The Genealogy Of Mass General

HE WAS A sixth-generation American, white and Protestant, educated at Princeton and the University of Pennsylvania Medical School, which, at the time, was the best in the country. Even in 1912, hiring David Linn Edsall would hardly seem to be a blow for equal-opportunity employment. But the place was Boston, the job was to lead the medical staff of the Massachusetts General Hospital. In the decades since 1821, when the hospital first opened its doors to patients, only Bostonians had been invited to practice at Mass General. Edsall was from Hamburg, New Jersey, of all places. Moreover, his main rival for the position was an ideal candidate—Richard Clarke Cabot, an extraordinary man, a gifted physician, a cousin by marriage of the retiring chief, and a member of Boston’s aristocracy.

That the city’s most thoroughly Brahmin institution (after Harvard) would pass over someone with Cabot’s name and qualifications to bring in a complete outsider—this was a remarkable, even a radical, turn of events. It was not quite as revolutionary, though, as rumor had it. Some of Boston society’s more parochial members thought Edsall was Jewish. What else could he be? His first name was David; he had supported Louis D. Brandeis’s appointment to the Supreme Court; and he was known to be a staunch Democrat.

Why had the hospital taken such a drastic step? The reason was, quite simply, that the people who supported and staffed it had always conceived of Mass General as an elite institution. But they feared the rest of the world would soon come to see their hospital as second-rate—a Brahmin backwater with some amusing traditions, but one that was making little contribution to the progress of modern medicine. It was not that the hospital had changed. What had changed was medicine itself.

Although Cabot had expected throughout most of his career that he would succeed to the top position in medicine, by 1912 even he declared himself eager to persuade the New Jersey doctor to come to Boston. His admiration for Edsall was based on that physician’s identification with the new style of medicine, one that fused modern laboratory investigation with an older tradition of pains-taking bedside diagnosis. Cabot had become so impressed with Edsall’s reputation over the years that he had declared himself “only too happy to serve under him.” And the move that originally had seemed so alarming to some turn-of-the-century Bostonians proved in the end to accomplish exactly what was intended. Under Edsall’s leadership, and with Cabot’s unstinting support, the Mass General staff succeeded in reshaping the hospital to meet new and changing standards. Today it is one of the world’s most famous medical institutions.

ALTHOUGH THE HOSPITAL’S original stone building remains in use, it is now barely visible to passersby. The large, and largely ugly, structures surrounding it provide for the care of some 31,000 inpatients and 144,000 outpatients a year. Many of these people are referred from hospitals elsewhere in the United States or the world in the hope that rare and difficult illnesses will be treated successfully at the “Mecca,” as it is sometimes called, only half-humorously. The visitor who enters this warren of brick and stone can walk from one building to another through a disorienting tangle of corridors that seem to end, as often as not, before a door marked “laboratory.” For it is research, and not only the occasional dramatic “cure” of a difficult case, that supports the enduring reputation of Mass General as a great hospital.

Boston was late to establish a general hospital. Both Philadelphia and New York had them by 1800. Boston, despite its importance in the Revolution, had neither a large enough population nor a complex enough social structure to sustain one. The almshouse was the only establishment that served any of a general hospital’s functions. Dr. Josiah Bartlett, writing in 1817, gave this rosy description of medical care at the poorhouse: “The Boston Almshouse has a spacious, well constructed edifice, with kitchens, a well, and forty-six other apartments. It is governed by the Overseers of the Poor, and is conducted by a master with proper assistants. The average number of inhabitants, for the past two years, is about 359 [a year, presumably] of whom 139 are state paupers. The objects of admission are the meritorious poor, unfortunate females, vagrants (who are kept employed), and maniacs. The usual number of sick and infirm is about fifty.”

Another description, however, asserted that the “Almshouse in this metropolis does not pretend to cure ” and “all it possesses is accommodations for eight patients.” Also, its critics contended, “it must necessarily happen that in many instances the worst members of the community, the debauched and profligate, obtain admission into this house. Hence it has become, in some measure, disreputable to live in it; and, not unfrequently, those who are the most deserving objects of charity cannot be induced to enter it …”

As Boston grew and prospered in the two decades after the Revolution, the inadequacies of the almshouse became more and more disturbing to the local citizens. The lack of a hospital, however, was hardly felt as a deficiency of medical care in the sense we now think of it. It was normal and proper to care for the sick at home; even surgery was better performed on a kitchen table than in a hospital, according to the prevailing wisdom.

What marked the need for a hospital in Boston was the emergence of a new social class: people who were respectable but nevertheless did not live in their own homes. As commerce and industry burgeoned, ever increasing numbers of journeymen mechanics—young laborers in manufacture and on the waterfront—were drawn into the city. They lived in boardinghouses, where their accommodations were “sufficient, but nothing more than sufficient, in health,” as the advocates of a hospital wrote. Moreover, these men were at risk of occupational accidents, something increasingly common as the pace of business picked up.

SERVANT GIRLS ALSO had need of such a facility. The aggressive economy of Boston Harbor at the end of the eighteenth century had covered Beacon Hill with mansions for the merchants and industrialists, and the domestic economy of these great houses depended on servant girls to get the work done. If one of these girls was incapacitated, her mistress hardly could take care of her and assume the undone chores of the household.

These two kinds of people, journeymen mechanics and servant girls, were explicitly identified in fund-raising efforts as the main classes of people for whom the hospital was intended: “generally those of good and industrious habits, who are affected with sickness, just as they are entering into active life.” In addition, women and children without means or a man to protect them—another by-product of urbanization—deserved special mention.

Of course, the poor in general might benefit from hospital care. But the fund-raisers had to tread lightly when making this suggestion, because of the nineteenth-century concept of “welfare chiselers.” Then as now, paupers—able-bodied but indolent persons dependent on public charity—were widely thought to be the product of social welfare programs. To counter this fear, the advocates of a new hospital for Boston wrote in 1810, “When in distress, every man becomes our neighbour, not only if he be of the household of faith, but even though his misfortunes have been induced by transgressing the rules of both reason and religion. ” Even these, “when labouring under sickness, must be considered as having claims to assistance.”

The authors of this generous sentiment were John Collins Warren and James Jackson, young physicians and professors of the Medical Institution at Harvard (now Harvard Medical School) who had decided to campaign in earnest for a hospital. As members of the medical faculty, their reasons extended beyond the purely charitable. Short of traveling to Philadelphia, they pointed out, New England’s medical students found it “impossible to learn some of the most important elements of the science of medicine, until after they have undertaken for themselves the care of the health and lives of their fellow-citizens …”

Medical education had begun in Boston in 1783 with the opening of a medical school loosely allied to Harvard. The quality of instruction could not have been terribly high at that time; some of the students appear to have verged on the illiterate. And clinical training was hampered for want of patients on whom to demonstrate. The Overseers of the Poor were first approached with a request to use the almshouse inmates for this purpose, but they refused out of fear that their budget would be strained by fees charged for the inmates’ care. What clinical instruction could be given, therefore, depended on the willingness of private patients to be used for the purpose.

By 1809 there was a general feeling that medical education at Harvard had begun to stagnate, and an effort was begun to improve it. The Overseers of the Poor were approached once again, and this time the appeal succeeded. But the professors had to accept two conditions: they must give their care free, and they themselves must pay for any medicines they prescribed to the inmates.

Warren and Jackson, the principal proponents of a hospital, had themselves had the benefit of training abroad before they started their practices in Boston. John Collins Warren, a driven, puritanical man, was utterly dedicated to his profession of surgery—so much so that his will called for his bones to be “carefully preserved, whitened, articulated and placed in the lecture-room of the Medical College near my bust; affording, I hope, a lesson useful, at the same time, to morality and science.” Starting in 1799, the young Warren spent three years studying in London, Edinburgh, and Paris. He returned to Boston as perhaps the best-trained surgeon in America.

James Jackson was a gentler character by far. Oliver Wendell Holmes would remember him as the “warm, ready, self-forgetting friend,/Whose genial visit in itself combines/The best of cordials, tonics, anodynes.” As a young man, however, Jackson too was ambitious. He was in London the first year that Warren was, and there he learned the new technique of vaccination for smallpox. Eager to return home with it and to establish his practice and marry Elizabeth Cabot, his fiancée of nearly four years, Jackson stayed abroad only that year. On October 1, 1800, some two days after his return, Jackson would later recall, “I began business. Vaccination had been introduced [principally by Dr. Benjamin Waterhouse of Harvard] about the time that I commenced my studies, but the practice had not been extensively adopted at that day even in England. …the cow-pox gave me notoriety, and that is a great advantage to a young man if it comes to him fairly, without any tricks.”

Notoriety soon matured into respect and faculty appointments at the medical school for both Warren and Jackson. The first ten years of the nineteenth century must have been an exhilarating time for them, as it was for the society in which they lived. For Jackson belonged to, and Warren married into, the group that would soon combine money and culture to form a distinctive urban aristocracy that Oliver Wendell Holmes later dubbed the Boston “Brahmins.” So, in 1810, when Jackson and Warren addressed a “circular letter” to the newly, and in some cases fabulously, wealthy citizens of Boston, they could be confident that they were addressing their social equals.

Most prominent among the supporters they recruited was Thomas Handasyd Perkins, who had amassed one of New England’s greatest fortunes, first in the China Trade and later in various financial transactions. Perkins would become one of the mainstays of the proposed hospital, both as donor and trustee. Other merchants and industrialists such as Francis Cabot Lowell, Stephen Higginson, Samuel Appleton, and Abbott and Amos Lawrence would also join the endeavor.

The War of 1812 set back the fund-raising efforts, and by 1816 the hospital had been chartered but lacked funds to begin construction. The trustees wrote, with some acerbity, “That Boston should be almost the only town of equal opulence and population in Christendom without one suitable and exclusive place of refuge for the sick and insane, must be attributed to any cause rather than a want of benevolence.” The town was divided into districts, and a few citizens in each district were designated to go around putting the arm on potential donors. In short order the necessary capital was raised, and the trustees were able to proceed with the purchase of land and then plan and build two hospitals—an asylum for the mentally ill (soon to be known as the McLean Hospital), and the general hospital, which was located on its current site north of Beacon Hill.

The hospital building was partially designed by the eminent Boston architect Charles Bulfinch and was completed by Alexander Parris. A graceful stone structure with such modern features as central heating and running water, Mass General was ready to receive patients on September 1, 1821. The first admission came two days later, and the second followed more than two weeks after the first. By early November, according to the hospital’s first official historian, Nathaniel I. Bowditch, “ten patients had been received at the Hospital, three discharged, one cured, and one relieved.”

Patients did not come to Mass General because they were sick but because they had no place else to be sick. This was true nearly to the end of the nineteenth century. Although Mass General was a hospital, in many ways it was not primarily a medical institution, and doctors played quite a different role from the one they would acquire fifty or sixty years later. For example, before 1837, patients were not, except in an emergency, admitted by the medical staff. A committee of the trustees was responsible for deciding whether admission was warranted, and the criteria they used were as much social as medical. Could other suitable accommodations be found? Was this person of good character and deserving of hospital care? Not until 1881 did the medical staff gain full control over the admission of patients. The trustees also made regular weekly visits to the hospital to monitor the progress of their charges. Thus the officers of Mass General were directly and actively involved in the day-to-day life and operation of the hospital. They obviously regarded it more as a charity than as the highly specialized repair shop for the human body that the modern hospital is today, and they administered it accordingly.

Mass General was, in many ways, the perfect expression of a peculiarly Bostonian conception of charity. It maintained the appearance of engaging an entire community in its efforts and of offering care to all and sundry, within the limits of its charter. The contribution of twenty-five cents given by a poor Negro was duly recorded, and so was a three-hundred-dollar pledge from Abraham Touro, head of the first Jewish household in the city and brother of the New Orleans philanthropist Judah Touro (both of these remarkable men would also leave Mass General large sums in their wills). Nevertheless, control over the hospital remained firmly with the city’s aristocrats. As the historian Ronald Story points out, “Of the twenty-three officers of the hospital from 1820 to 1850, the names of all but four appear on available lists of Boston’s wealthiest 200 individuals.” And although the state donated income-producing land as well as convict labor for construction, the major sources of income to the hospital were donations from Boston’s commercial aristocracy—a million dollars between 1800 and 1860. Only Harvard, with about $1,180,000, received more.

BESIDES THE principal donors, one of the hospital’s most important sources of funding was the Massachusetts Hospital Life Insurance Company, which was granted by its charter a monopoly on sales of life insurance in Massachusetts in return for giving a third of its net profits to the hospital. This firm grew to be the largest financial institution in New England, one more example of enterprise and charity properly meshed to do God’s work.

Yet another means to raise funds—one that would be unthinkable in today’s hospitals—was the “free bed.” Anyone who donated one hundred dollars gained the right for a year to have one patient of his choosing in the hospital at any one time. The free beds were often used for the victims of industrial accidents, which grew increasingly common in the nineteenth century, and they may have helped soothe the consciences of factory owners. This practice was still accepted as late as 1888, when the American Bell Telephone Company contributed the “use of 14 telephone sets in consideration of the right to the use of a free bed at the hospital by the Company.

No matter how lofty the hospital’s benefactors were, the day-to-day life there was solidly working class. Patients and caretakers came to form a social network of their own. The routine workings of the institution were supervised by the nursing staff under the superintendants direction. They provided food, support, and a clean environment that might at least allow the patients’ natural defenses to effect a recovery. No doubt this little society was relatively autonomous, except for the periodic intrusions of the trustees and doctors.

The physicians and surgeons who served at the hospital, though apparently less wealthy than the trustees, were largely from the same aristocratic families. Mass General had twenty-one attending physicians and surgeons in its first three decades; eight of them were relatives of the trustees; others married into the first families. The doctors thus had high standing in the community, and most of them left large estates. As the system was practiced, working at Mass General did not enrich these physicians directly—they were required to provide their services free of charge for nearly a century after the hospital opened—but the association did indeed enhance a doctor’s standing. At a time when the profession of medicine in America did not enjoy anything like the respect it does today, such enhancement helped in the competition for patients.

One major reason for this lack of respect was that, in the early 180Os, physicians’ techniques and knowledge were severely limited, and they insisted on treating diseases for which they had no effective therapy—pneumonia, for example. Of 187 cases that would be admitted to Mass General between 1822 and 1850, nearly two-thirds were treated with bloodletting, a cure-all that was actually used relatively sparingly in Boston by then. Boston doctors, having been exposed to the pioneering statistical study of Pierre Louis of Paris, which demonstrated that pneumonia victims recovered at least as often and as fast whether or not they were bled, gradually retreated from the use of bloodletting. In Benjamin Rush’s Philadelphia, on the other hand, where the aggressive influence of Edinburgh was felt more strongly, the therapeutic hemorrhage continued much longer.

SURGERY IN THE nineteenth century was also severely limited in what it could accomplish. Lack of anesthesia meant that operations had to be kept as brief as possible; ignorance of infection meant that wounds often became purulent. If death did not follow, recovery was likely to be very slow. What we now would call major surgery, particularly operations that required entry into the abdominal cavity, was then called capital surgery—in the same sense as “capital” punishment. The risk of death was so high that Mass General’s rules initially required an independent second opinion before the trustees would approve such an operation on the premises.

To their credit, the surgeons and physicians associated with the hospital were often skeptical of the practices known, aptly, as “heroic medicine” (the heroism, of course, was the patient’s). In the tough-minded spirit of selfcriticism that so often typified New Englanders, Jacob Bigelow, physician at Mass General from 1836 to 1855, conceded that medicine’s claim to honor seemed feeble indeed. Shortly before joining the hospital’s staff, Bigelow gave an influential address in which he admitted to the “humiliating conclusion, that while other sciences have been carried forward, within our own time and almost under our own eyes, to a degree of unprecedented advancement, Medicine, in regard to some of its professed and most important objects, is still an ineffectual speculation.” Over twenty years later he was still emphatic: the “unbiased opinion of most medical men of sound judgment and long experience” was that “the amount of death and disaster in the world would be less, if all disease were left to itself.…”

Two years later Oliver Wendell Holmes of the Harvard Medical School put the matter somewhat more pithily: “If the whole materia medica [that is, drugs and treatments], as now used , could be sunk to the bottom of the sea, it would be all the better for mankind—and all the worse for the fishes.” Responding later to outraged practitioners who heard his remarks, he observed: “One thing is certain. A loud outcry on a slight touch reveals the weak spot in a profession, as well as in a patient.”

Twenty-five years after it opened, however, the hospital made a very real and enduring contribution to medical care, in large part by exploiting its social influence. In 1846 a somewhat too enterprising Boston dentist, William Morton, persuaded John Collins Warren, still visiting surgeon at the hospital he helped found, to perform surgery on a patient exposed to the vapors of a substance that Morton called letheon . On October 16 the demonstration was carried out. A patient was successfully anesthetized with the vapors of ether (as anyone with a nose could tell), and a large tumor was painlessly removed from his neck. Warren is supposed to have looked up from his work and said to the assembled onlookers, “Gentlemen, this is no humbug”; and on that day the era of surgical anesthesia began.

Each year since 1903, the hospital has commemorated Ether Day on October 16, though it is now mainly an occasion for the trustees to give souvenir pins to long-term employees and deliver speeches to a small audience of staff members and their families. The amphitheater where the operation was performed, high under the dome of the Bulfinch Building, is called the Ether Dome, and many of the hospital’s meetings are held there.

In the general rejoicing over the introduction of painfree surgery, an important historical point about ether anesthesia at Mass General can be lost; the hospital itself had nothing to do with the discovery. Its surgeons, however, were clear-sighted enough to recognize a good thing and then use their influence to popularize it. The role the hospital played—entirely consistent with its character at the time—was to give the stamp of social approval to an innovation brought by an outsider.

The availability of anesthesia gradually increased the amount of surgery that was performed, but it did not improve success rates. The problem of infection continued, and another two decades would elapse before Joseph Lister published his first paper, in 1867, on the use of antiseptics to prevent wound infections. Unlike the use of anesthesia, which was rapidly adopted, sterile operating procedure came into use rather slowly at Mass General, and “capital” surgery remained out of favor at the hospital.

An aggressive Bostonian, Dr. John Homans, had begun performing abdominal surgery by the early 1870s, but he did his operations at a small private hospital on Beacon Hill. When he joined the staff of Mass General, the trustees explicity denied him permission to perform such surgery in their hospital, mainly because they were fearful of infection. Another surgeon at Mass General, Arthur Tracy Cabot, appears to have been the first staff member to cut into an abdomen under the hospital’s auspices. This was in 1874. But for the purpose he used rented rooms in a house near the hospital rather than run the risk of “hospitalism.” Only in 1884 did Cabot perform his first abdominal operations within the walls of the hospital.

Two years later, in 1886, Mass General made what was probably its first authentic and important contribution to modern medical research. That year Reginald H. Fitz coined the term appendicitis and gave an analysis of the disease that paved the way for proper diagnosis and successful surgical treatment.

In another ten years, and just a few months after Roentgen announced the discovery of X rays, the hospital acquired its first X-ray tube, brought back from Europe by J. Collins Warren, grandson of the hospital’s co-founder. The technique of using X rays for diagnosis was slowly developed at the hospital mainly by the hospital photographer, Walter J. Dodd, who had begun his career as a janitor in the chemical laboratory at Harvard. After becoming a self-made expert in the new technique, Dodd went to medical school at the University of Vermont and acquired his degree at the age of thirty-nine. Unaware of how hazardous X rays could be, Dodd suffered severe, unhealing burns and died at the age of forty-seven.

Richard Clarke Cabot, who had so selflessly promoted Edsall, was also one of America’s great innovators. Almost incidentally to his career, he reclassified heart diseases according to their cause rather than merely by anatomical abnormality, thus advancing the field of cardiology. But he is better remembered for two new ideas that were not, strictly speaking, scientific. The first was an educational exercise, known as the clinicopathological conference (or “CPC”), which is still a weekly ritual at Mass General. The medical staff assembles and listens as all the details of a complicated case are presented either to one of its members or to a distinguished visitor. The final diagnosis, as established by a biopsy or autopsy, is withheld. The discussant analyzes the facts and offers his or her diagnosis, which, at the end, is compared with the pathologist’s findings. These CPCs, under the title “Case Records of the Massachusetts General Hospital,” are still a prominent weekly feature of The New England Journal of Medicine , which includes, as part of the headline, the phrase “Weekly Clinicopathological Exercises: Founded by Richard C. Cabot.”

Also at Mass General, in 1905, Cabot founded the first full-time social service department in an American hospital. Cabot had always stressed not only the soul but also society as a factor in disease and health, and in teaching his students about tuberculosis, for example, he is supposed to have made the ironic remark, “Taking it by and large, consumption is curable in the rich, incurable in the poor, while in the moderately well-to-do the chances are proportionately intermediate.”

Part of the hope for his social service department evidently was that it would help to make “consumption” curable in the poor. Its first task was to arrange for proper management of tuberculosis patients at the hospital, with such measures as education in hygiene as well as “vacations and country outings for those who need them as part of their treatment. ” Other aspects of medical social work at the time included instruction for new mothers, “the care of unmarried girls, pregnant, morally exposed, or feeble-minded … help for patients needing work or a change of work … provision and provisions for patients ‘dumped’ at the hospital,” and “assistance to patients needing treatment after discharge from the hospital wards.”

At the turn of the century America lagged well behind Europe in its medical research. But there were clear signs of change. The Johns Hopkins School of Medicine in Baltimore had been opened in 1893 and was rapidly becoming preeminent in teaching and research. Then, in 1906, the Rockefeller Institute was opened in New York. At first staffed mainly by alumni of Johns Hopkins or European institutions, the Rockefeller rapidly became famous for truly outstanding laboratory investigation of disease. At these and other American institutions, the understanding of infection grew more sophisticated, and glimmerings of progress in other areas were to be seen.

MASS GENERAL was not conspicuous among the new generation of research institutions. It was organized in a way that hampered any efiort that its physicians, all of them part-time at the hospital, might make to carry on sustained laboratory research. Moreover, the staff was inbred and periodically smarted from charges of nepotism. Although the medical staff was no longer drawn exclusively from the Brahmin families, they were still all Bostonians, and almost all received training first at Harvard and then at the hospital itself before joining the staff.

By 1908 the self-criticism that eventually led to David Edsall’s appointment was under way. The senior medical staff realized that they must either reorganize so as to incorporate a strong program of research or else settle into a kind of quaint obscurity as the hospital remembered for the promotion of a discovery—ether anesthesia—made before the Civil War. The General might even lose its preeminence in Boston, for another hospital, the Peter Bent Brigham, was in the planning stages. The Brigham was to be built adjacent to Harvard Medical School and, like Johns Hopkins, it openly intended to recruit the best people it could from hospitals elsewhere in the country. Thus, in a letter to their trustees, the majority of Mass General’s “visiting physicians,” as the hospital’s doctors were called, advocated changing the system of appointments so as to bring in a full-time chief with a mandate to organize and advance clinical research. Within a year, David Edsall, from New Jersey by way of Philadelphia, was identified as the man they wanted.

When Edsall finally came, in 1912, the hospital was ready for him. He was able to work rapidly, and with remarkably little resistance, to make the changes he thought necessary. In part he simply opened the hospital to outsiders; graduates of medical schools other than Harvard were granted internships. In the meantime Edsall began to identify the most promising young men already at the hospital and to send them away for training in laboratories in Europe or elsewhere in America. Paul Dudley White, for example, was sent to England to study cardiology; he returned with a prototype of the electrocardiograph in his luggage (and many years later would serve as President Eisenhower’s cardiologist). When Mass General opened its luxury building for private patients (the Phillips House) in 1917, every room was equipped with its own electrocardiograph. In the same era, George R. Minot was sent to Europe to study blood. Two decades later he would share the Nobel Prize for his contribution to the treatment of pernicious anemia. Others of that generation went to study at Johns Hopkins, Rockefeller, or other institutions.

In 1913 J. Howard Means was dispatched to Copenhagen, where he studied the body’s conversion of oxygen to carbon dioxide with August Krogh, who was to receive a Nobel Prize seven years later for his work on the body’s handling of these vital gases. Means returned to Mass General and was put in charge of a machine designed to measure gas exchange. Located in a “small triangular room” that Edsall had managed to liberate for the purpose, this tiny laboratory became the hospital’s center for research on metabolism. By 1918 the metabolism laboratory had been assigned more spacious quarters, and Means had turned his attention primarily to diseases of the thyroid, which has a profound effect on metabolic rate. Studying metabolism in patients proved to be exceedingly complicated; the investigator required very accurate information about diet and often needed to obtain frequent samples of blood or body fluids. To do this, a special ward was opened in 1925 for patients undergoing metabolic studies. Named Ward 4, it became famous as a center for work on a variety of topics that required close monitoring of patients’ physiology.

The first patient in Ward 4 suffered from lead poisoning and was studied by Joseph Aub, one of the hospital’s first Jewish physicians, who was accepted as an intern immediately after Edsall’s arrival. Edsall had long been interested in occupational diseases, and he stimulated Aub’s interest in lead poisoning. Thus Aub used Ward 4 to explore the way in which the body’s handling of lead was related to its handling of calcium. One student of Aub’s, Fuller Albright, took up an investigation of bone disease and from there made fundamental contributions to the understanding of hormones and vitamins as well as to kidney research. Although Albright’s career was abruptly terminated nearly thirty years ago, when an experimental operation to relieve his Parkinson’s disease left him totally incapacitated, his name is still among the best known in American medicine. As Albright began studying bone, his contemporary Walter C. Bauer turned to the study of joints and arthritis. This work led to research on related inflammatory diseases and then to more basic studies of immunology, as it became apparent that rheumatoid arthritis and a group of related conditions appeared to result from a disordered immune response.

THUS, EACH OF THE research programs seeded by Edsall in the few years before World War I took hold and then branched into new ones as scientific problems revealed new complexities. At the outset the research tasks were defined mainly as practical and clinical ones; Edsall’s interest in industrial health, a major concern of the period, was reflected in his protégés’ work on lead poisoning. But as time went on, the work tended to be reoriented toward more “basic” problems, such as the body’s handling of calcium—knowledge that was needed to explain the reaction to toxic metals. By the middle of this century, many of the hospital’s laboratories were devoted to fundamental study of biochemistry, with little immediate relevance to patient care.

During the two world wars, Mass General diverted its energy into organizing and staffing a military hospital; between the conflicts, the hospital’s growing research effort received support mainly from foundations and private contributors. The trustees actively sought funds for research and in doing so began to shift away from the traditional concept of charity that had motivated the institution in its first century. Indeed, as early as 1907, the trustees asserted that “those who give money to the Hospital may well feel that they are aiding most intelligent and painstaking efforts to find new agencies to repress and cure disease and pain.” As Morris Vogel observes in his elegant book The Invention of the Modern Hospital , Mass General “directed these pleas toward a much larger public than ever before. Hospitals began to ask for money as participants in a democratic conquest of disease; they retreated from their image as an expression of aristocratic stewardship.”

In part this shift of emphasis became feasible as the whole social role played by the hospital began to change. During its first century a haven for the sick poor, Mass General went on to open accommodations, in 1917, for the wealthy and then, in 1930, for the middle class. The emergence of workmen’s compensation and medical insurance transformed the concept of hospital care from a gift into a paid service. In this same period the hospital gradually expanded the range of services that it offered, despite opposition from conservative practitioners and trustees. Soon, virtually everything that a private doctor might do for a patient, in or out of the hospital, could be done by the hospital as an institution.

Since the Second World War, research at Mass General, as elsewhere, has increasingly been funded by the government or by the national foundations dedicated to eradicating one or another disease. The hospital itself and its supporters no longer play a very prominent role in the support of its research program, nor do they directly pay for most of the care given to patients. Indeed, like many other research hospitals, Mass General must now combat the perception that high-quality hospital care is a drain on scarce resources rather than being a laudable means of sharing the wealth.

Edsall died in 1945, but virtually every active field of investigation at the hospital can be traced back to the clinician-scientists that he installed in his first years there. In a poignant echo of its past, Mass General—formerly charged with social snobbery—is now sometimes accused of having become scientifically inbred, of failing to make key appointments from outside the hospital. But nobody today doubts the hospital’s standing as one of the twentieth century’s monuments of scientific medicine. Whether Mass General, or any hospital, can successfully address the problems that worried Richard Cabot—that poverty makes disease and that suffering is more than physical pain—remains to be seen.