. Churchill, former MGH Chief of
Surgery, gives the following account:
The display of operations at the Hospital on Saturday mornings
continued well into the 1920's. Unusual cases were assembled so that the
senior surgeons on duty could have an impressive list of operations
scheduled for the amphitheater. The two services, East and West, vied with
each other in trying to stage the better show. In the Surgical Building,
opened in 1900, the display reached major proportions. When the morning's
list was a long one, an operation would be started in a small room and then
the entire outfit trundled like a troupe of gypsies into the pit of the
amphitheater, where the crucial phase of the procedure was demonstrated to
the visiting doctors. The surgeons would be allotted, say, fifteen minutes.
Whether or not the operation had been completed, at the expiration of the
allotted time the tents were folded, the troupe moved off stage to complete
the operation elsewhere, and a new act took over… Great weight was
placed on the speed and daring of the operator… Tension mounted when
some prima donna showed reluctance to withdraw from the spotlight and
overstayed his time to hold the audience spellbound in an ad lib recounting
of his surgical prowess.
The prowess of the surgeon has steadily increased since then, to the
point where reconstructing a nearly severed hand is, if not commonplace, at
least nothing to get very excited about.
And if, in this age of television, the surgeon shows more flamboyance
than is scientifically necessary, more sense of drama than is medically
indicated, he can at least be excused for upholding the traditions of his
calling-and, in a deeper sense, the facts of his life.
 Sylvia Thompson. Medical Transition
Flight 404 from Los angeles to boston was somewhere over eastern
Ohio when Mrs. Sylvia Thompson, a fifty-six-year-old mother of three,
began to experience chest pain.
The pain was not severe, but it was persistent. After the aircraft landed,
she asked an airline official if there was a doctor at the airport. He directed
her to the Logan Airport Medical Station, at Gate 23, near the Eastern
Airlines terminal.
Entering the waiting area, Mrs. Thompson told the secretary that she
would like to see a doctor.
"Are you a passenger?" the secretary said.
"Yes," Mrs. Thompson said.
"What seems to be the matter?"
"I have a pain in my chest."
"The doctor will see you in just a minute," the secretary said. "Please
take a seat."
Mrs. Thompson sat down. From her chair, she could look across the
reception area to the computer console behind the secretary, and beyond to
the small pharmacy and dispensary of the station. She could see three of the
six nurses who run the station around the clock. It was now two in the
afternoon, and the station was relatively quiet; earlier in the day a half
dozen people had come in for yellow fever vaccinations, which are given
every Tuesday and Saturday morning. But now the only other patient she
could see was a young airplane mechanic who had cut his finger and was
having it cleaned in the treatment room down the corridor.
A nurse came over and checked her blood pressure, pulse, and
temperature, writing the information down on a slip of paper.
The door to the room nearest Mrs. Thompson was closed. From inside,
she heard muffled voices. After several minutes, a stewardess came out and
closed the door behind her. The stewardess arranged her next appointment
with the secretary and left.
The secretary turned to Mrs. Thompson. "The doctor will talk with you
now," she said, and led Mrs. Thompson into the room that the stewardess
had just left.
 It was pleasantly furnished with drapes and a carpet. There was an
examining table and a chair; both faced a television console. Beneath the
TV screen was a remote-control television camera. Over in another corner
of the room was a portable camera on a rolling tripod. In still another
comer, near the examining couch, was a large instrument console with
gauges and dials.
"You'll be speaking with Dr. Murphy," the secretary said.
A nurse then came into the room and motioned Mrs. Thompson to take
a seat. Mrs. Thompson looked uncertainly at all the equipment. On the
screen, Dr. Raymond Murphy was looking down at some papers on his
desk. The nurse said: "Dr. Murphy." Dr. Murphy looked up. The television
camera beneath the TV screen made a grinding noise, and pivoted around to
train on the nurse.
"Yes?"
"This is Mrs. Thompson from Los Angeles. She is a passenger, fifty-six-
years old, and she has chest pain. Her blood pressure is 120/80, her pulse is
78, and her temperature is 101.4."
Dr. Murphy nodded. "How do you do, Mrs. Thompson."
Mrs. Thompson was slightly flustered. She turned to the nurse. "What
do I do?"
"Just talk to him. He can see you through that camera there, and hear
you through that microphone." She pointed to the microphone suspended
from the ceiling.
"But where is he?"
"I'm at the Massachusetts General Hospital," Dr. Murphy said. "When
did you first get this pain?"
"Today, about two hours ago."
"In flight?"
"Yes."
"What were you doing when it began?"
"Eating lunch. It's continued since then."
"Can you describe it for me?"
"It's not very strong, but it's sharp. In the left side of my chest. Over
here," she said, pointing. Then she caught herself, and looked questioningly
at the nurse.
"I see," Dr. Murphy said. "Does the pain go anywhere? Does it move
around?"
 "No."
"Do you have pain in your stomach, or in your teeth, or in either of your
arms?"
"No."
"Does anything make it worse or better?"
"It hurts when I take a deep breath."
"Have you ever had it before?"
"No. This is the first time."
"Have you ever had any trouble with your heart or lungs before?"
She said she had not. The interview continued for several minutes more,
while Dr. Murphy determined that she had no striking symptoms of cardiac
disease, that she smoked a pack of cigarettes a day, and that she had a
chronic unproductive cough.
He then said, "I'd like you to sit on the couch, please. The nurse will
help you disrobe."
Mrs. Thompson moved from the chair to the couch. The remote-control
camera whirred mechanically as it followed her. The nurse helped Mrs.
Thompson undress. Then Dr. Murphy said: "Would you point to where the
pain is, please?"
Mrs. Thompson pointed to the lower-left chest wall, her finger
describing an arc along the ribs.
"All right. I'm going to listen to your lungs and heart now."
The nurse stepped to the large instrument console and began flicking
switches. She then applied a small, round metal stethoscope to Mrs.
Thompson's chest. On the TV screen, Mrs. Thompson saw Dr. Murphy
place a stethoscope in his ears. "Just breathe easily with your mouth open,"
Dr. Murphy said.
For some minutes he listened to breath sounds, directing the nurse
where to move the stethoscope. He then asked Mrs. Thompson to say
"ninety-nine" over and over, while the stethoscope was moved. At length he
shifted his attention to the heart.
"Now I'd like you to lie down on the couch," Dr. Murphy said, and
directed that the stethoscope be removed. To the nurse: "Put the remote
camera on Mrs. Thompson's face. Use a close-up lens."
"An eleven hundred?" the nurse asked.
"An eleven hundred will be fine."
 The nurse wheeled the remote camera over from the corner of the room
and trained it on Mrs. Thompson's face. In the meantime, Dr. Murphy
adjusted his own camera so that it was looking at her abdomen.
"Mrs. Thompson," Dr. Murphy said, "I'll be watching both your face
and your stomach as the nurse palpates your abdomen. Just relax now."
He then directed the nurse, who felt different areas of the abdomen.
None was tender.
"I'd like to look at the feet now," Dr. Murphy said. With the help of the
nurse, he checked them for edema. Then he looked at the neck veins.
"Mrs. Thompson, we're going to take a cardiogram now."
The proper leads were attached to the patient. On the TV screen, she
watched Dr. Murphy turn to one side and look at a thin strip of paper.
The nurse said: "The cardiogram is transmitted directly to him."
"Oh my," Mrs. Thompson said. "How far away is he?"
"Two and a half miles," Dr. Murphy said, not looking up from the
cardiogram.
While the examination was proceeding, another nurse was preparing
samples of Mrs. Thompson's blood and urine in a laboratory down the hall.
She placed the samples under a microscope attached to a TV camera.
Watching on a monitor, she could see the image that was being transmitted
to Dr. Murphy. She could also talk directly with him, moving the slide
about as he instructed.
Mrs. Thompson had a white count of 18,000. Dr. Murphy could clearly
see an increase in the different kinds of white cells. He could also see that
the urine was clean, with no evidence of infection.
Back in the examining room, Dr. Murphy said: "Mrs. Thompson, it
looks like you have a pneumonia. We'd like you to come into the hospital
for X rays and further evaluation. I'm going to give you something to make
you a little more comfortable."
He directed the nurse to write a prescription. She then carried it over to
the telewriter, above the equipment console. Using the telewriter unit at the
MGH, Dr. Murphy signed the prescription.
Afterward, Mrs. Thompson said: "My goodness. It was just like the real
thing."
When she had gone, Dr. Murphy discussed both her case and the
television link-up.
 "We think it's an interesting system," he said, "and it has a lot of
potential. It's interesting that patients accept it quite well. Mrs. Thompson
was a little hesitant at first, but very rapidly became accustomed to the
system. There's a reason-talking by closed-circuit TV is really very little
different from direct, personal interviews. I can see your facial expression,
and you can see mine; we can talk to each other quite naturally. It's true that
we are both in black and white, not color, but that's not really important. It
isn't even important for der-matologic diagnoses. You might think that color
would be terribly important in examining a skin rash, but it's not. The
history a patient gives and the distribution of the lesions on the body and
their shape give important clues. We've had very good success diagnosing
rashes in black and white, but we do need to evaluate this further.
"The system we have here is pretty refined. We can look closely at
various parts of the body, using different lenses and lights. We can see down
the throat; we can get close enough to examine pupillary dilation. We can
easily see the veins on the whites of the eyes. So it's quite adequate for most
things.
"There are some limitations, of course. You have to instruct the nurse in
what to do, in your behalf. It takes time to arrange the patient, the cameras,
and the lighting, to make certain observations. And for some procedures,
such as palpating the abdomen, you have to rely heavily on the nurse,
though we can watch for muscle spasm and facial reaction to pain-that kind
of thing.
"We don't claim that this is a perfect system by any means. But it's an
interesting way to provide a doctor to an area that might not otherwise have
one."
Boston's Logan Airport is the eighth busiest in the world. In addition to
the steady stream of incoming and outgoing passengers, there are more than
5,000 airport employees. The problem of providing medical care to this
population has been a difficult one for many years. Like many populations,
it is too large to be ignored, but too small to support a full-time physician in
residence. Nor can a physician easily make the journey back and forth from
the hospital to the airport; though only 2.7 miles away, the airport is,
practically speaking, isolated for many hours of the day by rush-hour traffic
congestion.
The solution of Dr. Kenneth T. Bird, who runs the unit, has been to
provide a physician when the patient demand is heaviest, and to provide
additional coverage by television. The system now used, called Tele-
Diagnosis, is frankly experimental. It has been in operation for slightly
more than a year. At the present time, eight to ten patients a day are
interviewed and examined by television.
The Logan TV system is probably the first of its kind in the country, but
Bird refuses to discuss priority. "The first to have it," he says, "was Tom
Swift, in 1914."
Certainly there is a science-fiction quality about the station's equipment,
for along with the Tele-Diagnosis apparatus, there is also a time-sharing
station linked to the hospital's computer. Among other things, this computer
can be used to take a preliminary history-to function as a doctor in
questioning the patient about his symptoms and their nature. Some 15 per
cent of the patients examined by Tele-Diagnosis have had their medical
history taken by computer before they see the doctor himself. Like the
cardiogram, the computer history can be sent directly to the physician.
Being interviewed by a machine is less bizarre than it sounds. Indeed,
like the TV link-up, it is remarkable for the ease with which patients accept
it. The most common complaint is boredom: the machine sometimes pauses
three or four seconds between questions, and the patients get fidgety.
To be interviewed, one sits in front of a teletype console. The computer
asks questions, which are printed out, and the patient punches in his
answers. Whenever the computer gets a "yes" answer to some question, it
follows it up with more questions on the same subject. If it gets a "no"
answer, it goes on to the next topic. At the conclusion of the question, the
computer writes out a medical summary. Unlike the questions, the summary
is phrased in medical terminology. The entire process takes roughly half an
hour.
The result of one such interview is reprinted in part below. The
computer was given the same presenting complaint as that of Mrs.
Thompson: chest pain. In an attempt to confuse it, the machine was first fed
some false but suggestive information, namely, that there was a family
history of cardiovascular disease, and that the patient was taking digitalis.
However, in later questions, the machine was given a straightforward
history for the type of chest pain most common among medical students-
that of psychogenic, or musculoske-letal, origin.
A sample of the questions and answers ran as follows:
 SEVERAL MONTHS
A FEW YEARS

DO YOU HAVE THIS COUGH EVERY DAY?

YES

DO YOU BRING UP ANY MATERIAL (SUCH AS SPUTUM,

PHLEGM, OR MUCUS) FROM YOUR CHEST?
NO

HAVE YOU EVER COUGHED UP BLOOD?

NO

At the conclusion of these and other questions, the computer printed the
following summary:

HAS YOUR VOICE CHANGED (BECOME ROUGH, SCRATCHY,

OR HOARSE) DURING THE PAST YEAR?

NO

DO YOU HAVE A COUGH?

YES

HOW LONG HAVE YOU HAD THE COUGH?

1. A FEW DAYS
2. A FEW WEEKS

MEDICAL HISTORY SUMMARY DATE: MAY 27, 1969

NAME: MICHAEL CRICHTON UNIT #: DEMO
AGE: 26 SEX: MALE
CHIEF COMPLAINT: CHEST PAIN COMMUNITY PHYSICIAN:
NONE OCCUPATION: MEDICAL STUDENT

MEDICATIONS: DIGITALIS DRUG REACTIONS: PAN ALBA

HOSPITALIZATIONS: NONE
FAMILY HISTORY: HEART ATTACK, HYPERTENSION.

SOCIAL HISTORY
 PT. IS MARRIED, HAS NO CHILDREN. COLLEGE GRADUATE.
PRESENTLY A STUDENT, WORKING 50-60 HRS/WK. HAS BEEN
SMOKING 5-10 YRS, 1 PACK/DAY. ALCOHOLIC CONSUMPTION: 1
DRINK/DAY. FOREIGN TRAVEL WITHIN THE LAST 10 YEARS.

REVIEW OF SYSTEMS
GENERAL HEALTH
NO SIGNIFICANT WEIGHT CHANGE IN PAST YEAR. SLEEPS 6-
8 HRS/NIGHT. HEAD INJURIES: NONE WITHIN PAST 5 YRS. EYE
SYMPTOMS: NONE. HAS BEEN TOLD BY MD OF NO EYE
DISEASE. NO TINNITUS. NO EPISTAXIS, NOTES SINUS TROUBLE,
DENIES CHANGE IN VOICE.

RESPIRATORY SYSTEM
PT. NOTES COUGH OF SEVERAL MONTHS DURATION, WHICH
OCCURS DAILY. DENIES SPUTUM PRODUCTION, DENIES
HEMOPTYSIS. NOTES NO DYSPNEA. HAS HAD HAY FEVER. HAS
HAD NO KNOWN CONTACT
WITH TUBERCULOSIS. LAST CHEST X RAY -2 YRS AGO.

CARDIOVASCULAR SYSTEM
PT. NOTES CHEST PAIN OCCURRING LESS THAN ONCE A
MONTH, LOCATED "ON BOTH SIDES," WHICH RADIATES TO
NEITHER ARM NOR NECK. PAIN IS NOT AFFECTED BY DEEP
BREATHING, IS NOT ASSOCIATED WITH EATING, EMOTION, OR
EXERCISE. PAIN IS NOT RELIEVED BY RESTING. PT. NOTES
PALPITATIONS ON RARE OCCASIONS. DENIES ORTHOPNEA.
DENIES PEDAL EDEMA, DENIES LEG PAINS, DENIES VARICOSE
VEINS, DENIES PERIPHERAL REACTION TO COLD. CARDIAC
MEDICATIONS: NONE. HAS BEEN TOLD BY MD OF NO COMMON
CARDIAC DISEASE. NO ECG IN PAST 2 YRS.

This is only half the total report. Analysis of gastrointestinal

musculoskeletal, genito-urinary, hematologic, endocrine, dermatologic, and
neurological systems followed. This particular computer program draws no
conclusions about diagnosis; it only summarizes answers to its own
questions, and it does not cross-check itself. Thus, while the computer was
told the patient took digitalis, it later accepted the conflicting statement that
the patient took no cardiac medications.
This program, which was devised at the MGH, is a rather simple
example of the way that computers can and almost certainly will be used in
the future. But it is the least sophisticated of the medical-history programs
available; more complex ones already exist.
When Mrs. Thompson arrived at the MGH emergency ward, which had
been expecting her, she was taken down to the EW X-ray department. In
doing so, she passed a door near the front of the EW which is unmarked,
without a label. Over the door is a lighted sign that says, incongruously,
"On Air."
Dr. Murphy was behind that door, sitting in a corner of a small room,
surrounded by equipment. Directly in front of him was a camera and a large
TV screen, on which he watches the Logan patients. Built into his desk
were two other screens: one, a small monitor of the larger screen, the other,
a monitor that showed him his own image being transmitted to the patient.
This second monitor allowed him to check his own facial expressions, the
lighting in the room, and so on.
To his right was a panel of buttons that controlled the various remote
cameras-two in the examining room and one in the laboratory. The
examining-room remote camera is operated by a joystick: by pushing the
stick right or left, up or down, the camera moves accordingly. In addition,
there are buttons for focusing and zoom control.
Before going out to check on Mrs. Thompson, Dr. Murphy continued a
study of Tele-Diagnosis
capability: reading a series of 120 chest X rays that are set up for him at
Logan. He planned to read these by TV and later reread them in person, to
compare the accuracy and consistency of his diagnosis.
The nurse at Logan set up the next X ray.
"What's this one?"
"Jay-nineteen," the nurse said, reading off the code number.
"Okay." He moved the joystick and touched the buttons. The camera
tracked around the X ray, examining the ribs, then scanning the lung fields.
"Wait a minute." He zoomed in to look closely at the right-upper lobe; he
watched the little monitor, because resolution was better, but by glancing up
at the large screen, he could also get a magnified view. "No. Well, on
second thought…" He zoomed back for an over-all view. He zoomed in on
another part of the upper lobe. "Looks like a small cavitation there…" He
zoomed back, touching the buttons. He turned to the joystick, panned across
the rest of the lung field, occasionally pausing to look at suspicious areas.
"Nothing else, not really…" He finished his scan, and returned to the right-
upper lobe. "Yes, there's cavitation. I'd have to call it moderately advanced
tuberculosis. Next, please."
He was working with considerable rapidity.
"You get to be pretty good at this," he said. "At first, it all seems clumsy,
but as you get more accustomed to the equipment, you move faster." The
average time for a patient interview and exanimation by Tele-Diagnosis is
now twelve minutes, less than half the average figure a year ago.
"What I'm doing now," he said, "is really just a test of our capability. It
has no immediate practical use, because we can't take X rays at Logan-that's
one of the main reasons we brought Mrs. Thompson into the hospital. But
it's important to know if X rays can be read at a distance with accuracy. Our
impression is that you can read them as well on TV as you can in person."
"Jay-twenty," the nurse said, putting up another film.
Murphy began his scan. "Ah. What's this? Looks like a rib fracture…"
One can argue that for the past twenty years technology has defined the
hospital, has made it what it is today. That is, once a range of expensive,
complex therapeutic and diagnostic machinery became available, the
hospital assumed the role of providing a central location for such
equipment. This was inevitable: private practitioners and even large group
practices could not afford to buy such equipment, nor maintain it, nor pay
the personnel to operate it. Only the hospital could do this. It was the only
institution in existence that could possibly absorb the expense. Other
possible institutions, such as nursing homes, were wholly inadequate.
Furthermore, because the hospital was already oriented toward acute
care of critically ill patients, the technology that it absorbed was precisely
that
which helped in this area. Monitoring machines and life-support
equipment are clear examples. Thus technology reinforced an already
existing trend.
Now, however, the pressures and forces acting upon the hospital are
social and of a nature that is changing the meaning of technology within the
hospital. As C.P. Snow has said, "We have been letting technology run us as
if we had no judgment of our own." But such judgment is now required, and
one can argue that in the next twenty years the hospital will define
technology. That is, it will create a demand for new technological
applications- and in certain ways will itself produce the new technology.
By doing this, the hospital will be extending its newest and most
striking trend, which is to foster innovation, later to be picked up by other,
nonac-ademic institutions. The absurd end-point of such a trend would be
for the hospital to direct personally the diagnosis and therapy of a patient
who never enters the hospital. Absurd as it may be, it is already happening
in the case of many patients treated at Logan Airport. It will happen more
often, in other ways, in the future.
Of the almost limitless spectrum of potential technological advance, we
can concentrate here on two areas of imminent advance, television and
computers. One ought to say that they have been imminent for a long time;
a decade ago one heard that computers were about to revolutionize
medicine, and one still hears it today. It obviously hasn't happened yet.
Indeed, neither television nor the computer has made much difference yet to
routine hospital functioning. Television is employed on occasion for student
teaching; it is used in a small way for dispatching blood samples and other
items; it has some application in X-ray technology, in terms of image-
intensification systems. Computers remain primarily the plaything of
researchers. At the MGH there is now a computer program to help in
running the clinical chemistry lab, and a computer to help in billing and
patient record-keeping, but the computer and television as direct aids in
patient care have not made their appearance.
In contrast, the Tele-Diagnosis system at Logan Airport uses computers
and TV in direct confrontation with the patient. The system is expensive
and in some ways primitive. Also, its present thrust is diagnostic; therapy,
the steps following diagnosis, will still be directly carried out by a doctor,
nurse, or the patient himself. There are no machines to do this, unless one
stretches the definition to include renal-dialysis machines, exercise
machines, and the like.
In general, diagnostic automation appears much closer than therapeutic
automation-and is much more readily acceptable to physicians. Consider,
then, diagnostic automation first.
The first and most striking feature of the Logan system is that diagnosis
can occur at a distance. The doctor's stethoscope is three miles long. But,
oddly, that diagnosis at a distance is very old and has some humorous
elements. Beginning around
a.d. 900, for example, the practice of uroscopy, or "water casting," came
into vogue. It was felt that the amount of information obtainable from
inspection of urine was unlimited. The urine of a sick man was often sent
many miles to be examined by a prominent physician.
David Riesman cites a typical medieval interpretation of urine:
The urine is pale pink, thick above, thin below, becoming gray or dark
toward the surface. The grayness and obscurity is caused by overheating of
the material. The symptoms are these: pain in the head, especially in the
temples, sourness of the breath, pains in the back from bile descending to
the loins and kidneys, with paroxysms every day or every second day,
usually coming on after dinner time.
In medieval literature there are many discussions of the hazards to the
physician of uroscopy; even in those days, diagnosis at a distance had its
risks. The Spanish physician Arnold of Villanova, who lived in the
thirteenth century, wrote:
With regard to urines, we must consider the precautions to protect
ourselves against people who wish to deceive us. The very first shall consist
in finding out whether the urine be of man or of another animal or another
fluid.
The second precaution is with regard to the individual who brings the
urine. You must look at him sharply and keep your eyes straight on him or
on his face; and if he wishes to deceive you he will start laughing, or the
color of his face will change, and then you must curse him forever and in all
eternity.
The third precaution is also with regard to the individual who brings the
urine, whether man or woman, for you must see whether he or she is pale,
and after you have ascertained that this is the individual's urine, say to him:
"Verily, this urine resembles you," and talk about the pallor, because
immediately you will hear all about his illness…
The fourth precaution is with regard to sex. An old woman wants to
have your opinion. You inquire whose urine it is, and the old woman will
say to you: "Don't you know it?" Then look at her in a certain way from the
corner of your eye, and ask: "What relation is it of yours?" And if she is not
too crooked, she will say that the patient is a male or female relation, or
something from which you can distinguish the sex… Or ask what the
patient used to do when he was in good health, and from the patient's doing
you can recognize or deduce the sex…
The list continues through nineteen precautions, all designed to enable
the physician to pry information from the person bringing the urine, and to
prevent deception. Arnold was not above a little deception himself,
however:
You may not find anything about the case. Then say that he has an
obstruction of the liver, and particularly use the word, obstruction, because
they do not understand what it means, and it helps greatly that a term is not
understood by the people.
The modern counterpart of this medieval guessing game over urine is
the telephone conversation between physician and patient. For years after
the telephone became common, physicians resisted making telephone
diagnoses, and they still frown on them. But every practicing doctor now
spends a substantial part of his day talking to patients on the phone, and he
is resigned to making a large number of decisions, some of them uneasily,
by
phone.
Closed-circuit television, while far from the ideal of a personal
examination, is vastly superior to the telephone alone, and in many cases it
is surprisingly adequate. This does not mean that future patients will all be
seen by closed-circuit television, with neither doctor nor patient leaving
home. What it does mean is that television will probably work in certain
very special applications. One of these is the Logan application-providing a
doctor to a clinic during low-use periods. Another obvious use would be
specialist consultations. A hospital or clinic that needs a neurologist only a
few times a year cannot afford to staff one. Nor could it find one, even if it
could afford it. Television is perfectly suited to such consultation.
At the same time, a system such as that at Logan makes possible a
routine physical examination, but goes no further-and there are suggestions
that technology will ultimately change the very nature of physical
examination. Here the historical trend is clear.
Consider the innovations in physical diagnosis. In the nineteenth
century, there were three of great importance-the stethoscope, the blood-
pressure cuff, and the thermometer. Each of these is really nothing more
than a precise way to determine what can be inaccurately determined by
other means. Thus the thermometer is superior to the hand on the forehead;
the stethoscope superior to the ear against the chest [For the purposes of this
argument, I will ignore the fact that the stethoscope really initiated
auscultation as a useful examination procedure. In truth, ears were not
pressed against the chest with much regularity before Laennec invented the
stethoscope and described auscultation.]; and the blood-pressure cuff
superior to a finger compressing the artery to test its pressure.
Now, the first two advances of the twentieth century were quite
different: the X ray and electrocardiogram provided new information not
obtainable by physical contact. No amount of squeezing and touching the
patient will tell you anything directly about the electrical currents in his
heart. You may deduce this information from other findings, but you cannot
extract it directly. Similarly, X rays represent a new kind of vision,
providing a new kind of information.
At the present time a variety of examination procedures are being
tested. These include ther-mography, ultraviolet light, ultrasonic sound, as
well as mapping electrical currents in the skin. Except for thermography,
these all represent "new" sensory information for the doctor.
Thus the initial trend was to measure the patient more exactly, and later,
to measure the patient in new ways. The first approach has been to find new
sorts of measurements and new sensory information. But a second
approach, now in its infancy, concerns translation of old information into
new forms. The computer will be helpful here in a number of ways, in
producing what is called "derivative information."
In a simple way, this is already being done. The human computer
[Defmed as the only computer that can be produced by unskilled labor] and
the electrocardiogram are a clear example. The electrocardiogram measures
electrical currents within the heart muscle-the current that makes it contract
and beat. Often, when a physician looks at an electrocardiogram, he wants
specific electrical information. He wants to know about rate and rhythm,
about conduction of impulses, and so on. At other times, he wants
nonelectrical information. He may want to know how thick a part of the
heart wall is, for instance. In this case, he derives the information from the
electrical information.
But there are more complex forms of derived in-
formation. A physician examining a patient with heart disease may be
interested in knowing the cardiac output-exactly how much blood the heart
is pumping per minute. This is the product of heart rate (easily determined)
and volume of blood ejected per beat (very difficult to determine). Because
cardiac output is so hard to assess, it is not much used in diagnosis and
therapy. However, by measuring heart rate and the shape of the arterial
pulse (both easily done) a computer can calculate cardiac output and can
perform these calculations continuously over a period of days, if necessary.
If a physician needs to know cardiac output, he can have this information.
He can have it for as long as the patient is connected to the computer.
Does the physician really need cardiac output? At the moment, he can't
be sure. For centuries he's had to content himself with other information.
There is reason to believe, however, that cardiac output will be useful in a
variety of ways, as will other derived information.
An interesting technological application concerns the reverse of the
coin: determining which information the physician already has but does not
need. This is not to say that the information is inaccurate, but only that it
does not have diagnostic significance and is therefore not worth obtaining.
At present, the physician naturally tries to avoid gathering useless
information, but in certain circumstances he cannot perform as well as a
computer. Multiple discriminant analysis is a case in point. As one observer
notes, "There is a limita-
tion on the human mind regarding the speed, accuracy, and ability to
correlate and intercorrelate multiple variables with all possible outcomes
and treatment consequences." There is a limitation on the computer, too.
Practically speaking, there are many limitations. But in purely mathematical
capability, the human mind is much inferior to the computer in multiple-
discriminant analysis.
This is a function vital to diagnosis. It refers to the ability to consider a
large body of facts, and on the basis of those facts to assign a patient to one
diagnostic category or another on the basis of probability. Consider a simple
set of categories: appendicitis versus no-appendicitis. (This is a
simplification of what is, practically speaking, a larger problem in
diagnostic categories, but it will serve to explain the principle.) Let us
assume that a surgeon seeing a patient with pain on the right side must
make only this decision. How does he make it? No single piece of
information will tell him the answer (except, perhaps, the fact of a previous
appendectomy). Certainly such routine data as sex, age, white count, degree
of fever, duration of pain in hours will not tell him. But considered all
together, they permit him to arrive at a decision.
 This is all very familiar. But the point is that it is not very precise. A
discriminant function can be produced that weighs each variable-age, sex,
white count-on the basis of how important each variable has been in the
past. Thus the discriminant function has two uses. First, it can make a
diagnosis and act as a consultant to the surgeon.* Second, it can determine
which variables are most significant, which account for the greatest
proportion of the variance, in making a diagnosis. This can sometimes be
surprising. For example, one study of women undergoing gynecologic
surgery indicated that the age of the patient had great diagnostic
importance, and that notation of last menstrual period, biopsy of smear, pre-
operative hemoglobin, and urine-sediment study were all much less
important to making a diagnosis.
These applications of the computer are designed to be diagnostic aids to
the doctor, rather than a replacement. One hears, for example, that "even
though computers can be programmed to make diagnoses, it takes the
physician to perform the physical examination, and it takes the personal
contact of the doctor-patient relationship to gather the information needed
for the identification process."
For better or worse, this is not quite true. History-taking, long the
province of the physician and a keystone to his "art," is partially amenable
to automation. The Logan station utilizes a simple program, which is not so
much a conversation with the computer as a quiz. But more sophisticated
programs exist, and still better ones are being planned.
*Several discriminant functions have been made and shown to be as
accurate as the surgeons, though interpretation is made more complex by
the fact that these functions are generated from data on previously
diagnosed patients.
Some years ago, Joseph Weizenbaum of MIT designed a program to
conduct psychiatric interviews. Although in some senses the program can
be regarded as a "trick," it can nonetheless achieve impressive results. Dr.
Andrew T. Weil has reported one interaction between the computer and a
human psychiatrist as follows (the computer writes in upper-case letters;
mere humans, in lower-case).
Doctor, I have terrible news
YOU SAY YOU HAVE TERRIBLE NEWS
yes, there is a computer program at m. i. t. that'11 rui n us
WHY DO YOU SAY THAT
 i have seen it working
YOU SAY YOU HAVE SEEN IT WORKING
it's frightening - you must see it
YOU THINK I MUST SEE IT
you sound depressed to me
IN YOUR FANTASY PERHAPS WE SOUND DEPRESSED TO
EACH OTHER
yes - pe rhaps
I UNDERSTAND
i do too
YOU SAY YOU DO TOO
we are both in the same boat with respect to the computer
LET'S CONTINUE TO TALK ABOUT YOU - SHALL WE
you are a comfort
WHAT MAKES YOU THINK I AH A COMFORT
at a time like this you want to talk about me
WHY DO YOU THINK I WANT TO TALK ABOUT YOU
because you share my feelings about that damned computer
WHAT DOES THAT SUGGEST TO YOU
that, of course, you hate computers too
YOU THINK I HATE COMPUTERS TOO
why not, they're hardly human, are they
PERHAPS THAT'S WHAT WE ARE HERE TO FIND OUT
no computer could converse as you can, for example
OH
i can't understand how anyone could be fooled by a mere machine
CAN'T YOU REALLY
no, after all, there is nothing creative about a computer program
YOU ARE BEING NEGATIVE
i am convinced i am correct
ARE YOU WORRIED TO HAVE BEEN CONVINCED YOU ARE
CORRECT
no, not in the least, not at all. not even a little
YOU ARE BEING NEGATIVE
you said you agreed with me, didn't you
IS THAT WHAT YOU HEARD ME SAY
 why don't you try to dissuade me - computers diddle with numbers that
'sail
YOU WISH ME TO TRY TO DISSUADE YOU
you can't
YOU THINK I CAN'T
for example, could a computer in conversation like this raise a new topi
c
YOU SEEM TO HAVE AVOIDED SPEAKING OF YOUR PARENTS
ALTOGETHER
precisely as you just did YOU THINK I JUST DID
yes, and that's what shows the difference between a man and a computer
I SEE
This kind of interaction is suggestive, at least, of the ways computers
can be utilized in the future. And as the hospital reaches out into the
community, these may be increasingly important. According to Jerome
Grossman of the MGH Computer Sciences Laboratory, "A large part of
history-taking is directed toward finding out how sick a person really is.
The first question is always whether a patient needs to see a doctor at all.
That's the biggest decision doctors make over the phone now-talking to the
patients, trying to decide whether they're sick enough to be seen now, or
whether it can wait. The patients want to know the same thing, so they
spend all night or all weekend trying to get hold of the doctor, who's off
duty, or out of town, or something…
"In the near future, when the home computer and television set is
practical, you're going to be able to plug right into the hospital computer
without ever leaving your home. The computer will flash questions on the
screen, like 'Do you have a cough?' and you answer by touching the screen
with your finger at the appropriate place. We've just developed a screen like
this. It doesn't require any special gadgets or light pens or anything, just
your finger. Touch the screen, and the information is recorded. Eventually,
the computer will flash back some directions, like 'Come to the hospital
immediately' or 'Call your doctor in the morning' or 'Have a check-up
within six weeks,' or 'Someone will come on the screen, if further
classification is necessary.' So there you have it. That first big decision-who
needs to be seen-is settled by the computer, without ever having required
the doctor's presence."
 The idea is interesting not because it is an imminent practical
development-it is not [What is imminent is the use of computer stations to
take a portion of routine history and to advise the doctor on further tests.
Such consoles are already in use experimentally in the MGH medical
clinics and in certain private doctors' offices] -but rather that it represents a
further extension of the hospital into the community-not only into clinics
via TV, but into the homes of many individuals, via computer. One can
argue, in fact, that those who predict the hospital's role as "primary
physician" or "first-contact physician" is declining are wrong. It will,
ultimately, increase with the use of computers.
Automated diagnosis is one thing; automated therapy, quite another. It is
probably fair to say it is feared equally by both patients and physicians. It is
also important to state firmly that the following discussion is largely
speculative; automated diagnosis is in its infancy, but automated therapy
has hardly been conceived. Its modern forerunners are the monitoring
systems that check vital signs and the electrocardiogram. These monitors
are not computers at all, in any real sense; they are just mechanical
watchdogs, about as sophisticated as a burglar alarm.
At the present time, there are serious problems facing anyone who
wishes to automate the therapy of even a circumscribed class or category of
patient. To automate the therapy of all patients, with the full spectrum of
disease, would be an enormous undertaking. Whether or not it is done will
depend largely upon the demand for it, which in turn depends upon the
availability of physicians. In assuming that it will be done, at least to some
extent, I have also assumed that the shortage of physicians in this country
will increase in the foreseeable future, necessitating a practical change in
the doctor's functions.
Partially automated therapy is already desirable. The reasons are
twofold. First, modern therapy makes necessary an enormous amount of
paperwork; one hospital study concluded that 25 per cent of the hospital
budget was devoted to information processing. The usual hospital systems
for collecting, filing, and retrieving information consume great quantities of
time for nearly everyone working in the hospital, from the physician who
must spend time thumbing through the chart, to the nurses who must record
routine data, to the personnel who work full time in the chart-record storage
rooms. One consequence of the present methods, aside from the expense, is
the number of
 errors that occur at various points along the line. And the possible
advantage of putting all data through computers is the ability to check
errors. For instance, if medications are ordered by the physician through a
computer, that computer can tirelessly review orders for drug
incompatibilities, inappropriate dosages, and so on.
The second reason comes from experience with present monitors in
intensive-care units. These monitors "watch" the patient more carefully than
any group of physicians could; the patient's condition is sampled
continuously, rather than just during rounds. Such monitoring has already
changed many ideas about the nature of disease processes [One example:
the incidence of cardiac arrhythmia following myocardial infarction is now
suspected to be virtually 100 per cent; it is thus an almost certain
consequence of heart attack- this is useful information since the arrhythmia
are the most common cause of sudden early death from heart attack.] and it
has renewed consideration of therapy at intervals. For example, most drugs
are now given every six hours, or every four hours, or on some other
schedule. But why not continuously, in an appropriate dose? And in that
case, why not have a machine that can correct therapy on the basis of
changes in the patient's condition?
Seen in this light, automated therapy becomes a more reasonable
prospect. It will require adjustment, of course, by both doctors and patients.
But that adjustment will be no more severe than in other sectors of society.
In the past fifty years, society has had to adapt to machines that do
mechanical work-in essence, taking over functions of the musculoskeletal
system. It is now quite accepted that almost nobody does anything "by
hand" or "on foot," except for sport or pleasure. But what is coming is what
Gerard Piel calls "the disemployment of the nervous system," in a manner
comparable to the disemployment of the musculoskeletal system. Man has
accepted the fact that there are machines superior to his body; he must now
accept the fact that there are machines in many ways superior to his brain.
The image of the patient, lying alone in bed, surrounded by clicking,
whirring stainless steel is certainly unnerving. It is easy to agree with the
doctors who fear automation as leading to depersonalized care, and the
computer, as psychologist George Miller notes, as "synonymous with
mechanical depersonalization." But that is probably because we are so
unfamiliar with them, and, in any event, man has found ways to personalize
machines in the past-the automobile is a baroque example-and there is no
reason to think he cannot do it in the future.
One example of an attempt to computerize some elements of patient
therapy is the computer-assisted burns treatment project being carried out,
with the Shrine Burn Institute, in Dr. G. Octo Bar-nett's Laboratory of
Computer Science at the MGH. The project director, Kathleen Dwyer, notes
that "there's no theoretical reason why you couldn't build a program to carry
out some functions of a doctor, at least for certain kinds of patients. But,
practically speaking, it's a long way off."
In trying to find out why, precisely, it is a long way off, one gets two
kinds of answers. The first is that nobody is really interested in working
very hard, at the moment, to duplicate a doctor on magnetic tape. The
second answer is that doctors don't know themselves precisely how they
operate; until doctors figure it out, no one can program a machine to carry
out the same functions. The classic situation is that of the physician who
enters the room of a person with normal temperature, heart rate, blood
pressure, and electrocardiogram, takes one look at him and says: "He looks
sick." How did the physician arrive at that conclusion? If he can't tell you
the signals he used, then the programmers can't computerize them.
This situation is often held up as a kind of limit on the application of
machines to medicine. How can one imitate the "unconscious" or
"instinctive" or "intuitive" or "experiential" functions of a doctor? But, in
fact, as Kirkland and others have pointed out, the argument is really more
damaging to the reputations of physicians than machines. For, unless the
doctor is flatly guessing when he says, "The patient looks sick," he is
drawing a conclusion on the basis of some input, presumably visual. One
need only identify that input-and then plug it into the computer. But if the
input is truly unidentifiable, one must strongly suspect that the doctor is
guessing or expressing a prejudice.
In any event, there is considerable interest in knowing how a doctor
decides that a patient looks sick, or looks better, for, as Dr. Jerome
Grossman says: "Working with computers has made us look closely at how
people think."
But at the moment computer-assisted programs are all that are being
used. Dwyer's program, which will be in pilot use by the end of 1970, is
specifically designed to help in a major management problem-the burned
pediatric patient. These young patients require close monitoring and
frequent changes in therapy. This in turn produces an enormous amount of
paperwork and accumulated data that is hard for a physician to summarize
in his own mind simply by reading the chart. Dwyer anticipates that a
computer-assisted program would "facilitate the orderly collection and
retrieval of information [and] would not only improve patient care… but
would also lead to the development of optimal therapeutic models and a
better understanding of the disease process."
The first phase of the project will be a simple bookkeeping function:
storing information about the patient and his treatment and displaying it on
command on a teletype, or a cathode-ray tube (essentially, a TV screen),
whenever the physician requests it. A hypothetical example of such a
display is shown on the next page.
Here the computer is summarizing intravenous (Ringers) and oral fluid
intake, urine output, and weight change over a five-day period. This
achievement will not be very exciting to anyone who has not spent half an
hour going through a patient's chart attempting to extract this information-
which the computer can provide in milliseconds.

8/2/68 11 30AM EUTH. JOHN 123-46-67

TUB RIKGERS ORAL OKIHB HT(KG) OTHER IV
TODAY 8/2/68
BAM 800/300 - 100/100 82
MM 250/650 100/100 100/200 82.6
10AM 100/660 200/300 155/326 S3 100B
11AM 200/850 60/360 122/447 82.5

FLUID TOTALS INPUT: 1300 OUTPUT: 447 «T. CHANGE: +.8

YESTEBDAX 8/1/68

BAH 100/100 60/50 76/76 81

Bill 200/300 -/SO 60/126 81

10AM 800/600 100/160 76/200 81.6 800P

11AM 800/900 100/260 100/300 81.7

UFM 200/1100 76/326 100/400 88
UN 150/1250 -/Z26 160/660.
11PM 12AU
 6111 100/2600 -/TOO ZOO/1200 7AM 72/2576 60/750 100/1300
FLUID TOTALS INPUT: 3325 OUTPUT: 1300
82 82 BT. CHANGE: +1
1/31/68 300(200)/3200 1/30/68 3000(-I/3000 1/89/68 4200 (100)/4300
1100 1000 900
B,P

But the second stage is rather different. It is called "computer-generated

treatment regimen," and what it means is that the computer will itself advise
future therapy, which the physician is free to accept or ignore.
Another hypothetical example, for a new patient admitted to the unit:
ADMISSION DATE T
05/08/69 ADMISSION TIMEN^ 11.22AM ADMITTING DOCTOR'S
INITIALS… KRD PATIENT'S NAME… SMITH, JOHN BIRTH DATE…
it/20/65 UNIT NUMBER… 1234567
THIS UNIT NUMBER IS ALREADY ASSIGNED.
TRY AGAIN OR USE TEMP. UNIT NUMBER… 123456
LOCATION… SBI WEIGHT (LB OR KG?)… 20 KG HT (IN OR CM?)…
110 IN/CM? CM^ BURN DATE T TIME SAM TOTAL PERCENT
BURtT… 16
PERCENT 1ST DEGREE… 0
2ND DEGREE… 9^
2ND-3RD DEGREE… 27
BURN SURFACE COMPUTEoTo BE
0.27 SQ METERS TREATED PREVIOUS TO EW

NO

ew therapy
N/S
.0
ye? enter totals (ml) l!c~ringers… 200 plasma…? blood, urine.. 0~
vomitus
SUGGESTED INITIAL REPAIR AND MAINTENANCE 1440 ML
RINGERS BEFORE 4.00 PM 05/08/69 RATE: 315 D/M PED (80 AD)
1640 ML RINGERS BEFORE 8.00 AM 05/09/69 RATE: 100 D/M PED
 SUGGESTED INITIAL REPAIR AND MAINTENANCE 1440 ML
RINGERS BEFORE 4.00 PM AT A RATE OF 310 D/M (PED)
1640 ML RINGERS BEFORE 8.00 AM ON 05/09/69 AT A RATE OF
100 D/M (PED)
Now this is not really so ominous. The suggestions for therapy are
actually based on principles that come from John Crawford, chief of
pediatrics at the Burns Unit. In essence, they represent (assuming no error
in the program, and no variables that he would take into account but the
machine does not) his therapeutic program were he personally treating the
patient.
Thus the computer is at best as clever as a single clever man, and at
worst considerably less astute than that one man.
Once in use, the MGH burns project will be analyzed by doctors, and
adjustments made to refine the program. And as the program improves, it
may become more and more difficult for a physician to ignore the
computer's "advice."
In the future, it may be possible to have a computer monitor the patient
and carry out therapy, maintaining the patient within certain limits
established by physicians-or even by the computer itself.
The major consequence, indeed the avowed aim, of computer therapy in
any form will be to reduce the routine work of patient care done by doctors.
Other elements of that care are already disappearing; nurses have taken over
several of these, and technicians have taken over others. Thus, during the
week, the MGH has routine blood samples drawn by technicians and
routine intravenous maintenance-starting IV lines and keeping them
running-done by specially trained IV nurses. These programs were quite
radical a few years ago, when doctors thought nurses constitutionally
incapable of dealing with intravenous lines or drawing blood from a vein.
But a startling consequence of this new specialization of nonphysician
health personnel has been better care, in certain areas, than the physician
himself could deliver. Even if doctors don't believe this, the patients know it
well. On weekends, when the IV nurses and the blood technicians are off
duty, the patients complain bitterly that the physicians are not as skilled in
these tasks.
As for the special skills still reserved to physicians, such as lumbar
punctures and thoracic and abdominal taps, it is only a matter of time before
someone discovers that these, too, can be effectively delegated to other
personnel.
It would thus appear that all the functions of a doctor are being taken
over either by other people or by machines. What will be left to the doctor
of the future?
Almost certainly he will begin to move in one of two directions. The
first is clearly toward full-time research. The last fifteen years have seen a
striking increase in the number of hospital-based physicians and the number
of doctors conducting research in governmental agencies. This trend will
almost surely continue.
A second direction will be away from science toward the "art" of
medicine-the complex, very human problems of helping people adjust to
disease processes; for there will always be a gap between the illnesses
medicine faces and science's limitations in treating them. And there will
always be a need for people to bridge that gap.
Physicians moving in either direction will be helped by a new freedom
from the details of patient care; and physicians now emotionally attached to
those details, such as those doctors who religiously insist on doing their
own lab work, are mistaking the nature of their trade. Almost invariably,
they would do better spending their time talking with the patient, and letting
somebody else look at the blood and urine or count the cells in the spinal
fluid-especially if that person (or machine) can work more rapidly and
accurately than the physician himself.
One can argue that this presages a split among physicians, between
those with a scientific, research orientation, and those with a behavioral,
almost psychiatric, orientation. That split has already begun and some
bemoan it. But, in reality, art and science have rarely merged well in a
single individual. It is said that Einstein would have starved as a cellist, and
it is certainly true that the number of doctors in recent years who have been
both superb clinicians and excellent laboratory researchers is really quite
small. Such men certainly can be found, and they are always impressive-but
they are distinctly in the minority. In fact, the modern notion that the
average physician is a practitioner of both art and science is at best a
charming myth, at worst a serious occupational delusion.
In the final analysis, what does all this mean for the hospital and for the
patient in the hospital? One may look at the short-term possibilities, as
represented by the burns treatment program.
 It will reduce the mundane work of ward personnel, both doctors and
nurses, and leave them more time to spend with the patient. For doctors, it
should mean more time for research as well. And for the patient, that should
ultimately be a good thing.
Furthermore, as an extension of the hospital, a computer program offers
quite extraordinary possibilities. Any hospital in the country-or even any
doctor's office-could utilize the program, by using existing telephone lines.
A community hospital could plug into the MGH program and let the
computer monitor the patient and direct therapy. As a way to utilize the
innovative capability of the hospital, and its vast resources of complex
medical information, this must surely represent a logical step in 2,500 years
of evolution. And for the patient, that, too, should ultimately be a good
thing.
 Edith Murphy. Patient and Doctor
Six months before she came to the MGH, Mrs. Murphy, a fifty-five-
year-old mother of three, began to notice swelling of her legs and ankles.
This swelling increased and she became progressively weaker, until finally
she had to quit her job as a filing clerk. She consulted her local doctor, who
prescribed digitalis and diuretics. This reduced the swelling but did not
eliminate it completely. She continued to feel very weak.
Finally she was admitted to a local community hospital where she was
found to be severely anemic, to have bleeding in her gastrointestinal tract,
to have chemical evidence of liver disease, and X rays suggestive of cancer
of the pancreas. At this point, she was transferred to the MGH. She knew
nothing of her suspected diagnosis.
On arrival she was seen by Edmund Carey, a medical student, and Dr.
A. W. Nienhuis, a house officer. They found that she was slightly jaundiced
and that her abdomen was distended with fluid. Her liver could not be felt
because of this fluid. Her legs and ankles were still swollen. They
confirmed the presence of blood in her stools.
Laboratory studies indicated a hematocrit of 18 per cent, which meant
that she had less than half the normal number of red blood cells. Her reticu-
locyte count, a measure of new-blood-cell production, was increased. A
measurement of iron in her blood showed that she was iron-deficient. The
total picture was thus consistent with chronic anemia from blood loss
through the gastrointestinal tract, [The technical reader must excuse some
simplification in this presentation] but the situation was more complex: A
Coombs blood test was positive, suggesting that her body was also
destroying red cells by an allergic mechanism.
A chest X ray and electrocardiogram and kidney studies were normal.
Barium X-ray studies of the upper GI tract, to check the suggestion of
pancreatic cancer, could not be done immediately. A bone-marrow biopsy
was done, but it gave no further clue to the nature of the anemia. Her
abdomen was tapped and a sample of fluid withdrawn for analysis. There
was laboratory evidence to suggest liver disease and perhaps insufficient
proteins in her blood, but this could not be immediately confirmed on the
night of admission.
 Mrs. Murphy thus presented a complex and puzzling problem. The first
question was whether a single disease process could explain her three major
difficulties, which Dr. Nienhuis summarized as anemia, gastrointestinal
disease, and edema. As he noted, they could all be explained, in whole or in
part, by cancer or liver disease, by invoking mechanisms that are quite
complicated.
Implicit in his thinking was the notion that the body is constantly
changing, and that those features of the body which appear static are really
the product of a dynamic equilibrium. Thus the red-cell volume of the body,
which usually appears fairly constant, is really the product of ceaseless
creation and destruction of cells. The average red cell has a life span of 120
days; anemia can result from either inadequate production of cells or
excessive destruction of cells. In Mrs. Murphy's case, production seemed
actually increased, but she was losing cells through bleeding and allergic
destruction.
Similarly, water, which normally accounts for 70 per cent of body
weight, is carefully distributed in a healthy person-so much inside cells, so
much outside cells. Individual water molecules are constantly shifting
around the body, but the balance in each compartment is closely
maintained. Edema, the pathological swelling of certain tissues with water,
can be caused by a wide range of factors that disrupt the normal distribution
of body water. The same effect can be produced by heart disease, liver
disease, or kidney disease, each by a different mechanism.
Mrs. Murphy was admitted to the Bulfinch medical wards and passed an
uneventful night. In the morning she was seen on work rounds by Carey,
Nienhuis, and another resident, Dr. Robert Liss. Practical aspects of her
condition were discussed, particularly the question of transfusion. It was
decided to postpone transfusion since she appeared comfortable for the
moment. Later in the day Mrs. Murphy's problems were discussed with the
visiting senior physician on the wards, Dr. John Mills. He felt that "tumor in
the abdomen was strongly indicated," but for a variety of reasons felt that
lymphoma, a cancer of lymph glands, was more likely than pancreatic
cancer.
That same day, a radioactive liver scan was done to determine the size
of the liver, since it could not be felt directly. The liver was found to be
small and shrunken, suggestive of scarring from cirrhosis. The basis for this
cirrhosis was unclear. Mrs. Murphy maintained that she was a non-drinker.
She had no history of hepatitis in the past, and no occupational exposure to
liver poisons. The cirrhosis was therefore labeled "cryptogenic," meaning of
hidden cause.
For the next three days the question of cancer, or liver disease, or both,
was widely discussed. As evidence of liver damage accumulated,
cryptogenic [To an outsider, the tendency among physicians to call certain
diseases cryptogenic or idiopathic-and then to discuss them as if they were
well-defined, understood clinical entities-may be perplexing. But in fact it
serves a purpose. For one thing, it excludes diagnoses: anyone who speaks
of cryptogenic cirrhosis has excluded alcoholic or post-hepatitic cirrhosis.
By implication, the term conveys more information than a simple "We don't
know why." In the same way, idiopathic hypertension implies prior
exclusion of the few known causes of this condition] cirrhosis became the
favored diagnostic possibility.
Meanwhile, Mrs. Murphy began to feel better. She received a
transfusion of three units of blood, and felt better still. She did not,
however, receive any further therapy.
Everyone agreed that a liver biopsy would be useful, but the patient had
a bleeding tendency- presumably secondary to liver disease-which made a
biopsy impossible. Other diagnostic procedures were not helpful.
Sigmoidoscopy and barium enema failed to determine the origin of
gastrointestinal bleeding. A check for cancer cells in her abdominal fluid
was negative.
On the seventh hospital day, she was seen by Dr. Alexander Leaf, who
suggested thyroid tests as well as tests for collagen diseases. The following
day, Dr. Nienhuis raised the question of whether this patient might have
lupoid hepatitis, a rare and somewhat disputed clinical entity.
In the next forty-eight hours, two important pieces of evidence were
obtained. First, an upper GI series was done, and it was normal. There was
no sign of cancer of the pancreas.
Second, a re-examination of the patient's white cells revealed several
with large, abnormal, bluish lumps imbedded within the cell substance.
These cells are called LE cells, for they are virtually diagnostic of a
collagen disease, systemic lupus erythematosus.
This is a disease of enormous interest to physicians at the present time.
Once considered rare, it is now seen with increasing frequency as
diagnostic tests become more refined. Classically it has been considered a
disease of middle-aged women, characterized by protein manifestations-
fever, skin eruptions, and involvement of many other organs, particularly
joints and kidneys. However, as lupus is better understood, the classical
description is changing: more males are now found with SLE, and the range
of clinical manifestations has broadened.
Lupus is called a collagen disease because it shares with certain other
diseases a tendency to alter blood vessels and connective tissue, and
because it seems, like these other diseases, to be caused by some form of
hypersensitivity (allergy). This question of causation is by no means clear,
but patients with the disease certainly show a wide variety of biochemical
disorders of the immune system; lupus is frequently called "the autoimmune
disease par excellence."
Normally, the body's immune mechanism produces antibodies to fight
agents, such as invading bacteria. This response is generally beneficial to
the individual, although much recent work has gone into suppressing the
response so that foreign organs can be transplanted.
However, it is now recognized that the body's natural rejection
mechanism can sometimes be mistakenly directed toward the body itself. In
some way the individual's capacity to distinguish what is native from what
is foreign is disrupted; the patient attempts to produce immunity to himself-
and proceeds to attack certain of his own tissues, leading to "a chronic civil
war within the body."
In the case of lupus, the patient produces several sorts of antibodies
against himself. One of these attacks DNA, the genetic substance of
chromosomes. This damaged DNA is later ingested by white cells,
producing the characteristic bluish lumps. However, SLE patients also
produce other auto-antibodies, which are seen in other conditions. Thus
Mrs. Murphy was found to have anti-DNA antibodies, increased gamma
globulin, and antibodies against thyroid, as well as antibodies found in
rheumatoid arthritis.
Immune disorders as a cause or complication of illness are now
suspected for a great range of diseases, including rheumatic fever,
pernicious anemia, myasthenia gravis, multiple sclerosis, Hashimoto's
thryoiditis, and glomerulonephritis. Immune and auto-immune mechanisms
are thus of considerable interest; investigation of these mechanisms
represents one of the major thrusts of current medical research.
 For systemic lupus erythematosus, however, there is no cure and no
good information on prognosis. Patients have died within a few months of
onset; others have lived fifteen or twenty years. For Mrs. Murphy, therapy
consisted of diuretics, which resulted in loss of thirty-two pounds of fluid,
and a cautious trial of corticosteroids to suppress some effects of the
disease. She was discharged feeling well and returned to her job.
The case of Mrs. Murphy illustrates an important function of the ward
patient in the university hospital that differentiates him from the private
patient: the ward patient is there in part to help turn students into doctors.
For the patient, this has its drawbacks as well as its advantages.
First, to clarify some terms:
A medical student is anyone with a bachelor's degree who is in the
midst of four years of graduate work leading to the M.D. degree, but not yet
to a license to practice. To be licensed, he must spend an additional year as
an intern in a teaching hospital.
An intern is thus anyone with an M.D. who is in his first year out of
medical school. An intern is licensed to practice only within the hospital.
After a year of internship, he could theoretically leave and begin private
practice, but practically nobody does. Instead, interns go on to become
residents.
A resident is anyone who has finished his internship and is continuing
with more specialized training in such areas as pediatrics, surgery, internal
medicine, or psychiatry. A residency may be taken at the same hospital as
the internship or at another; residencies last from two to six years,
depending on the field.
Medical students are primarily responsible to the medical school, not
the hospital; within the hospital they are referred to, somewhat ironically, as
"studs."
Interns and residents, on the other hand, are hospital employees and are
referred to as "house officers." Collectively the interns and residents
comprise the "house staff," as distinct from the "senior staff," meaning the
private physicians or academic teachers affiliated with the hospital.
This hierarchy is analogous to a university with its undergraduates,
graduate students, and professors. There are departments within the hospital
corresponding to university departments; these departments give courses for
medical students and house officers, termed "rotations." Primarily, the
teaching is informal, but there is also a heavy schedule of formal rounds,
lectures, and seminars.
In the history of the teaching hospital, as in the university, the
undergraduate (or medical student) appeared much earlier than the graduate
student (or house officer). Indeed, the beginnings of the teaching hospitals
are closely associated with the beginnings of medical schools in this
country. This was clearly the case for the first three medical schools, and
the first three teaching hospitals in America: in Philadelphia, New York,
and Boston.
The Massachusetts General had Harvard students on the wards from its
inception. There is no reason to believe the students made the hospital more
appealing; Warren recalled that students in his day "were of the crudest
character," and remembers that it was no recommendation to a landlady to
say you were a medical student. Even a century later, Harvey Gushing
grumbled that "students in a hospital, like children in a lodging house, are
not an unmixed blessing." But despite persistent reservations, the teaching
hospital has always taught medical students. What is new is the teaching of
house officers.
Originally, medical students were required to take two years of
academic courses, followed by a third year as an apprentice to a practicing
physician. In those days the MGH had two house-officer positions-then
known by the considerably more humble term "house pupils"-and these
posts were acceptable substitutes for an apprenticeship. Beginning around
the time of the Civil War, however, the hospital began to expand its house-
officer posts; the greatest growth came at the turn of the century. In 1891,
there were seven house officers; by 1901, fourteen; by 1911, twenty-one.
As mentioned, there are now 304.
Part of this growth represents a simple growth of the hospital. As it
became larger, there were more patients to care for, and to learn from, and
more day-to-day work to be done by house officers.
Part of the growth represents the increasing role of the hospital as an
acute-care facility. The hospital sees fewer patients with chronic diseases
and more acutely ill patients who require continuous and careful
management. This requires a larger house staff.
Partly, too, the growth represents a shift away from the old personal
apprentice system toward an "institutional apprenticeship." In the 1930's
and 1940's, it became clear that house officers who remained in the hospital
were better trained than those who left early and linked up with private
practitioners. This observation finally led to virtual abandonment of the
personal apprenticeship. Thus, formerly, surgical residency was three years,
followed by two years of apprenticeship under a private man; now it is five
years (including internship), and the only reason for joining a private
surgeon at the end of that time is to build a practice, not to gain more
experience.
All this means that the structure of patient care is quite different today
from what it was when the hospital first opened. In 1821, patient care was
essentially in the hands of private, senior men who donated their time to the
hospital and agreed to take students around with them on the wards. But
between student and senior man there has sprung up a large body of
individuals who are now essential to the functioning of the hospital. The
MGH could cheerfully dispense with its medical students, but it would
come to a grinding halt in a few hours if deprived of its house staff.
It is no exaggeration to say that the house staff runs large areas of the
hospital, with senior men advising from above, and students looking on
from below. One may applaud this system for providing a spectrum of
competence and responsibility, allowing students to move up the ladder to
internship, then junior and senior residency, in easy stages. But in fact the
emergence and proliferation of house officers has another, much harsher
rationale. For the hospital, they provide a source of trained, intelligent,
hard-working, very cheap labor.
This has always been true. In 1896, when Gushing was an intern, he
noted that "house officers are about as hard worked men as I have ever
seen. Every day is twenty-four hours long for them with a vengeance."
The modern house officer generally works an "every other night"
schedule, meaning roughly thirty-six hours on duty, and twelve off. In
practice this means arriving at the hospital at six thirty or seven in the
morning, working all day and probably most of the night, continuing
through the following day until late afternoon, and then going home to
sleep-until six thirty or seven the next day. Payment for this effort, which is
sustained over many years, was until quite recently nonexistent. Some
hospitals were so bad that they worked their house officers at this pace, paid
them nothing, and charged them for laundry and parking.
Others would provide a few meals, and perhaps an honorarium fee of
twenty-five dollars a year. At the MGH, a senior man recalls that as recently
as ten years ago, "I was chief resident in surgery, eight years out of medical
school, having spent two years in the army; I had a wife and four children; I
was responsible for the conduct of an entire surgical service-and I was paid
just under two thousand dollars a year."
Such a situation requires either an independent income or a great
tolerance for debt; one wonders whether the modern stereotype of the
private physician as crassly avaricious can be traced back to these years of
early, absurd financial hardship. Fortunately, the salaries of house officers
have climbed sharply in recent years. In many hospitals an intern now
receives six thousand dollars, a senior resident eight or nine. Many factors
are responsible for the increase: the effect of Medicare, which permits the
hospital to charge patients for the services of a resident; the fact that the G.I.
bill has been extended to cover residency training; the realization among
medical educators that you cannot get and keep good people in an affluent
society without paying them.
As the house officers have become more numerous and more skilled,
the position of the medical student has changed. House officers are licensed
to practice medicine; students cannot practice by law. A student cannot
write orders, even for something as simple as raising a patient's bed,
without having them countersigned by a house officer.
Legally, a student is permitted to employ nothing other than diagnostic
instruments, and then only for the purpose of diagnosis. In practice, this
ruling is stretched to mean that a student can, under supervision, perform a
lumbar puncture, a thoracic or abdominal tap, or a bone-marrow aspirate; he
can suture wounds in the emergency ward; he can also mix medicines, start
intravenous infusions, inject medicines intravenously, and give a blood
transfusion. Additionally, he is expected to have competence in a variety of
laboratory procedures and tests.
The medical student's officially sanctioned functions thus lie
somewhere between those of a doctor, a nurse, and a laboratory technician.
It is not surprising that no one knows what to call him. Instructors with a
group of second- or third-year students will often introduce them to patients
as "doctors in training" or "these young doctors." Fourth-year students,
seeing patients alone, will introduce themselves as "doctor." Until a few
years ago, the students even wore name tags which said
"Dr.," but this practice was abandoned
 after the hospital was advised it constituted misrepresentation that might
have legal consequences. Student name tags now give only their names;
those of interns and residents say "Dr."
It is not clear why medical students are called doctors in front of
patients, especially since so few patients are fooled by the appellation. One
can view the whole business as a harmless convention,
in which the hospital pretends that its students are doctors, and the
patients pretend to be taken in.
Why bother? Instructors say that this small white lie comforts the
patients, who would be upset to learn they were being examined by
students. Something of the same sort happens with interns, who
occasionally pass themselves off as residents in the belief that this soothes
patients. It is true that the folklore-and the mass-media image-of the
medical student and the intern is distinctly unfavorable, and these negative
connotations persist until residency. (Dr. Kildare, that charming, all-
knowing physician, was a resident who spent much prime time dealing with
neurotic, guilt-ridden, fumbling interns and students.) "Even now,"
according to George Orwell, "doctors can be found whose motives are
questionable. Anyone who has had much illness, or who has listened to
medical students talking, will know what I mean." In a single, paradoxical
stroke, he dismisses the motivations of some doctors, but all medical
students.
The position of the medical student is thus peculiar, and occasionally
comical. In society at large, he finds himself eminently marriageable and a
good credit risk, thus enjoying the approval of those two bastions of
conservative appraisal- matrons and bankers. In the hospital, however, those
same matrons and bankers want nothing to do with students, and nearly
every student has had the experience of examining a woman who grumbles
and complains throughout the history and physical and then politely asks if
the student is married.
In the end, one suspects that the practice of labeling students as doctors
is misguided. Patients ought to be told explicitly who the students are; a
moment's reflection shows many advantages to such a practice.
For one thing, most patients coming into a teaching hospital are already
apprehensive about being used as guinea pigs. They have heard vague
reports that "You'll be in the hands of students and interns," and this is not
really true. Patients entering the hospital-already sick and afraid-are almost
always unfamiliar with the hierarchy of decision-making that provides
careful checks on junior men. Against this background of apprehension is
added the fact that everyone introduces himself as a doctor, while the
patient knows perfectly well that some of those doctors are students. Thus,
failure to identify students increases anxiety instead of relieving it.
Further, it is a common observation on the wards that students are
popular with patients. Students have more time to talk to patients; hospital
life for a patient is boring; patients like the attention. (Frequently they will
rank the house staff according to warmth and attentiveness. A friendly
student who has had the experience of working with a brusque resident
knows how often patients
conclude that the resident is a student, and vice versa.[This implies that
patients associate brusqueness with professional ineptitude, and that may be
valid])
Finally, it is explicit in the bargain any teaching hospital makes that a
patient will receive better care, but in return must put up with teaching. The
teaching function might as well be identified as such. In any case, as
Frederick Cheever Shattuck said many years ago, "Before swerving from or
denying the truth we should ask ourselves the searching question, 'For
whose advantage is this denial?' If it is in any measure for our advantage, or
seeming advantage, let us shame the devil."
How do students, house officers, and senior men combine to produce
the ward teaching system? As exemplified by Mrs. Murphy's experience,
the system works as follows.
When the ward is notified that a new patient is being admitted, the
student goes down to the EW and examines the patient. On occasion, he has
to hurry to beat the house officer, but students learn to do this, and the best
house officers will go to great lengths to allow the student to perform the
initial examination. The reason for this is that with each succeeding history
and physical, the patient becomes more accustomed to the routine of
delivering his story in an orderly but unnatural manner. Fresh patients are
the most difficult to get a history from, and therefore the most prized.
After a student has examined the patient, the resident conducts a second
examination, and then comes out to talk to the student about the case. The
resident generally has only three questions: "What did you find?" "What do
you think he has?" "What do you want to do for him?" Interestingly, these
are the only really important questions in all clinical medicine.
 A discussion of diagnosis and treatment follows; if the resident agrees
with the student, he will let him write the orders, then countersign them.
Diagnostic procedures such as lumbar puncture, bone-marrow biopsy, and
so on are usually done by the student under the resident's supervision. By
tradition, patients are expected to be "worked up" as much as possible on
the day (or night) of admission. This means that in addition to the history
and physical, the ward team is supposed to look at the blood morphology,
do a white-cell count, a hema-tocrit, an electrocardiogram, urinalysis,
review the chest X ray-and whatever other, more sophisticated, tests are
necessary, all at the time of admission.
The student may do much or all of this, but he really has no control over
the patient's care. Most of the decisions-decisions at the time of admission,
and all later decisions-are made by the admitting house officer. This is why
the medical service regards "admitting a patient" as directly equivalent to
the surgeon's "doing a case." In each instance, only one person can have the
responsibility of decisions on patient care. And while it is valuable to look
on, it is not the same thing as doing it yourself. The experience of
responsibility is not transferable.
Each house officer thus has a series of "his patients" on the ward; these
are the patients he originally admitted, and he feels primary responsibility
for them throughout their hospital stay. He is expected to know more about
his patients than anyone else, though others must know enough to handle
details of care when the resident is off duty. The sense of individual
responsibility is so strong that it is couched in possessive terms. One house
officer may ask another, "Is Mr. Jones your patient?" and be told, "No, he's
Bob's."
The student's role in all this is to pretend that he is the admitting house
officer, and to continue pretending so throughout the hospital stay. A
student generally works closely with one intern or resident, keeping the
same hours, following him along. Among students there is an active
grapevine to keep everyone informed about which house officers are good
to work with and which not. A good house officer is one who is confident
of his skill (insecurity is catching); willing to take time to teach the student;
and unwilling to delegate all routine work, termed "scut," to the student.
On the morning after a patient's admission, during "work rounds" from
7:45 to 9:00, when the ward team goes from patient to patient, the student is
expected to summarize informally the history, physical, and lab tests for the
benefit of those team members who were off duty the previous night. A
formal discussion is given by the student during "visit rounds" later in the
day, when he relates the details of the case to the visiting physician, usually
just called "the visit." The visit is a staff member of the hospital, assigned to
the wards for a month, and legally responsible for all the patients on the
ward.
The student's formal discussion is known as "presenting." To present a
patient means to deliver the salient information in a brief, highly stylized
form. The student is expected to do this from memory. A presentation
begins with events leading up to admission for the present illness; then goes
on to past medical history; then a review of organ systems; family and
social history; physical findings beginning at the head and working down to
the feet. Laboratory data is then presented in a specific order: blood studies,
urine studies, cardiogram, X rays, and finally more specialized tests.
The entire process is not supposed to take more than five minutes.
A good presentation is difficult, for along with summarizing positive
findings, the student is expected to include certain "pertinent negatives"
from among the almost infinite number of symptoms and signs the patient
does not have. These pertinent negatives are intended to exclude specific
diagnoses. Thus, if a patient has jaundice and a large liver, the student
should state that the patient does not drink, if this is the case.
Aggressive students can be quite abstruse in their negatives, hoping that
the instructor will interrupt and ask (for example): "What were you thinking
when you said the patient had never danced in Tibet?"
To this the student can triumphantly name some obscure disease that
vaguely fits the situation, such as "the Kurelu Dancing Syndrome, sir." He
thus appears well read. The game can be dangerous with a knowledgeable
visit, however, for he is likely to shoot back: "The Kurelu Dancing
Syndrome never occurs in males under forty, and your patient is thirty-six.
If you want to do some reading, I refer you to the Kurelu Medical Journal,
volume ten, number two." This is a signal for the student to crumble; he has
lost the round-unless, of course, he has a rejoinder. There is only one
acceptable form: "But, sir, in the Mauritanian Journal of Midwifery last
week there was a report of a case in a ten-year-old boy." This may, or may
not, work. The visit may reply, "The what journal? Wasn't that the one
which reported that skimmed milk caused cancer?"
That ends the discussion.
 Among students, visits are classified into two groups-"benign," and the
others. It depends on how the visits treat students. Generally the visit sits in
silence throughout the presentation; he then begins by pointing out all the
things the student forgot to mention; and then proceeds to ask questions. He
is entitled to ask questions on anything he likes, so long as it vaguely relates
to the case at hand. He can, if he wishes, keep the student hopping.
For example, a typical discussion about a case of stress duodenal ulcer
might have the visit first asking the anatomy of the four parts of the
duodenum; then the arterial supply to the stomach; the common
complications of duodenal ulcer; the factors that classically increase and
decrease ulcer pain; the features that distinguish ulcer pain from the pain of
acute pancreatitis, gall bladder disease, or heart attack; the four indications
for surgical intervention; the reasons for measuring serum pancreatic
amylase and serum calcium; the mental changes one might expect with GI
bleeding in the presence of liver disease, and the reason for the change; the
other causes of upper GI bleeding; the way to distinguish upper and lower
GI bleeding; and so on.
Furthermore, the visit can shift to a related topic at any point. If he asks
about serum calcium and the student correctly answers that there is a
relation between parathyroid disease and ulcer, the visit may go on to ask
how calcium fluctuates in parathyroid disease; the associated changes in
serum phosphate; what changes might be seen in the electrocardiogram;
what mental changes are associated with increased and decreased serum
calcium, in adults and in children.
Thus a student who began talking about ulcer disease is effectively
shunted to calcium metabolism. And, at any time, the visit can turn around,
demand to know six other conditions associated with ulcer, [Such as
chronic lung disease, cirrhosis, rheumatoid arthritis, burns and strokes,
pancreatitis, and the effects of certain drug therapies, especially
steroids] and go on to discuss each of them. Visit rounds are two hours
long. There is plenty of time.
For the most part, interns and residents are exempt from grilling; it is
considered too undignified. The visit treats house officers as colleagues, but
not students. A house officer who asks a question of the visit will get an
answer. A student who asks a question will most often get a question back,
as in "Sir, what does the serum calcium do in Chicken Little disease?"
"Well, what do the plasma proteins do in Ridinghood's Macro-
globulinemia?" If the student fails to see the light, he will get another hint,
also in the form of a question: "Well, then, what about the serum phosphate
in Heavyweight's Syndrome?"
This is a form of a game which is repeated over and over again in
medical teaching. It is a game useful to the conduct of medical practice. A
very simple example of the game is the following:
student: "The patient has a rash and fever."
visit: "Has he ever been to Martha's Vineyard?"
student: "No, he does not have Rocky Mountain spotted fever."
The point is that the student sees the implication behind the question-
that each year one or two cases of Rocky Mountain spotted fever are
contracted on Martha's Vineyard. Such deductive processes are precisely
those important to the conduct of medicine, and therefore represent a useful
teaching method. In the extreme, this can lead to a leap-frog interchange
which is almost beyond the understanding of the casual observer:
student: "The patient has kidney disease consistent with
glomerulonephritis."
visit: "Was there a recent history of infection?"
student: "Anti-streptolysin liters were low."
visit: "Was there a facial rash?"
student: "LE prep and anti-nuclear antibodies were negative."
visit: "Were there eyeground changes?"
student: "Glucose-tolerance test was normal."
visit: "Did you consider rectal biopsy?"
student: "The tongue was not enlarged."
This is jumping from mountaintop to mountain-top, skipping the
valleys. In translation, the visit is asking, first, whether the
glomerulonephritis was caused by streptococcal infection; second, whether
it is due to lupus; third, to diabetes; and finally, whether due to amyloidosis.
The student is denying each diagnosis by presenting negative data. Neither
teacher nor student specifies the diagnosis; the game is to figure out what
each is talking about without saying what it is.
This Socratic tradition of teaching medical students dates back to the
days when medicine was an apprenticeship in the strictest sense. The
Socratic method has the virtue of informality: on work rounds, the resident
can ask the student in passing, "How will we know when Mr. Jones is
adequately digitalized?" and the surgeon can pause in his operation to ask
the student, "What would happen if I cut this nerve here?" It is a good way
to keep the student constantly recirculating his knowledge through his
brain, and by and large it works well.
Why not just state the fact, as a declarative statement, for the edification
of the student? There is just one major reason: most medical students are
tired. At any given moment, a lecture to a medical student is a signal to
click off, to tune out, to go to sleep. Partly, this is a learned response. It is
common, during the first two years of medical school, to have four hours of
lectures and five hours of laboratory work in a single day. Students who are
studying late into the night on top of this schedule learn to sleep during
lectures with great facility. The pattern carries on into the clinical years.
One can observe lectures to medical students and house staff in the hospital
in which 20 to 50 per cent of the class is slumped over in their chairs. The
lecturer pays no attention. To a lecturer, it is not an insult, but a fact of life.
Everybody accepts it; everybody expects it.
The only way to beat the dozing off is to ask questions. Supposedly this
makes the learning experience more active, less passive. But, as anyone
who has ever attempted to put together a programmed text knows, teaching
by questions is extraordinarily difficult. The ideal set of questions is graded,
going from fact to fact, leading the student from information he knows well
to the reasoning out of information he does not know. On the other hand,
the usual unplanned set of questions just draws a blank look and a guess.
For some reason, the question-and-answer teaching method is a
peculiarity of professional school instruction. It is common in law,
medicine, and business, and practically unknown in other graduate fields.
The best teachers can employ it to great effect; most teachers are hopeless
at it.
The system is most likely to succeed when applied to an individual-and
almost certain to fail when applied to large groups. I have watched a
specialist in diabetes walk into a room full of third-year students, rub his
hands together, and say: "All right. Let's suppose you've gotten your
diabetic patient. He has a blood sugar of three hundred. What kind of diet
are you going to put him on?" Nobody in the room had the faintest idea
what kind of diet to put him on. "How many grams of carbohydrate do you
want to give him?" the instructor demanded. Nobody knew; nobody said
anything. Finally he pointed to a student and insisted on a figure. "Ninety
grams?" the student said. "Wrong!" said the instructor, and went around the
room until somebody finally guessed one hundred grams, the figure he
wanted to hear. "Now then, how much insulin do you want to start him
with?" the instructor asked, and the game began again.
It would be pleasant to think such examples atypical of medical
education, but in fact they are more the rule than the exception.
Considerable dedication is required of students to learn medicine in the face
of such teaching; one often has the impression that medical education works
despite itself.
Useful changes can be made in all elements of the process^-changes in
the students, changes in the teachers, changes in the teaching methodology.
Of these, only one appears very likely: the traditional routine of every-
other-night for clinical students and house officers is dying. Many hospitals
are shifting to an every-third-night schedule, which makes a considerable
difference. The student or house officer sleeps through his first night off,
but he is able to read during the second night; and during the day he is more
alert, more awake. This helps to remove one of the oldest paradoxes in
medical education-namely that the hospital claims to provide an excellent
learning environment, while systematically depriving its students of sleep.
A change in teachers is less likely. Clinical teaching posts have status
attached to them; a private man likes to be able to say he "spends some time
with the students." At the same time, teaching hasn't got much value as a
way to be promoted within the academic hierarchy; medicine, like every
other field, puts its emphasis on published research. This leads to a
multitude of rather casual teachers who may spend only a few hours a year
with the students. These people-like the diabetes expert, who comes to the
hospital once every three months to deliver his little talk-are most
pernicious. They do not care enough about teaching to attempt to do it well;
they don't have enough experience with students to know how to direct their
talk; they have never received any training in exposition and attach no
significance to a good delivery.
Having dismissed these people, one should say that medicine does
indeed correctly sense that private, experienced practitioners have
accumulated practical knowledge that ought to be communicated to
students. Unfortunately, this is not the way to do it.
Methods of teaching require considerable revision. You can be assured
that this is taking place-it is always taking place and always has been.
Curricula change, new courses spring up and others die, grand lectures on
education are given citing Gushing and Osier, but somehow the
fundamental quality of medical education remains the same.
The methodology continues to be perplexing. The notion that the
subject should be suited to the manner of teaching; the idea that certain
things are best taught in lectures, others in seminars, others individually; the
understanding of those qualities that distinguish the lecture from the slide
from the
printed page from the visceral experience-all these things are
traditionally lacking in medicine.
Future medical educators, for example, will probably look back on the
teaching hospital and shake their heads at the way "patient material" was
used. One can argue that this use, at the present time, is highly inefficient.
The individual patient in a teaching hospital is not intensively used for
teaching. A bizarre case may be seen by fifty or sixty people, but the
average ward patient is seen by many fewer, particularly if his problem is
common and his stay in the hospital is short.
The need to see patients firsthand is an important part of medical
education; one must have experience with many ill individuals, exhibiting
many different manifestations of disease. This is necessary because there
are both many diseases, and many forms that a disease will take in different
people. To obtain the proper depth and breadth of experience requires a
long time; a student or house officer must remain in the hospital at all hours
for many years. Otherwise, he is going to miss vital experiences.
However, a number of ways of "saving the patient for future reference"
are now possible. Teaching collections of X rays have existed for several
years, enabling students to gain broad radiological experience without
waiting for the patients actually to come in. But this is only the beginning:
one can record a patient's appearance and important physical findings on
video tape; one can even record an interview and history-taking. By such
techniques literally hundreds of students can, over a period of years, have
some experience with a given p;
And one can go further. For example, one n most severe limitations of
modern clinical tea is that the student cannot really use the pati«"practice
on." While mistakes are an imp* part in any learning process, in the hospita
are discouraged and guarded against-and n so.
What is needed, of course, is a disposable tient, for whom mistakes do
not matter. In the one can argue, the disposable patient was pro by society in
the form of the charity case (at this was the popular belief); but this requiu
can now be provided by technology. Anesti have developed a lifelike plastic
dummy i for students to practice on; this dummy can allergic reactions to
anesthesia, cardiac and n atory arrests, and a variety of other serious ci
cations. The student can practice on the di«with impunity. So far, the only
analogous sin is that provided by the post-mortem patient used for practice
of surgical procedure. B» will see much more in the future.
For example, a teaching program can be pii a computer, enabling the
student to ask ttu tient" questions, and get back replies. On th-. of such an
interview, the student can make a nosis and institute therapy. The computer
car inform the student of the consequences of hi scribed regimen.
In fact, such methods are already in usual Board Examinations, Part III-
the section to interns prior to certification. The exam imong other things,
film clips of patullowed by questions about the patient's It also contains a
most interesting section if brief histories, followed by specific such as
"What would you do immedi- iiis patient?" After each question is a :ssible
answers, such as "Begin intrave- :eplacement," "Start antibiotics," "Give iid
so on. And following each answer is 'lit space.
nt selects the therapy he wants and er- acked-out space to reveal the
conse- his choice. If he has chosen correctly, i will be encouraging: "Patient
im- Hut if he is wrong, the answer is likely to Patient dies."
se techniques, it is possible to give the posure to rare clinical situations
he r see otherwise. It is also possible to ulent exposure in depth to a
problem. iiki program the differing clinical histories patients with
hyperthyroidism, for ex-let the student work through them all, idea of the
differences from case to nt this will ever replace experience at the it it will
certainly supplement that and very soon. There are two reasons L-chniques
will gain rapid acceptance.
is a slowly simmering rebellion against the length of medical education.
In this country the average physician is almost halfway to the grave before
he is prepared to start practice-and the trend is toward even longer
educational periods, not shorter ones. At the same time, there is a demand
for more physicians, and the suggestion that this demand can be met, in
part, by faster education. There is also a growing suspicion that in affluent
America some of the best young men shun medicine because the
educational period is so long.
 As an educational process, medicine has suffered the full effects of the
scientific outpouring of information; the response of medical educators has
been simplistic-to lengthen the period of formal training as the body of
knowledge has increased. This cannot go on indefinitely, and specialization-
breaking up knowledge into smaller and smaller areas-will not provide the
whole solution.
As a stopgap measure, medical schools have kept the total number of
years constant, but have lengthened the per-week teaching load. Thus
medical students at Harvard attend twice as many hours of classes per week
as law or business students. Of necessity, this makes medical education a
very passive business and deprives the student of the single most important
thing he desperately needs to learn while at school-how to initiate the
educational process for himself, later on, when he is a practitioner.
For medical schools there are only two solutions: to teach less or to
teach more efficiently.
Medicine has been reluctant-sometimes wisely, sometimes not-to teach
less. Curriculum changes are a traditional sport, but they occur slowly (John
Foster notes that "it is easier to move a graveyard than to change a medical
curriculum") and never seem to make manageable the total information to
be mastered. The current administrative structure of medical schools
appears incapable of curtailing the curriculum. Educators must therefore
devise ways to teach faster. It is the only solution.
If it is hard to be a student, it is much harder to be a good visit, for a
visiting physician has the most difficult teaching job in the world. His
"class" of students, interns, and residents is small, but their depth of
knowledge is dissimilar, and the visit must endeavor to teach everyone. His
subject matter is all of medical knowledge; he must act simultaneously as
adviser, librarian, lecturer, and, at the bedside, as a direct example in
dealing with patients. The best visit is a marvel to watch. In an hour he can
listen to the student, quiz him, arrive at a diagnosis, proceed to deliver a
ten-minute extemporaneous lecture on some aspect of the diagnosis, throw
in one or two humorous anecdotes, see the patient and elicit more
information than the students and house staff were able to obtain, in the
process demonstrate an obscure physical sign, then step into the hall and
summarize the entire situation in a few minutes.
And then go on to the second patient of the day.
 The whole act depends on vast knowledge, clear organization,
boundless energy. But it is also the final check in the long system of built-in
checks- the intern checks on the student, the resident checks on the intern,
and the visit checks on everybody.
What does all this mean for the patient? Most teaching hospital
physicians believe it produces better patient care. According to Dr. Robert
Ebert, dean of Harvard Medical School, "It is far easier to check on the
mistakes of an incompetent intern than the mistakes of an incompetent
private physician. It is one of the ironies of our system of medicine that a
very sick charity patient in the ward is likely to receive better and more
constant medical attention than his counterpart on the private side of the
hospital."
These considerations lead Dr. Ebert to talk of "the privileges of being
used for teaching." This is an idea foreign to most private patients, yet our
definition of the "teaching patient" is in the midst of drastic revision for that
most fundamental of reasons, money. The financial structure of the hospital
is changing, and with it, everything else.
Originally, the Massachusetts General and hospitals like it were founded
to care for the sick poor. Patients entering the hospital agreed to be used for
teaching, in exchange for medical care they could obtain no other way. At
this time, there were virtually no private patients in the hospital. Any
individual of means preferred to be treated- and to be operated on, if
necessary-in his own home. Even at the turn of the century, the hospital was
no place for the wealthy. When the Peter Bent Brigham Hospital was built
in Boston in 1913, its planners made no provision for private patients.
Soon thereafter things began to change. The development of anesthesia
made operations more common, and the use of Listerian antisepsis did
much to reduce cross-infection and epidemics of "hospitalism." The
hospital emerged as a place for all severely ill patients, private or charity
cases alike. In 1917, the MGH built a pavilion entirely for private patients,
and in 1930, another. By 1935, 40 per cent of hospital beds were occupied
by paying patients. By 1955, it was nearly 50 per cent. In 1967, some 60 per
cent of patients admitted to the hospital went to private pavilions.
Nor do these figures tell the whole story, for even on the wards, patients
with no financial resources for medical care hardly exist. At present, 85 per
cent of all MGH patients have some form of "third-party" health coverage-
and most of those who do are very wealthy patients, not poor ones.
 Third-party payment, whether by insurance plan such as Blue Cross,
state welfare, or Medicare, has revolutionized the position of the teaching
hospital. Put bluntly, it is no longer possible to trade free care for teaching;
nearly everyone can pay for his care, and can afford a private doctor, and a
private or semi-private room.
The MGH is, at this writing, closing down its wards. Some other
hospitals have already done so. Such structural changes are relatively
simple, but a major dilemma remains. There are no charity patients left, and
no private patient wants to be a "teaching patient," since this has
disagreeable connotations.
What is the solution? There are, obviously, only two answers. Either
teaching is halted or private patients are used for teaching purposes. The
first solution is impractical, the second highly controversial. But it is clearly
in the cards: someday, all patients in a teaching hospital will be used for
teaching. Such a program has already been set up at another Boston
teaching hospital, the Beth Israel. There, "ward" and private patients lie side
by side, and all patients, whether they have private physicians or not,
receive their in-hospital treatment from house staff.
Now all this may seem like a minor matter. After all, just 2 per cent of
American hospitals are teaching hospitals. The rest have no such problem.
But one may ask, if the teaching hospital truly delivers better medical care-
if this claim is more than a rationalization for making private patients
available for poking and prodding by medical students and interns-then
shouldn't all hospitals adopt the methods of the teaching hospital? Shouldn't
all patients have the benefits of the system?
There are some practical considerations, in terms of the availability of
interns and residents, but we can ignore these and simply look more closely
at the intrinsic quality, the advantages and disadvantages, of teaching-
patient care.
Certainly there are some classic advantages. The fact that residents are
literally that-individuals residing in the hospital-means there are more
doctors around, day and night, to treat acute emergencies. A patient with the
finest private physician in the world will not be consoled if his doctor is
away in his office when the patient has a cardiac arrest.
Second, as the pace of medical development accelerates, the hospital's
staff of academicians and researchers can claim up-to-date, specialized
information of a depth and variety that other hospitals, and individual
private physicians, cannot hope to match. The impact of this on patient care
can be considerable in some instances. For most of medical history, it did
not matter whether your doctor was up to date or ten years behind the times;
now it may matter if he is only one year behind. Therefore, one of the great
new appeals of the teaching hospital is the availability of the most recent
knowledge in patient care.
Third, the academic orientation of the staff leads them to attack
perplexing problems with unusual vigor, reviewing the medical literature,
utilizing the laboratory and referral resources of the institution. Endless
rounds and discussions among house staff and visits mean that a problem
will receive the benefit of many opinions. Thus a patient with an obscure
disease or a difficult diagnosis will get a great deal of attention-much more
than any single physician could give him.
Fourth, because the hospital is structured to teach and do research, it is
critical of all medical practice, including its own. Each physician has
several others looking over his shoulder, and this tends to minimize
mistakes. To that extent a teaching patient is "safer" than a private patient
All this is clearly evident when one looks at Mrs. Murphy's history. She
is a patient with an uncommon, though not rare, disease-but a disease that
manifested itself in an extraordinarily rare way. Mrs. Murphy first saw a
private physician, who treated her complaint of swelling legs as if she had
heart failure. She did not have heart failure. She did not improve. She then
went to a community hospital, where more sophisticated tests were done.
There, she was correctly found to have liver disease, GI bleeding, and
hemolytic anemia. Each of these problems could have been discovered by
her private doctor, with the help of a private clinical laboratory, but for
reasons which cannot be assessed, he failed to do so.
At the community hospital, evidence was also found for pancreatic
cancer. This evidence was incorrect. (Furthermore, important pathology
unrelated to her primary disease was missed. This was not discussed in the
earlier section, out of a desire to avoid complicating an already intricate
story. However, in the report sent by the hospital to the MGH when the
patient was admitted, a physical examination form clearly stated that a
pelvic exam was normal. In fact, Mrs. Murphy had a cervical polyp the size
of a large marble. It was easily felt and clearly visible. The only reasonable
conclusion is that a pelvic examination was not, in fact, done at the other
hospital.) And the only reason Mrs. Murphy was transferred to the MGH
was because of this suspected diagnosis.
Two points about this story should be made immediately. The first is
that the MGH, by its very nature, sees a great many patients whose
diagnoses have been missed. It is easy to gain the impression that all
practicing doctors are inept, and all community hospitals incompetent. But,
in fact, the great majority of patients who receive correct diagnoses and
good care never show up at the MGH.
Second, no medical system is perfect. Teaching hospitals make mistakes
just the way community hospitals and private physicians do. Each teaching
hospital in Boston delights in getting the patients of others, and making
diagnoses that were missed. The point of Mrs. Murphy's story, therefore, is
not the glorification of the teaching hospital, but rather that this woman,
with a complex disease and unusual manifestations, received nine days of
the most intense academic scrutiny before a diagnosis was established. She
was immersed in an environment geared to such scrutiny. A great many
people-from students to the chief of medicine-saw her, examined her, and
contributed suggestions concerning her care. And from that eventually
came a diagnosis that might not have been made otherwise.
At the same time, there are some classic complaints about teaching-
service care, from both patients and physicians. Patients dislike multiple
examinations, and having to tell their story over and over again. Physicians
complain that the academic orientation of a teaching service leads to
excessive lab tests, too many diagnostic procedures, less briskly efficient
care, longer in-hospital stays, and ultimately more expensive treatment.
Without question, these complaints have some truth in them.
For example, it is relatively easy to dismiss the protests of a patient with
an unknown disease who objects to many examinations by different people.
It is in his own best interests to be examined by everyone, at least until a
diagnosis is arrived at. However, it is less easy to shrug off the complaints
of a patient who may have, unknown to him, a "classic case" of something
that is neither rare nor unusual. An intelligent patient with a lucid history of
ulcer may find himself visited by a large number of students who are
directed to him by an instructor who tells them, "Mr. Jones has a good story
and good findings." And worse, if the patient complains to a resident, the
resident cannot evaluate the complaint. No one keeps track of how many
students are visiting any given patient. It is impossible to know whether he
is objecting to two visits or to twenty [Despite the above, most patients are
not seen by many students. A fair percentage never set eyes on a student].
.
The question of excessive and unnecessary tests is difficult to evaluate.
Everyone who works in a hospital sees patients who receive too many tests,
under the guise of a "thorough work-up"; everyone has seen diagnostic
procedures carried out where at least an element of motivation was the
resident's desire to practice the procedure. These cases are rare, though they
stick in one's mind.
Frequently, the issues can be subtle. They are polarized in the following
verbatim exchange between a particularly obnoxious student and a
particularly obnoxious visit. The patient under discussion was one who had
documented obstructive lung disease with advanced emphysema. He was
on the respirator full time.
visit: "Do you think we should do cardiac cathe-terization and get a
pulmonary wedge pressure on this man?"
student: "No."
visit: "Can you think of any additional information we might get from
the wedge pressure?"
student: "No."
visit: "In point of fact, we know that in emphysema, if we find the
wedge pressure elevated, then the severity of the disease is increased."
student: "Will that change your course of therapy?"
visit: "I'm not sure mat's a valid consideration."
student: "There's a morbidity attached to pulmonary catheterization."
visit: "Yes, but it's very slight."
student: "It exists. If it won't change your therapy, how can you justify
it?"
visit: "I don't think you can say it won't change our therapy."
student: "Then how might it change your ther-apy?"
visit "Over the long haul. For instance, in this lab we do VD/VT
measurements, though similar labs do not. We've found it very valuable."
student: "This man has emphysema. He's seventy-three. He's dying."
visit: "We are nonetheless obligated to learn all we can about his
disease."
student: "But it won't help him."
 visit: "The Respiratory Unit has multiple functions. We are at once
engaged in research and therapy."
student: "Will you tell the patient that the procedure won't help him, that
it's just for the sake of curiosity?"
visit: "I wouldn't call it curiosity."
student: "Then you have a formal experiment going? A protocol? This
patient is part of a defined study series?"
visit: "No, but we are gathering data. All patients are available for
research here."
Perhaps the most common criticism of the academic service is that "the
doctors are not interested in patients, only in diseases," a harsh complaint,
and an old one. Oliver Wendell Holmes said in 1867 that he did not want a
researcher-clinician for his doctor: "I want a whole man for my doctor, not
half a one." (As a teacher, Holmes could be brutal about academic medical
instruction: "What is this stuff with which you are cramming the brains of
young men who are to hold the lives of the community in their hands? Here
is a man fallen in a fit; you can tell me all about the eight surfaces of the
two processes of the palate-bone, but you have not had the sense to loosen
the man's neckcloth, and the old women are still calling you a fool.")
Certainly the researcher-clinician has split loyalties and conflicting
interests. A GI consult who sees a patient is specifically called in to give
advice about the patient's abdomen; and to some extent, the consulting
physicians are more interested in the patient's stomach than the rest of him.
The consequence of this may be to surround the teaching patient with many
people interested in his problems, but less interested in the patient himself.
The patient gets excellent but impersonal care-if that is not a contradiction
in terms.
The idea that an orientation toward disease can ever lead to poor care is
furiously denied by academicians. But it is disturbing to note, for instance,
that Death Rounds at the MGH, which once reviewed a deceased patient's
hospital course with a view to discussing whether anything more could have
been done for him, are now almost entirely given over to academics: the
patient's disease is discussed, not the patient. (This is only true on the
medical service. Surgical Death and Complication Rounds still deal with
the patient's course. In general, the surgical service is more pragmatic and
less academic than the medical-a point of some friction between the two
groups.)
 Eventually, one comes to the conclusion that care on a teaching service
is not so much better or worse as different. Some patients will benefit from
these differences more than others. A patient with an obscure malady can
do no better than a teaching service, where he will be fussed over,
considered, and reconsidered endlessly; a patient with a common, well-
understood complaint may get quicker, more practical treatment from a
private doctor in a nonacademic setting.
This would seem an excellent argument for transforming the teaching
hospital into a referral institution, and that is what has happened to many of
them. But there are two reasons to deplore the change.
First, it means that research on the most common-and therefore, one
might argue, the most important-diseases stops. This is unwise; there are
many times in medical history when a researcher has "gone over old
ground" and come up with something new and important. Reginald Fitz
went over "perityphlitis" and came up with appendicitis, thus changing the
course of surgical history.
Second, it ignores the community in which the hospital stands. The
community is likely to sense this rapidly, and resent the fact that although
the hospital personnel did a great job for Uncle Joe's unpronounceable Latin
ailment, they could hardly be bothered with Sally's ear infection.
What is the hospital's responsibility? Originally, the answer was quite
clear-it was built to care for any needy person in Boston who had the
initiative to seek it out. With the passage of time, its community became not
the entire city, but a part of it, the so-called North End. This is a community
of working-class Italians and Irishmen, with areas of considerable poverty.
But the hospital has never lost its passivity, a tradition that can be traced
all the way back to Greece. Patients are expected to come to the hospital,
and not the reverse. And while the hospital will never turn anyone away
from its doors, neither will it actively seek out illness in the community.
Furthermore, the impact of technology over the last twenty years has been
to make the hospital even more passive, as it becomes more preoccupied
with acute established disease, to the almost total neglect of preventive
medicine.
But the role of the hospital is going to change, as public expectations for
medical care change. According to Alexander Leaf, Chief of Medicine, "For
a long time-since Hippocrates-we have not attached any broader social
obligation to the physician's education. You went through your training
program whether in school or as an apprentice, and men you hung out your
shingle and treated whoever could pay you. But now that is unacceptable to
society, which is making other demands from physicians." He says, further:
"I think we have to restructure the functions of the hospital if it is to survive
for the next twenty years."
Implicit in this is the notion that what the hospital now does, it does
well. But it is not doing enough, and the times, indeed, are changing. To
quote Galbraith, "One must either anticipate change or be its victim."
The hospital can no longer be a charitable refuge for the poor patients-
the poor patient (or, rather, the patient whose bills can't be paid) is
disappearing from the landscape.
The hospital can no longer act as a stronghold of technological,
scientific excellence for a few patients, when the disparity between in-
patient marvels and community horrors is ever-increasing.
Dr. John Knowles, director of the hospital, observes that "When I was
recently the visit on the medical service, the first five patients presented to
me all happened, by a curious coincidence, to have the same problem. And
it serves to point up the incongruity of what we're doing here. All five were
elderly, chronic alcoholics with massive GI bleeding and end-stage liver
disease. All five were in coma and we were treating them vigorously, with
everything medicine has to offer. They had intravenous lines, and central
venous pressure catheters, and tracheostomies, and positive pressure
respirators, and suction and Seng stocking tubes, and all the rest. They had
house staff and students and nurses working on them around the clock.
They had consultants of every shape and sort.
They were running up bills of five hundred dollars a day, week after
week… Certainly I think they should be treated, just as I think that a large
hospital like this is the place where this brand of complex medicine ought to
be carried out. But you can't help reflecting, as you look at all this stainless
steel and tubing and sophisticated equipment, that right outside your door
there are people with TB who aren't getting antibiotics, and kids who aren't
getting vaccinations, and women who aren't getting prenatal care… I think
we have an obligation to these other people, as well."
The hospital's new objective is to spread its resources more widely, at
the expense of its traditional passivity. The first step has been to begin an
ambulatory care center in Charlestown, a depressed area of 16,000 people.
This sort of "satellite clinic" is widely debated in medical circles today.
 Dr. Leaf: "The Charlestown project is interesting to us, to see if we can
begin to restructure the way we deliver care. I hear arguments from my
colleagues in the medical school, saying that no satellite clinic has ever
worked. They say the research interest isn't there, the way it is in a hospital.
They say you can't find doctors to work in them. Well, then, we just have to
get some new physicians who see their research as working in the
community, devising ways to give better care, rather than being in the
hospital and doing research on, say, gastric physiology."
Certainly the academic hospitals will have to abandon what Dr.
Knowles calls "the present defensive isolation… in a bastion of acute
curative, specialized, and technical medicine." The impact of this on the
inner workings of the hospital itself may be extensive, and beneficial.
In 1896, the intern Harvey Gushing referred to the MGH as "this little
world of ours"-and he meant precisely that. It was a little world, and it was
"ours"; it belonged to the doctors, not to the patients. Doctors were a
permanent fixture in this world. The patients were transients who came and
went. (Patients are well aware that the hospital is for doctors, and not for
themselves. They frequently report that they feel like "specimens in a zoo."
Indeed, nearly every literate person who has recorded his experience in an
academic hospital, from the late Philip Blaiberg on down, has mentioned
this disturbing association.)
Initially the hospital was designed to be a little world for the patients,
supplying all their needs. In those days, there were few resident physicians.
But the hospital has evolved into a complete world for doctors as well.
Indeed, it would be surprising if it did not, for there is one house officer for
every four patients, and the house officers spend almost as much time in the
hospital as the patients.
For a resident, the completeness of the little world-with its dormitories,
libraries, cafeterias, coffee shops, chapel, post office, laundry, tennis and
basketball courts, drugstore, magazine stand- combined with the intensity of
training (the average resident spends 126 hours a week in the hospital) can
have some peculiar effects. It is quite possible to forget that the hospital
stands in the midst of a larger community, and that the final goal of
hospitalization is reintegration of the patient into that community. In this
respect, the hospital is like two other institutions which have a partially
custodial function, schools and prisons. In each case, success is best
measured not by the performance of the individual within the system, but
after he leaves it. And in each case there is a tendency to view institutional
performance as an end in itself.
This is true for both doctors and patients. The ideal of the physician-
scientist, the clinician-researcher, is very much a product of academic
hospital values. The educational process designed to mold this product has
some paradoxical aspects. One may reasonably ask, for example, what is a
medical student being trained to become?
Without doubt the answer is: a house officer in a teaching hospital. A
good medical student graduates with all the necessary equipment: a
background in basic science, some clinical experience, familiarity with the
journals, and an academic orientation.
What, then, is a house officer being trained to become? The answer is,
an academic physician specializing in acute, curative, hospital-based
medicine [A student of my acquaintance, now a psychiatric resident,
endeared himself to the house staff of hospitals where he was a student by
doggedly asking each resident he met to define, in a simple sentence, the
difference between neurosis and psychosis. He concluded that 15 per cent
had some vaguely appropriate notion; the rest were appallingly wrong. The
fact that a doctor does not know the difference between neurosis and
psychosis does not necessarily mean he will be a poor physician; a doctor
who cannot articulate these distinctions may conceivably handle them
deftly in his practice. But it is a clear indication he has not had much
training in behavior, and the question is whether he ought to have such
training and whether his patients would benefit from the training]. This is
heavily scientific and not very behavioral; it must be so. (As the visit said:
"Tell me about his kidneys, not his marital troubles." And the visit was
right: the hospital is geared to treat his kidneys, and not his arguments with
his wife.)
But the great majority of house officers do not become academic
physicians, at least not full time. They go out into the community to begin,
in many respects, a totally different kind of practice from any they have
ever seen. They are shocked to discover that 70 per cent of their patients
have no identifiable illness; they are besieged and pestered by "crocks";
they have relatively few acutely ill patients, and relatively few hospitalized
patients. They are, in short, called upon to practice a great deal of
behavioral art and relatively little science.
 These doctors suffer from what Grossman calls "acute organically
trained syndrome." The rationale for giving them the training they got, as
preparation for the work they would be doing, was formerly couched as "if
they can handle the problems they see in the hospital, they can handle
anything." It is obviously untrue, except for those diseases that are
scientifically understood and medically treatable; patients with other
complaints may get a more sympathetic ear from their next-door neighbor.
*This same argument has been made by Peter Drucker concerning
undergraduate, liberal arts colleges, where he points out that professors of
English or History are not training liberal humanitarians or anything else so
noble-they are training future professors of English and History.
Underneath it all is a sense that modern, scientific medicine can be
taught, but the vague, amorphous "art" cannot be taught in the same way.
This is true, but it does not mean it cannot be taught at all. Nor does it mean
that simply watching the visit examine five or ten patients a week is a
sufficient background in how to deal with a patient's psyche.
What a medical resident knows about science he has gotten from
intensive courses, rounds, seminars, and journal reading; what he knows
about behavior, psychiatry, psychology, or sociology depends on what he
has managed to pick up as he goes along. This generally amounts to
pitifully little.* It is hard to estimate the amount of time a doctor spends
studying behavioral science during his years as a student, intern, and
resident. Formal training-lectures as a student, rotations as a clinical clerk,
social service and psychiatric rounds as a house officer-probably account
for no more than 1 to 2 per cent of his total time; the extent of informal
training is impossible to guess.
There is now a growing movement within medical education to provide
more formal training in behavior, but there is also formidable opposition.
As John Knowles has pointed out, medicine gained acceptance within the
university as a valid discipline not because of its advances as a social
science, but because of its discoveries as a natural science. For nearly a
century, natural science has been the paydirt, and the behavioral art has
taken a subordinate position. Reversing the trend of a century will take
some doing.
Of course, the hospital has an out-patient department and emergency
ward, where the interface of hospital and society is more sharply seen. But
the addition of community clinics, separate from the hospital, will almost
certainly change the psychological set of doctors working within the
physical setting of the hospital itself.
It is too early to know whether the satellite clinics are going to work.
The question of physician acceptance is one problem; the question of
community acceptance another. But if they do not work, something else
must be found, and at this time it appears social pressures are sufficiently
intense to guarantee such a search for new delivery systems.
The concept of a "patient-oriented hospital" is fashionable at the
moment. The phrase is widely used, though the idea is shopworn. People
have recognized for a long time-at least twenty-five years-that hospitals are
designed for the patient's needs only when those needs do not conflict with
the doctors' convenience. Nor is there any mystery about why this is so.
Whenever a new hospital is built, it is the doctors who are consulted on
design requirements, not the patients.
All this has produced a great deal of talk among doctors, architects,
patients, engineers, interior decorators, and innumerable other people-but
very little innovation, very little experimentation. For the majority of
hospitals, and the majority of new hospitals, the classic complaints still hold
true:
The hospital is difficult to adapt to. It brings in individuals from outside,
and plunges them into a totally new existence, with new schedules, new
food, new rules, new clothing, new language, new sounds and smells, fears
and rewards. For the patient entering this foreign environment, there are no
guides or guidebooks available to him. A person visiting Europe can get
better advance information than a person entering the "foreign country" of
the hospital.
The hospital building disregards physical factors that might promote
recovery. Colors are bland, but instead of being restful, are more often
depressing; space is badly distributed, so that a patient may be stranded in a
large room, or crowded in a small one; private and semi-private patients
often feel isolated in their rooms. (A Montefiore Hospital study concluded
that while families of ward patients were eager to see their relatives
transferred to private rooms, the patients wanted to stay on the wards,
where they would have more contact with other people.) Windows are
badly placed, and the view most often shows an adjacent large hospital
building or a parking lot.
 The hospital makes psychological demands that may retard recovery.
According to Stanley King, these include dependence and compliance with
hospital routine; a de-emphasis on external power and prestige; tolerance
for pain and suffering; and the expectation that a patient will want to get
well. These can easily work at cross-purposes. For example, a proudly self-
reliant man may find his passive role as threatening as his illness. Or a
person may become so dependent, and regress so far toward a child-like
state, that he becomes more petty, complaining, and intolerant of pain than
he would be otherwise. Or he may find his dependent role so satisfying that
he loses his desire to get well.
One may immediately object that despite all this, the majority of
patients adjust well to the hospital, recover, and go home. That is true, but
as an argument it is a little like saying that the world got on perfectly well
without electricity, which is also true.
But assuming these complaints have validity-assuming that patients
would really recover more swiftly in a better designed environment-how
should the new environment be designed? There is a spectrum of proposals,
ranging from minor adjustments to quite radical innovations.
Perhaps the most radical, and the most interesting, comes from a simple
observation: the modern hospital is best suited to a severely ill person.
These people are most tolerant of hospital routine and its indignities,
irritants, and difficulties.
On the other hand, persons recovering frequently become less tolerant
as their physical condition improves. The phenomenon is so well known
that doctors notice when a previously compliant patient begins to grumble
about the food or the noise at night. These gripes are interpreted as a sure
sign the patient is improving. Related to this is the so-called "lipstick sign,"
referring to the fact that as women begin to feel better, they start wearing
lipstick and combing their hair in the morning. Essentially, all this means
that the patients are acting in ways not demanded by the environment
(lipstick) or else positively condemned by the environment (griping). Such
activities are more appropriate to the outside world, and they are a signal
that the patient, in his own mind, is preparing to leave the hospital for the
outside.
How can one capitalize on this? At present, not at all. This is because, at
the present time, patients are assigned to different parts of the hospital on
the basis of only three criteria-financial resources, sex, and anticipated
therapy. No other attribute of the patient matters, not even diagnosis.
(Patients with ulcers, pancreatitis, or cancer, for example, will be assigned
to medical or surgical floors depending on whether their treatment calls for
operation or not.)
The various floors of the hospital operate with their own nurses, their
own visits, their own house staff, their own stocks of supplies. This is the
arrangement found in most American hospitals, and as a way of structuring,
it has distinct advantages. For many years, it was thought to be the best way
of matching the patient to the facilities he would most need.
However, each of the three criteria-sex, money, and therapy-has come
under attack. Money, because third-party payment has made financial
structuring obsolete; sex, because if everyone is in private or semi-private
rooms, segregation by whole floors becomes unnecessary.
Anticipated therapy has also been questioned. Some even argue that the
distinction between surgical and medical patients be abandoned in favor of
distinctions based on severity of illness, and the need for close medical and
nursing attention.
Under this system, medical and surgical patients would be intermixed in
units that differed in the degree of care they provided-intensive care,
recuperative care, minimal care, and so on. Patients would be moved about
in the hospital as their illness became greater or less.
Some clear psychological benefits for patients are apparent. As they
become healthier, they would be moved to new areas of the hospital, where
they would be encouraged to be more self-sufficient, to wear their own
clothes, to look after themselves, to go down to the cafeteria and get their
own food, and so on. They would, at every point, be surrounded by patients
of equal severity of illness. Their dependency needs would be fulfilled in a
graded way, since the hospital would be providing a spectrum of care and
close attention. To a degree, the hospital already does this, with its recovery
rooms and intensive-care units [The hospital already has intensive-care
units for respiratory care, cardiac care, neurological care, surgical care,
medical care, transplantation patients, pediatric patients, and burns
patients.]. But more could be done-and, indeed, one can predict that more
will almost certainly be done in this direction. This will happen not because
the hospital is preoccupied with the patient's psyche-it is not-but rather
because graded care is economically more efficient. At the present time 30
per cent of the cost of a room goes to nursing care. For the average MGH
hospital room, this amounts to some $22 a day. Although the percentage
cost may not rise in the future, the absolute cost will. Ultimately it will be
necessary to give patients no more nursing care than they really need; the
present inefficiency in personnel use will become too costly to continue.
Among physicians, a restructuring could be more efficient as well.
Consider anesthetists: in the last decade, they have emerged as the experts
in the support of vital functions. They are called for every cardiac and
respiratory arrest; they know more about drugs than anyone else; they are
expert in the use of respirators. Most physicians would agree it is handy to
have an anesthetist around any intensive-care unit, but at present the
anesthetists are dispersed throughout the hospital. By restructuring on the
basis of severity of illness, one important resource, anesthetists, would be
made more available to patients who need them.
Indeed, "human resources" are just one argument for restructuring.
Hardware and technology resources represent another. For example, the
kind of electronic and mechanical equipment required for a patient with a
heart attack and for a postoperative cardiac patient is very similar. As time
goes on, and larger and more all-inclusive machines become available, it
will be increasingly advantageous to bring patients with similar
technological requirements together, so that they may share certain large
machine capabilities and so that medical personnel trained in the use of
these machines can be centralized.
The bringing together of patients, personnel, and hardware has certainly
been valuable in cardiac intensive-care units; in some units immediate
mortality from myocardial infarction has been cut as much as 30 per cent.
We are already seeing a pro-
liferation of these specialized units, and we will certainly see more-and
from there it is only a small step to complete reordering of the hospital
along new lines.
Afterword
although it comes from an ancient tra-dition, the modern hospital, in
fully recognizable form, is less than fifty years old.
At most it will last, in fully recognizable form, another decade or so.
But by then, almost surely, what is different from the present will
overshadow what is similar. And we may expect these changes to represent
more than improved technology and differently trained personnel. For there
will certainly be a change in the function of hospitals, just as there has been
a change in function during the past half century.
During that period, the hospital evolved into a positive, curative agency
specializing in highly technical, complex medical procedures. Very likely
the hospital will continue to function in this capacity. But it will abandon
certain other functions in the process. It will cease to be a convalescent
facility, for example, as more specialized convalescent homes appear. It will
curtail its in-patient diagnostic work to that which absolutely requires
hospitalization. Its custodial function-whether.
 Afterword
Represented by a young couple "dumping" grandpa for the weekend, so
that they can have a few days to themselves, or by the admission of
alcoholics and derelicts who would otherwise have nowhere to go-has
already been reduced and will soon be eliminated. One can say this with
some confidence because in every case the rationale is economic, not
philosophical. Hospitals are becoming so expensive that financial
considerations will soon become the paramount determinant of function.
Less certain are those new tasks and responsibilities that the hospital
will assume in the future. Here, the pressures are largely social, and their
manifestations not easily anticipated. Perhaps the clearest-and most general-
trend is the hospital's notion of an extended responsibility, which goes
beyond the confines of its walls. A teaching hospital such as the
Massachusetts General now sees its job as dealing both with the hospital
patients and with the surrounding community. It defines this new role in
two ways: discovering those patients who need hospitalization but are not
receiving it, and treating other patients so that future hospitali-zations will
be prevented.
But the hospital is going further. It is spreading its research and its
knowledge beyond the local community to a broader population. In the past,
it did this in the form of research papers printed in scientific journals. That
form persists, but more directly the hospital now uses television and
computer programs to disseminate its knowledge and its resources.
For the patient, something rather paradoxical is happening. Broadly
speaking, the whole thrust of enlightened medical thinking is directed
toward getting more care to more people. The problem is as enormous and
as important as curing any specific disease process. In examining the
situation, both doctors and patients express the fear that the individual may
cease to be treated as a person, that he may become merged into some
faceless, very lonely crowd. Yet at the same time, the hospitals, which have
traditionally been the most impersonal elements in any health-care system,
are more concerned than ever about tailoring the hospital so it treats every
patient individually.
 For medical education, the impact of changes in hospital function may
be considerable. For the last half century, medical education has been
almost exclusively in-patient education-the emphasis has been upon care of
the patient who is in the hospital and not outside it. But as the hospital
reaches outside its walls, so will medical education.
There is another point about medical education, not often considered in
formal discussions. It is a problem, a fact of medical life, which can be
dated quite precisely in terms of origin: it began in 1923, with Banting and
Best. The discovery of insulin by these workers led directly to the first
chronic therapy of complexity and seriousness, where administration lay in
the hands of the patient. Prior to that time, there were indeed chronic
medications-such as digitalis for heart failure or colchicine for gout-but a
patient taking such medications did not need to be terribly careful about it
or terribly knowledgeable about his disease process. That is to say, if he
took his medicines irregularly, he developed medical difficulties fairly
slowly, or else he developed difficulties that were not life-threatening.
Insulin was different. A patient had to be careful or he might die in a
matter of hours. And since insulin there has come a whole range of chronic
therapies that are equally complex and serious, and that require a
knowledgeable, responsible patient.
Partly in response to these demands, partly as a consequence of better
education, patients are more knowledgeable about medicine than ever
before. Only the most insecure and unintelligent physicians wish to keep
patients from becoming even more knowledgeable.
And when one considers a medical institution, such as the hospital, the
importance of a knowledgeable public becomes still clearer. Hospitals are
now changing. They will change more, and faster, in the future. Much of
that change will be a response to social pressure, a demand for services and
facilities. It is vital that this demand be intelligent, and informed.
 Glossary
Abrasions - Scrapes.
Acidosis - Excessive acidity in the blood.
Acute - In medical reference, meaning of short duration. There is no
connotation of severity. The opposite of an acute illness is a chronic illness.
Ampoule - A drug container, usually made of glass. amylase An enzyme
produced in the pancreas and found in elevated blood concentration when
the pancreas is diseased. amyloidosis A disease characterized by deposits of
amyloid in various tissues. Amyloid is a protein substance.
Angiogram - An X-ray study of blood vessels. arrhythmia Irregular
heartbeat.
Barium - A metallic element. Barium sulfate, a salt, is opaque to X rays
and is not absorbed by the gastrointestinal tract. When a liquid suspension
of barium sulfate is swallowed by the patient, the stomach and intestine are
outlined in white on X rays and can be better studied.
Bilirubin - A golden pigment formed when the hemoglobin in red blood
cells is broken down. Bilirubin is normally excreted by the body; in various
disease states it can accumulate, causing jaundice (q.v.).
Biopsy - Removal of a sample of living tissue for examination.
Blood pressure - Expressed in millimeters of mercury, this is generally
the pressure within the brachial artery of the arm. Blood pressure is
expressed as a fraction, such as 120/80. The first figure is known as systolic
blood pressure, and represents the peak pressure inside the artery
corresponding to each contraction of the heart. The smaller figure is known
as diastolic blood pressure, and represents the pressure inside the artery
between contractions.
Blood sugar - Blood normally contains a certain amount of sugar, but
the amount can be increased in disease states such as diabetes.
Bone marrow aspiration - Removal of some bone marrow by suction
through a needle.
Catheter - A hollow cylinder of metal, rubber, or plastic designed to be
passed through any of several body channels, such as the arteries, veins, or
the urinary system.
Catheterize - To pass a catheter through a body channel.
 Celiac angiogram - An X-ray study of blood vessels which supply
abdominal organs, that is, of the so-called celiac arteries.
Cerebrospinal fluid - The fluid which bathes the brain and spinal chord.
Cirrhosis - From the Greek for "tawny," and the early observation that
scarred organs became yellowish in appearance. The term refers to
destruction of parts of an organ and replacement of the damaged areas by
fibrous scar tissue. One can speak of cirrhosis of breasts, kidney, or lung,
but the term usually refers to scarring of the liver, following damage from
alcohol or other causes.
CPK - Creatinine phosphokinase, an enzyme. When the concentration
of this enzyme in the blood is increased, it suggests tissue damage,
particularly heart muscle damage.
CSF - Cerebrospinal fluid (q.v.).
Digitalis - A drug to improve the strength of heart muscle.
Disseminated cancer - Widespread or metastatic (q.v.).
Diuretic - A drug that promotes excretion of urine.
Diverticulitis - Inflammation of a diverticulum, generally the tiny
diverticula of the lower intestine.
Diverticulum - Literally a pouch opening out from some hollow organ,
such as the gut or bladder.
Edema - Accumulation of excessive fluid in tissues; dropsy. It can be
observed in a wide range of disease states.
Electrocardiogram - A graphic record of the electrical activity of the
heart, revealing information about the rhythm, the electrical conduction
within the heart, the health and thickness of heart muscle, and so on.
Encephalitis - Inflammation of the brain.
Glomerulonephritis - Inflammation of the kidney; specifically, of a part
of the kidney known as the glomerulus.
Guarding - In medical reference, it refers to a patient's tensing his
muscles in a painful area when he is touched there.
Hematocrit - A centrifuge for separating cells from the liquid portion of
the blood. In medica-lese, the volume percentage of red cells to fluid in
blood. Normally 40 to 45 per cent.
Hepatitis - Inflammation of the liver, usually caused by a virus.
Idiopathic - Of unknown origin.
IVP - Intravenous pyelogram, an X-ray study of kidneys made while
they excrete a special dye.
 Jaundice - A yellow staining of skin and eyes, from accumulation of
bilirubin (g.v.) in the body.
Lacerations - Cuts.
LDH - Lactic dehydrogenase, an enzyme. Blood levels are increased
with tissue destruction in various organs.
Lumbar puncture - Passage of a needle between lumbar vertebrae in the
lower spine, in order to enter the spinal canal and remove for analysis some
of the fluid that bathes the brain and spinal cord.
Metastatic cancer - Cancer that has spread throughout the body to
distant sites. myocardial infarction Heart attack. morphology Physical
appearance.
Obtunded - Literally blunted, in medical reference to demonstrate
decreased mental alertness and acuity.
Pancreatitis - Inflammation of the pancreas. pathological Diseased,
abnormal.
Platelet A small, flat, plate-like cell in the blood that aids in clotting.
Platelet count - A count of such cells. prognosis Foretelling of the
outcome of a disease.
Reticulocyte - An immature blood cell.
Reticulocyte count - A counting of the number of immature red cells in
circulation. Normally only a small percentage of red cells are immature; if
the bone marrow is making more blood, the number of reticulocytes in
circulation will increase.
Tap - As in thoracic or abdominal tap, medicalese for passage of a
needle into the chest or abdomen to drain off ("tap") fluid inside; centesis.
Toxin - Poison.
Triage officer - An emergency-ward physician who decides which
patient requires treatment first.
Ventricles - The paired lower chambers of the heart.
Sequestered - Hidden.
SCOT - Serum glutamic oxaloacetic transaminase, an enzyme. When
present in elevated concentrations in blood, it implies tissue damage.
Stenosis - Narrowing of any canal or aperture, such as aortic stenosis,
narrowing of the aortic valve of the heart.
Sternum - Breastbone.
Steroids - A class of chemical agents with a characteristic ring structure
that are produced within the body (as well as artificially). Many sex
hormones are steroids. Cortico-steroids, which are produced in the cortex of
the adrenal glands, have the power to suppress inflammation and the
immune response.
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