I. Bowditch. Most of the foregoing account of the Hospital has been
derived from this source.
CLINICAL ADVANTAGES AT HARVARD 581
medical and surgical science, and in the mechanical part of the latter, they
have always thought of great consideration. Something has already been
done in this way; but as yet the arrangements are imperfect. Time is
required to bring into order an institution, in which everything is new ;
but they are much satisfied with the rapid advances made towards the
state of improvement which will crown their wishes.
" We are fully sensible of the difficulties which many students of medi-
cine have to encounter in finding means to go through a regular medical
education ; at the same time we feel ourselves called on to act for the
general welfare as well as the partial good, and to consider the future, as
well as the present.
2. " The attending physicians and surgeons of the Massachusetts Gen-
eral Hospital have determined to fix on the fee of twenty dollars for a
pupil's attendance, from the first day of March unto the first day of No-
vember, 1822.
" The pupils will be admited twice a week at least, at specified hours,
and oftener when circumstances render it expedient.
"' This fee may appear large from the circumstance that the patients are
now few in number ; and no fee has yet been demanded.
" It is necessary however that the fee determined on should be so with
a view to the future; and the advantages even now, at the hospital, are
considerable, greater probably than can elsewhere be obtained for the same
sum ; and they are daily increasing.
" Some persons may view this subject so slightly as to think that pupils
should be admited to the hospital as a public institution without any fee
or for a very small fee.
; ' The trustees of the hospital have determined that the medical attend-
ants shall receive no other fee than that for admission of pupils — there is
no salary nor no perquisites ; but even some direct expenses.
" Now it is not to be presumed that any will expect physicians in full
practice to leave their business and devote a considerable time to a public
institution, without compensation. Every man must be paid for his labours
in some way or other, and time and charge of such a public institution is
not a small affair to those who would do justice to it. The idea that the
increase of reputation or of business or of benefit through the medical
school are to be a sufficient compensation for the arduous duties of this
place, is not well founded. Any one who considers the matter in a dis-
interested way will perceive that neither of these are adequate sources of
reward for so much time and responsibility as will be required here, espe-
cially if the physicians happened not to belong to the Medical School.
' The arrangements made now are not so much with a view to the
present as the future. Some sort of return compensation must be pro-
vided to insure the attendance of medical men, such as the public demand
for these situations. That which is contemplated will not amount to any-
582 HARVARD MEDICAL SCHOOL
thing like compensation for the services rendered ; but it will be something
to be added to other considerations; and as little as the respectability of
the institution will admit.
"No doubt there arc physicians and very respectable ones who would
undertake to attend the Hospital for nothing; but that they would continue
to do so in a faithful manner for a succession of years is incredible. It is
contrary to the common course of human affairs; and will never happen.
(Italics mine.)
" In regard to the claim which some may think they have to admission ;
because this is an institution of publick nature; such a claim is unfounded.
Students of medicine have no claim on this Hospital, any more than other
classes of the community. If the trustees of the Hospital think proper to
admit them there for a reasonable fee ; and they, on their part, think the
advantages to be obtained will balance their fee — then there is a fair bar-
gain between two parties. At one time there was much probability that
medical pupils would be wholly excluded on account of the prejudices
against their admission."
" MASSACHUSETTS GENERAL HOSPITAL.
" The Subscribers are desirous that pupils should derive all the benefit,
which the Hospital can afford them ; at the same time it is their duty to
regard the good order of the Institution and the comforts of the patients.
For these purposes they have drawn up the following rules for the ad-
mission and conduct of pupils.
" I. During the lectures the pupils attending the anatomical course will
be admitted to see the surgical practice, and those attending the course on
the theory and practice of physic will be admitted to see the medical
practice of the Hospital.
" 2. At other times the private pupils of the physicians and surgeons
of the Hospital will be admitted equally to see all the patients; except
where very peculiar circumstances may forbid.
" 3. Hospital tickets will be furnished to other medical pupils, who will
thereby be entitled to the same privileges at the Hospital, as the private
pupils of the physicians and surgeons. All such tickets will be dated on
the first day of either March of September. A Hospital ticket will admit
a pupil to the Hospital for one year from its date, exclusive of the period
of the lectures in the Massachusetts Medical College. The fee for a
Hospital ticket shall be thirty dollars.
"4. The days and hours of attendance by the pupils at the Hospital
will be from time to time made known to them. They will not be per-
mitted to visit the Hospital on Sundays; nor at any other than the ap-
pointed hours on other days; except by the special order of the physician
or surgeon.
" 5. On the regular days of visiting the pupils are not to remain at
CLINICAL ADVANTAGES AT HARVARD 583
the Hospital longer than is absolutely necessary for the visits. They are
not to converse with the patients or nurses. During operations and while
in the wards they are to abstain from conversation with each other ; they
are not to walk about ; nor in any other way disturb either the medical
officer, or the patients.
" 6. In all cases, in which it will be proper for the pupils to make any
personal examination of a patient, such as feeling the pulse, examining a
tumour, &c. an intimation to that effect will be given them by the physician
or surgeon. It must be obvious that the greatest inconveniences must
arise, if such examinations were commonly made by the pupils.
" 7. In all cases the pupils should carefully abstain from any gesture or
remark, which may tend to alarm the sick, or which may be regarded by
them as an expression of contempt, or of ridicule. Likewise the pupils
should carefully keep secret all such facts respecting the patients, as these
would be unwilling to have known to the world.
" 8. The pupils are invited to ask questions of a practical nature relat-
ing to the patients, being careful to be out of hearing of the patients.
" 9. A Dresser will be appointed by the Surgeon ; but will be liable
to be removed for any indecorum or neglect of duty ; and with the condi-
tion that he do not remain in the Hospital longer than his duties require.
The periods and frequency of his attendance will be regulated by the
Surgeon.
" 10. The Superintendant will be requested to give notice to the Physi-
cian and Surgeon of any breach of these rules, which comes to his knowl-
edge ; and he will take immediate measures to enforce them, whenever
the good order of the Hospital may render such measures necessary.
The byelaws of the Corporation render pupils liable to a dismissal from
the Hospital, for any indecorum or immorality.
" James Jackson,
"John C. Warren."
"Boston, May, 1824."
That all surgeons did not find the appointment to a place
on the Hospital staff advantageous is evident from Edward
Reynolds's letter of resignation, March 24, 1829, in which
he says, "excepting to a student, there is no honor and no
profit in it." In that year (1829) it became necessary to pass
rigid rules on account of "having found that very serious in-
conveniences and alarming consequences have arisen from
the manner in which the examinations of subjects in the Hos-
pital have been conducted." This was at a critical time, and
584 HARVARD MEDICAL SCHOOL
it seems to have been a wise precaution to limit the perform-
ance of post-mortem examinations to a few trusted officials.
The payment of a fee for the privilege of attending lec-
tures and operations at the hospital was soon discontinued.
In 1867 an attempt was made to revive the custom, but it
failed with the Trustees. In June, 1867, it was voted to
allow women students the privileges of "medical visits," sub-
ject however to the discretion of the Visiting Physician and
Surgeon, individually, and then only in separate classes, and
to the female wards exclusively. In 1846, when the North
Grove Street School was contemplated, John C. Warren ad-
dressed a communication to the Board of Trustees request-
ing the views of that body as to the erection of a Medical
School in the neighborhood of the Hospital. The reply was
as follows :
" At a meeting of the Trustees of the Massachusetts General Hospital
held February 22, 1846, it was
" Voted, on the communication made to this Board by Dr. J. C. Warren
on behalf of the Professors of the Medical School of Harvard University ;
That ihis Board are sensible of the courtesy which dictated the com-
munication, but in regard to the subject of building a Medical College in
immediate proximity to the grounds of the Hospital, they cannot perceive
any advantage to this Institution to arise therefrom ; but they think
thej' can see that some disadvantages would be occasioned thereby. In
stating, however, this opinion the Board do not assume any right to object
to the course suggested in the communication, but intend simply to make
an answer to the question proposed to them.
" attest, Marcus Morton, Jr.
" Secretary Mass. Gen. Hospital."
It is not necessary to follow the growth of this Hospital
further. One should note, however, that in that growth the
advantages offered to students have been constantly increased.
Department after department has been established and main-
tained for, as well as given in charge to, teachers at the
School, until to-day the Hospital and School seem supple-
mentary to each other. The new Out-patient Department
CLINICAL ADVANTAGES AT HARVARD 585
building, opened on the fifty-seventh anniversary (October 16,
1903) of the first public demonstration of ether calls for
special mention. One of the conditions enjoined by the prin-
cipal donor of funds for this building was that the interests
of medical education should be considered in the outlay of his
gift. Following this stipulation, lecture-rooms and rooms
for students' section work were incorporated in the plans. The
structure is of brick and stone, and is built in the shape of
a letter L, a plan which insures good light in all the rooms.
The whole building has been arranged in order to give stu-
dents the advantage of the large amount of "clinical material"
presenting itself. Indeed, the new Department calls for more
than passing notice. In itself it is a great educational plant,
supplementing the school buildings proper. The staff of the
Department consists (1904) of eighteen physicians and sur-
geons, who also assist the visiting Staff of the Hospital ; fif-
teen assistant physicians and surgeons, beside externes, grad-
uate and undergraduate assistants, matron, nurses, clerks, etc.,
etc.
The Massachusetts General Hospital of today is governed
by twelve trustees. The Medical Staff consists of six Visit-
ing Physicians, and the Surgical Staff of nine Visiting Sur-
geons and three Assistant Visiting Surgeons together with one
Aural Surgeon and four pathologists. The out-patient de-
partment has eighteen Physicians and Surgeons, and twenty-
three specialists. Besides the four Resident Physicians there
are twenty House officers. The capacity of the hospital is 265
beds. The number of house-patients in 1903-04 was 5,204,
while there were 25,082 out-patients.
At the McLean Insane Hospital, which was removed to
Waverly in 1895 there were 341 patients treated in 1903-04.
The Convalescent Home is also at Waverly, a useful institu-
tion.
Following the establishment of the Massachusetts General
586 HARVARD MEDICAL SCHOOL
Hospital, came the Massachusetts Eye and Ear Infirmary,
established 1824; the Institution for the Blind, established in
1829; and the Boston Lying-in Hospital founded in 1832.
This last was the first of its kind in New England, and has
maintained a leading position among similar hospitals of this
country. The funds for its establishment were raised by sub-
scription, and its first location was at 718 Washington Street.
The first Resident Physician was Hook, and the Attending
Physicians Channing and Hale, the Consulting Physicians
being Warren, Bigelow and Hayward. It is now governed
by a board of ten trustees, and the Medical Staff is composed
of one Consulting Physician, one Visiting Physician, one As-
sistant Visiting Physician, and four Out-patient Physicians.
The Resident Staff are three internes and six externes. In
1903-04 there were over 600 house patients and over 1,600
out-patients cared for by this institution. It was at this hos-
pital that O. W. Holmes made that study of puerperal sepsis
on which he founded his well known thesis.
In 185 1 Elisha Goodnow bequeathed to the city of Boston
twenty-five thousand dollars to found a local hospital. No
action was taken upon the matter until 1857, when the mayor
recommended the establishment of a City Hospital, transmit-
ting to the city council at the same time a memorial from sev-
eral physicians, giving their opinions of the necessity and
value of such an institution. In the following year the Legis-
lature passed an Act authorizing the city to establish and
maintain "a hospital for the reception of persons who, by mis-
fortune or poverty, may require relief during temporary sick-
ness." In i860 the city authorities selected a site consisting
of about seven acres of land reclaimed from the sea, situated
in the South End of Boston. The hospital was formallv
opened in 1864. It is governed by five trustees, one nomi-
nated each year by the mayor. The staff consists of four Con-
sulting Physicians and Surgeons, sixteen Physicians and five
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CLINICAL ADVANTAGES AT HARVARD 587
Assistant Physicians, nine Surgeons and eleven Assistant Sur-
geons, three Aural Surgeons, one laryngologist, four patholo-
gists, six neurologists, three dermatologists, seven opthalmolo-
gists, six gynaecologists, besides medical registrars and sur-
gical registrars. The house-staff consists of a Medical Su-
perintendent, a Resident Physician, three Executive Medical
Assistants, two Assistant Physicians, three Assistant Pathol-
ogists, eleven House-Physicians and Surgeons, two clinical
clerks, four surgical dressers, eight externes, and two special
externes. The total number of beds is 828, with an average
of 730 occupants. The number of house cases in 1903-04
was about 9,000, the number of out-patient cases about 22,000.
There are eight distinct out-patient departments besides a
Convalescent Home of thirty-four beds and a model Relief
Station in the north end of the city.
The House of the Good Samaritan was established in i860
and the Children's Hospital in 1869. The Children's Hos-
pital is governed by a board of twelve managers. It has a
staff of eight Consulting Physicians and Surgeons, three Phy-
sicians and three Assistant Physicians, two Surgeons and four
Assistant Surgeons, with three junior Assistant Surgeons,
and ten specialists. The house is in charge of one medical
and two surgical officers, and has a capacity of one hundred
beds.
In addition to these hospitals, clinical advantages are
offered to the students of the Harvard Medical School at the
following places : Boston Dispensary ; The Infants' Hos-
pital, in the wards of which are treated children exclusively,
under two years of age. It has also an out-patient depart-
ment with an average yearly attendance of three thousand
children. There is also the Free Hospital for Women and
the Long Island Hospital, Boston Harbor, devoted almost en-
tirely to the treatment of chronic cases. It has two hundred
and fifty beds, with an average daily population of two hun-
588 HARVARD MEDICAL SCHOOL
dred and twenty. It is said that fully fifty per cent of the
deaths at this institution are followed by autopsy, and afford
abundant material for pathological study. Then there is the
Carney Hospital, a large and flourishing institution which may
some day rival in size the Massachusetts General.
From such statements it may be seen that the increase of
clinical advantages for Harvard students has been very great;
indeed, so far as I can learn, the Harvard clinic is the largest
in this country. How well the School avails itself of these
advantages, I shall attempt to show later in considering the
separate branches of medical study.
ETHER, 1846.
ETHER, 1846 591
CHAPTER XXIV.
ETHER, 1846.
The introduction of the use of ether into surgical prac-
tice in 1846 was through no accident, nor was it the re-
sult of prolonged research and experiment. It came as a sur-
prise, but as a perfectly matured discovery for which many
had hoped; yet remarkably few had sought it. No great
scientist had wrought it out; no deep thinkers had prophesied
it. It was, in fact, a part of the wave of world-advance which
prevailed at the time. Everything felt the impulse of that
wave. New political parties took life, and with them de-
veloped new conditions of old questions — political and social
— conditions, many of which were to be settled finally among
us only through the merciless sacrifices of a civil war. Our
country had doubled its population in the first thirty years of
the century,* and in the decade 1830- 1840 the population in-
creased by 4,000,000. Civilization kept pace with the growth.
An American literature in some fashion was beginning ade-
quately to supplement works of foreign authors; Bancroft,
Hawthorne, Emerson, Holmes, Longfellow, Poe, Prescott
and Whittier were writing. Newspapers, wretched as many
of them were, vied with each other rapidly to spread news
through the country. The introduction of the power-loom
by an alumnus of Harvard§ made possible the growth of
many thriving and permanent cities. The omnibus was giv-
ing way to the street car, the stage-coach to canal boats and
* Population of United States in 1830 was 12,866,020.
§ Francis Cabot Lowell, 1793 H. U.
592 HARVARD MEDICAL SCHOOL
steam railroads. Most important of all was the discovery
by Morse in 1844 of the magnetic telegraph, and then fol-
lowed a multitude of minor miracles.
In medicine the speculative and dogmatic philosophies were
passing. The labors of Bichat, Magendie, Johannes Miiller,
Rokitansky, Laennec, and Louis were supplemented by those
of Claude Bernard, Du Bois-Reymond, Helmholtz, Ludwig,
Virchow and others (names, names, alas! mostly, to modern
readers, but names much repeated) resulting in the establish-
ment of experimental physiology and pharmacology. In such
a time, then, the world learned suddenly that surgical pain
had been abolished. It was the fulfilment of the promise in
Revelations, "Neither shall there be any more pain."
Certain pain-killing drugs had long been known. Ancient
history tells of sundry instances of surgery dene upon patients
under the influence of opium, hyoscyamus, conium, bella-
donna, mandrake, Indian hemp, and other narcotics — all
given to the point of intoxication, with the hope that painless
surgery would result. Physiology has long since taught the
reason why these means failed. Napoleon's surgeon, Baron
Larry, operated on his half-frozen, wounded soldiers, at the
battle of Eylau, and bore testimony that intense cold produced
partial insensibility. But, like mesmerism, hypnotism, nerve-
clamping, and alcoholic intoxication, all these lacked the sine
qua n-on of Bigelow's test, — inevitable, complete, and safe.
Ether was the first substance found to fulfill all these condi-
tions. Remember, too, that in many of the agents used for
the prevention or relief of pain, the real discovery was often
within view, that the progress of surgery was retarded by
the want of an anaesthetic, and, when we picture the horrors
of those operations, we marvel at the seeming indifference of
the scientific world, to the sufferings of mankind.
The introduction of Petit's tourniquet in 1718 advanced
our art somewhat in the estimation of men, by robbing ampu-
ETHER, 1846 593
tations of some of their sickening unsightliness; yet the cen-
tury was far advanced before the old prejudice against sur-
gery was mitigated. Even in such a brilliant thinker and
disciple of surgery as John Hunter there were traces of the
early prejudice that surgery was beneath the calling and dig-
nity of the physician, on account of the cruel nature of surgi-
cal work, which he terms ''humiliating examples of the im-
perfectness of the science." Robert Liston, as late as 1844,
said of operative surgery, to his class at the University Col-
lege Hospital, "This is regarded as an inferior part of our
professional duties, and truly it is so. The field of operative
surgery, though happily narrowed, is still extensive." In his
lectures Liston paid special attention to instructing students
how to give the least pain in operating, especially in dividing
the skin. Sir James Simpson relates how near he came to
abandoning the study of medicine on account of the horrors
of the operating room. Abernethy and Cheselden dreaded
every operation they performed, and the latter is said seldom
to have slept the night before an operation. John C. Warren
refers to the sinking of heart he felt in the distress of every
painful operation to which no habit could render him insen-
sible. Here is a story of Nathan Smith which does credit
to that great man's sensibility; and it can truly be said that
the introduction of anaesthesia has not robbed the human sur-
geon today of the tenderness and sympathy illustrated by this
anecdote :
'' Before the discovery of anaesthesia, surgeons suffered in their sensi-
bilities, as well as their patients. With other pupils I accompanied the
doctor to a distant town to see a capital operation. It was a case to excite
commiseration. The patient was old enough to understand the purpose
in hand, but not sufficiently mature to perceive its necessity. It was
a chilly morning, as we sat by the fire, and the doctor looked at the
patient at the farther end of the room. The lad was emaciated and
trembling. Dr. Smith was visibly affected, his eyes dropped tears, and
his heart trembled as he whispered to me, 'I shall not do what they
expect! It is a cruel business, and I wdl perform a less severe operation.
594 HARVARD MEDICAL SCHOOL
in the hope that it may have the same effect.' On examination it became
apparent that the severer operation (amputation of the thigh) could not
be avoided. Before we returned to the room, he said to the attending
physician, 'Hall, you know all about this boy's sufferings; at the moment
we begin, bend over and across the bed to hide us from his sight, and do
your best to comfort him,' the tears still falling from his eyes. At once
he became calm, the tremor left him, and in less time than while I write
this period, the operation was completed, and the patient recovered."
Then there is that striking picture so graphically sketched
by Ashurst ;* of a physician of the old days, himself the patient,
who speaks:
" I at once agreed to submit to the operation, but asked a week to pre-
pare for it ; not with the slightest expectation that the disease would take