Michael Crichton: Five Patients

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.