bIOLOGICAL & mEDICAL wASTE hAZARDS
SOUTH BAY RESEARCH NOTES & RESOURCES:
Boston City Hospital; MAss. Homeopathy; University Hospital; Boston University; Naval Blood Lab
1870 City Hospital
1874 City Hospital
1885 Boston City Hospital
1895
1902 Boston City Hospital
1912 Boston City Hospital
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Radiology & Radiation Physics
"In decommissioning medical research buildings at this institution, most areas surveyed were not contaminated above NRC 1993 release limits. Most contamination found was fixed. Wipe tests were inefficient at assessing removable contamination. An initial approach to surveying such a facility should begin with limited sampling emphasizing fixed contamination detection. Recent NRC guidance on decommissioning suggests that the requirements are becoming less stringent for medical facilities. This seems to support our limited decommissioning survey strategy for medical research buildings where radioisotopes have been used."
Addresses:
Evdokimoff, V. “Lessons learned in decommissioning medical facilities.” Health physics vol. 77,5 Suppl (1999): S77-80. doi:10.1097/00004032-199911001-00006
Radioactive excreta from nuclear medicine patients can enter solid waste as common trash and medical biohazardous waste. Many landfills and transfer stations now survey these waste streams with scintillation detectors which may result in rejection of a hospital`s waste. Our survey indicated that on the average either or both of Boston University Medical Center Hospital`s waste streams can contain detectable radioactive excreta on a weekly basis. To avoid potential problems, radiation detectors were installed in areas where housekeepers carting trash and medical waste must pass through to ensure no radioactivity leaves the institution. 3 refs.
Evdokimoff, V, et al. "Potential for radioactive patient excreta in hospital trash and medical waste." Health Physics, vol. 66, no. 2, Jan. 1994. https://doi.org/10.1097/00004032-199402000-00013
"In decommissioning medical research buildings at this institution, most areas surveyed were not contaminated above NRC 1993 release limits. Most contamination found was fixed. Wipe tests were inefficient at assessing removable contamination. An initial approach to surveying such a facility should begin with limited sampling emphasizing fixed contamination detection. Recent NRC guidance on decommissioning suggests that the requirements are becoming less stringent for medical facilities. This seems to support our limited decommissioning survey strategy for medical research buildings where radioisotopes have been used."
Addresses:
Evdokimoff, V. “Lessons learned in decommissioning medical facilities.” Health physics vol. 77,5 Suppl (1999): S77-80. doi:10.1097/00004032-199911001-00006
Radioactive excreta from nuclear medicine patients can enter solid waste as common trash and medical biohazardous waste. Many landfills and transfer stations now survey these waste streams with scintillation detectors which may result in rejection of a hospital`s waste. Our survey indicated that on the average either or both of Boston University Medical Center Hospital`s waste streams can contain detectable radioactive excreta on a weekly basis. To avoid potential problems, radiation detectors were installed in areas where housekeepers carting trash and medical waste must pass through to ensure no radioactivity leaves the institution. 3 refs.
Evdokimoff, V, et al. "Potential for radioactive patient excreta in hospital trash and medical waste." Health Physics, vol. 66, no. 2, Jan. 1994. https://doi.org/10.1097/00004032-199402000-00013
To NRC:
We are furnishing additional information requested by David Mann of your - staff at a site inspection of our facility on November 17, 1993. This letter further expands on ash measurement of our radioactive incinerator as described in our February 19 and June 17, 1993 letters. We wish to amend condition 18C of our NRC license # 20-02215-01 whereby " ash residue generated at the 700 Albany St. facility must be stored or disposed of as radioactive waste. We ask that this proposal be considered under 10 CFR 20.302.
Criteria for Ash Being Radioactive: We will dispose .of ash generated from radioactive incineration to common trash if it is determined not to be radioactive. Radioactivity is defined as a 95% chance that counts are not due to statistical fluctuations in background but are due to radioactivity as determined on . sensitive radiation measurement equipment. We have previously described the measurement equipment and their MDA's in item #4 in our June 17 letter . Ash that is not radioactive will be discarded to common trash. Radioactive ash will be shipped to our commercial radwaste company or stored for decay if less than a 90 day halflife. If we cannot send our radioactive waste to a commercial licensed radwaste broker, it will be stored within our NRC license condition and/or other regulations for extended radwaste interim storage.
Strategv: We believe that it is prudent to. decay out radwaste with half-lives less than 90 days and incinerate radioactive waste (lab trash and animals) with half-lives greater than 90 days. Although we could incinerate radioactive waste with half-lives less than 90 days e.g. sulfur 35, there is nothing to gain if the
ash becomes radioactive and/or presents greater exposure potential to waste handlers. Therefore incinerating long-lived H-3 and C-14 radwaste would cause volatilization as tritiated gas / water vapor and 14Co2 These radionuclides should then be removed in the wet scrubber pollution . system to sanitary sewer and not be in ash or be released as an air effluent to the atmosphere. Thus, economically and socially there are benefits is to dispose of ash from radioactive incineration if the ash can be disposed of as non-radioactive to common trash. We realize this. goal may be unrealistic since we expect to incinerate radioactive carcasses that contain radioactivity that could yield radioactive
ash e.g. microspheres. We feel nonetheless that our strategy is ALARA.
Monitoring System: We will do controlled burns of known quantities of radioactive H-3 and C-14 in laboratory trash to determine where the radioactivity goes. Especially critical will be to establish whether our hypothesis of .H-3 and/or C-14 going to the wet scrubber is correct. Representative samples will be taken of all ash after incineration, its pollution equipment and stack monitors to fulfill the following goals: 1) to measure where the radioactivity goes; 2) to establish a sampling and measurement program; 3) to assure compliance with NRC and other regulations
Once we - have established experience and acquired reliable reproducible data by monitoring the radioactive incinerator and its ash, we will begin to incinerate BUMC long lived radwaste. The frequency and extent of our monitoring this incinerator will be dependent upon what we learn about the radioactivity and its distribution in the controlled burns. We will commit that before ' ash is discarded to common trash that has resulted from radioactive incineration, we will monitor the ash . to determine whether it is radioactive or not. Radioactive ash will not be discarded into common trash but disposed as a radioactive waste. Ash that is determined by measurement not to be radioactive, will be discarded into common trash.
Should you desire further information, please do not hesitate to contact me so that we can expedite this request.
Sincerely, Victor Evdokimoff, Director Radiation Protection, BUMC, Boston University Medical Center 1993
We are furnishing additional information requested by David Mann of your - staff at a site inspection of our facility on November 17, 1993. This letter further expands on ash measurement of our radioactive incinerator as described in our February 19 and June 17, 1993 letters. We wish to amend condition 18C of our NRC license # 20-02215-01 whereby " ash residue generated at the 700 Albany St. facility must be stored or disposed of as radioactive waste. We ask that this proposal be considered under 10 CFR 20.302.
Criteria for Ash Being Radioactive: We will dispose .of ash generated from radioactive incineration to common trash if it is determined not to be radioactive. Radioactivity is defined as a 95% chance that counts are not due to statistical fluctuations in background but are due to radioactivity as determined on . sensitive radiation measurement equipment. We have previously described the measurement equipment and their MDA's in item #4 in our June 17 letter . Ash that is not radioactive will be discarded to common trash. Radioactive ash will be shipped to our commercial radwaste company or stored for decay if less than a 90 day halflife. If we cannot send our radioactive waste to a commercial licensed radwaste broker, it will be stored within our NRC license condition and/or other regulations for extended radwaste interim storage.
Strategv: We believe that it is prudent to. decay out radwaste with half-lives less than 90 days and incinerate radioactive waste (lab trash and animals) with half-lives greater than 90 days. Although we could incinerate radioactive waste with half-lives less than 90 days e.g. sulfur 35, there is nothing to gain if the
ash becomes radioactive and/or presents greater exposure potential to waste handlers. Therefore incinerating long-lived H-3 and C-14 radwaste would cause volatilization as tritiated gas / water vapor and 14Co2 These radionuclides should then be removed in the wet scrubber pollution . system to sanitary sewer and not be in ash or be released as an air effluent to the atmosphere. Thus, economically and socially there are benefits is to dispose of ash from radioactive incineration if the ash can be disposed of as non-radioactive to common trash. We realize this. goal may be unrealistic since we expect to incinerate radioactive carcasses that contain radioactivity that could yield radioactive
ash e.g. microspheres. We feel nonetheless that our strategy is ALARA.
Monitoring System: We will do controlled burns of known quantities of radioactive H-3 and C-14 in laboratory trash to determine where the radioactivity goes. Especially critical will be to establish whether our hypothesis of .H-3 and/or C-14 going to the wet scrubber is correct. Representative samples will be taken of all ash after incineration, its pollution equipment and stack monitors to fulfill the following goals: 1) to measure where the radioactivity goes; 2) to establish a sampling and measurement program; 3) to assure compliance with NRC and other regulations
Once we - have established experience and acquired reliable reproducible data by monitoring the radioactive incinerator and its ash, we will begin to incinerate BUMC long lived radwaste. The frequency and extent of our monitoring this incinerator will be dependent upon what we learn about the radioactivity and its distribution in the controlled burns. We will commit that before ' ash is discarded to common trash that has resulted from radioactive incineration, we will monitor the ash . to determine whether it is radioactive or not. Radioactive ash will not be discarded into common trash but disposed as a radioactive waste. Ash that is determined by measurement not to be radioactive, will be discarded into common trash.
Should you desire further information, please do not hesitate to contact me so that we can expedite this request.
Sincerely, Victor Evdokimoff, Director Radiation Protection, BUMC, Boston University Medical Center 1993
Docket No. 030-01807 License No. 20-00275-08, Boston City Hospital, Department of Radiology and Radiation Physics
ATTN: David Hardy Assistant Director, Division of Operations, 818 Harrison Avenue, Boston, Massachusetts 02118
Gentlemen: Subject: Routine Inspection No. 030-01807/89-001, On March 29, 1989, John T. Jensen of this office conducted a routine safety inspection at the above address of activities authorized by the above listed NRC license. The inspection was an examination of your licensed activities as they relate to radiation safety and to compliance with the Commission's regulations and the license conditions. The inspection consisted of observations by the inspector, interviews with personnel, and a selective examination of representative records. The findings of the inspection were discussed with you and Gene A. Cardarelli, of your staff, at the conclusion of the inspection. Based on the results of this inspection, it appears that your activities were not conducted in full compliance with NRC requirements. A Notice of Violation is enclosed as Appendix A and categorizes each violation by severity level in accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (Enforcement Policy). You are required to respond to this letter and in preparing your response, you should follow the instructions in Appendix A. In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and your reply will be placed in the Public Document Room. The responses directed by this letter and the accompanying Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511.
Your cooperation with us is appreciated. Sincerely, Original signed by, E. Glenn, Ph.D.
John E. Glenn, Ph.D, Chief. Nuclear Materials Safety- Section A, Division of Radiation Safety and Safeguards
Enclosure: Appendix A, Notice of Violation
ATTN: David Hardy Assistant Director, Division of Operations, 818 Harrison Avenue, Boston, Massachusetts 02118
Gentlemen: Subject: Routine Inspection No. 030-01807/89-001, On March 29, 1989, John T. Jensen of this office conducted a routine safety inspection at the above address of activities authorized by the above listed NRC license. The inspection was an examination of your licensed activities as they relate to radiation safety and to compliance with the Commission's regulations and the license conditions. The inspection consisted of observations by the inspector, interviews with personnel, and a selective examination of representative records. The findings of the inspection were discussed with you and Gene A. Cardarelli, of your staff, at the conclusion of the inspection. Based on the results of this inspection, it appears that your activities were not conducted in full compliance with NRC requirements. A Notice of Violation is enclosed as Appendix A and categorizes each violation by severity level in accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (Enforcement Policy). You are required to respond to this letter and in preparing your response, you should follow the instructions in Appendix A. In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and your reply will be placed in the Public Document Room. The responses directed by this letter and the accompanying Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, PL 96-511.
Your cooperation with us is appreciated. Sincerely, Original signed by, E. Glenn, Ph.D.
John E. Glenn, Ph.D, Chief. Nuclear Materials Safety- Section A, Division of Radiation Safety and Safeguards
Enclosure: Appendix A, Notice of Violation
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Docket No. 0304)1807, License No. 20-00275-08, FA No. 93-256
Ms. Rita Whelan, Assistant, Deputy Commissioner, Boston City Hospital, 818 Harrison Avenue, Boston, Massachusetts 02118
Dear Ms. Whelan: SUBJECT: NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL, PENALTY - $2,500 (NRC INSPECTION REPORT NO. 030-01807/93-001)
This refers to the inspection conducted on October 6,1993, at your facility in Boston, Massachusetts. During the inspection, apparent violations of NRC requirements were identified. The inspection report was sent to you on October 29,1993. An enforcement conference was 6 conducted on November 9,1993, with you and other members of your staff to discuss the apparent violations, their causes and your corrective actions. A copy of the enforcement conference report is enclosed. Seven violations are being cited and are described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) (Enclosure 1). The most significant violation, set forth in Section I of the enclosed Notice, involves the failure to control access to licensed radioactive material. Specifically, on the day of the inspection, the inspector observed that you left the door to the hot lab open for a period of time when no member of your staff was in the room, thus allowing unchallenged access to the licensed radioactive material (approximately 200 millicuries of technetium-99m and 40 microcuries of iodine-131) stored in the room. The inspector had entered and stayed in the lab for about five minutes, and only after the inspector called out to announce his presence did a technician enter the area from an adjacent room. Apparently, the door was kept open, even though constant surveillance was not provided, because deterioration of the hot lab floor necessitated extra effort to close the door. At the time, the entry to the hot lab was not in the line of sight of personnel in the other rooms that were occupied, because of ongoing construction in an area adjacent to the hot lab and a temporary wall built in the corridor in front of the hot lab. The NRC license issued to Boston City Hospital entrusts the licensee with the responsibility for - j maintaining control of access to licensed material so as to prevent the loss or theft of the material and unnecessary exposure of individuals to radiation. Although there was no loss or theft of the licensed radioactive material, and no unnecessary exposures, the failure to maintain - proper security created an opportunity for such events. This failure was particularly disturbing ; since the deterioration of the floor which resulted in the inability to keep the door closed was -known by your staff, but timely corrective actions were not taken. Therefore, in accordance. with the " General Statement of Policy and Procedure for NRC Enforcement Actions," ,(Enforcement Policy) 10 CFR Part 2, Appendix C, this violation is classified at Severity Level : 111 and is set forth in Section I of the enclosed Notice. I The NRC recognizes that subsequent to the inspection, prompt and comprehensive actions were, taken to correct the violation and prevent recurrence. These actions, which were described during the enforcement conference, included relocating the hot lab to a new room-on ; October 28,1993, and implementation of measures to ensure that security of the new hot lab,| door is maintained in that the door is self-locking with a combination lock. Notwithstanding these actions, to emphasize the need to maintain access control over licensed material at all times, and to assure that your corrective actions are long lasting, I have been ; authorized to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty ; j in the amount of $2,500 for this Severity Level III violation. The base amount of a civil penalty for a Severity Level III violation for medical institutions is $2,500. The civil penalty adjustment factors in the Enforcement Policy were considered. The base civil penalty was escalated by 50% because of NRC's identification of the violation, and | : mitigated 50% in view of your prompt and comprehensive corrective actions. In addition, with respect to your prior performance, although there were only four violations in the two previous ; inspections, which generally is good performance, no mitigation is warranted because the seven i violations in the enclosed Notice indicate a general decline in your recent performance. Therefore, on balance, no adjustment to the base civil penalty was made.. The other adjustment factors in the policy were considered and no further adjustment to the base civil penalty was; considered appropriate. Six other violations identified during the inspection are set forth in Sections II and III of the enclosed Notice. The violations in Section II are related to your failure to implement the Quality Management Program (QMP), and follow the requirements of the QMP. These violations also represent a failure of the Radiation Safety Officer (RSO) to ensure that radiation safety activities were being performed in accordance with approved procedures and requirements. Specifically, these violations include failure of the authorized user to complete written directives by signing the form so as to indicate review prior to administration; failure to instruct all supervised users on the requirements of the QMP; and failure to develop procedures ~for conducting a review of j the QMP. At the enforcement conference, you indicated that a review of the written directives, including the changes made to the initial directives, was performed by the authorized user via ; j conversation with the technicians, or by an actual review of the directive prior to administration. , The NRC notes that to ensure licensed material is administered as directed, a review of the : written directive by the authorized user is necessary on a!! occasions. Three other violations are set forth in Section III of the Notice and involve the failure to appropriately test the dose calibrator for linearity, failure to instruct all of the technicians in proper use of the survey instruments, and failure to notify the NRC when authorized users left the licensee's facility. In addition, regarding another apparent violation identified in the inspection report, related to a failure to include the date of birth and identification number in the
radiation records of two individuals, you stated at the enforcement conference the reasons for this apparent violation and your corrective actions to prevent recurrence. After considering this information, the NRC has determined that the apparent violation satisfied the criteria for enforcement discretion in paragraph VII.B.(1) of the Enforcement Policy in Appendix C of 10 CFR Part 2. Therefore, this violation is not being cited. Finally, the inspection report discussed an apparent violation for not adhering to a QMP requirement for submitting the written directives to the Radiation Safety Office prior to administration of iodine-131 in amounts greater than 30 microcuries. This apparent violation has been withdrawn based on your response that the 30 microcurie limit was a typographical error in the QMP. This limit, based on your statement at the enforcement conference, is 30 ; millicuries, and you also indicated that no administration reached this limit to require such a review. You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," a copy of this letter and its enclosure will be placed in the NRC Public Document Room. The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511.
Thomas T. Martin, Regional Administrator
Enclosures: 1. Notice of Violation and Proposed Imposition of Civil Penalty, 2. Enforcement Conference Report
Ms. Rita Whelan, Assistant, Deputy Commissioner, Boston City Hospital, 818 Harrison Avenue, Boston, Massachusetts 02118
Dear Ms. Whelan: SUBJECT: NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL, PENALTY - $2,500 (NRC INSPECTION REPORT NO. 030-01807/93-001)
This refers to the inspection conducted on October 6,1993, at your facility in Boston, Massachusetts. During the inspection, apparent violations of NRC requirements were identified. The inspection report was sent to you on October 29,1993. An enforcement conference was 6 conducted on November 9,1993, with you and other members of your staff to discuss the apparent violations, their causes and your corrective actions. A copy of the enforcement conference report is enclosed. Seven violations are being cited and are described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) (Enclosure 1). The most significant violation, set forth in Section I of the enclosed Notice, involves the failure to control access to licensed radioactive material. Specifically, on the day of the inspection, the inspector observed that you left the door to the hot lab open for a period of time when no member of your staff was in the room, thus allowing unchallenged access to the licensed radioactive material (approximately 200 millicuries of technetium-99m and 40 microcuries of iodine-131) stored in the room. The inspector had entered and stayed in the lab for about five minutes, and only after the inspector called out to announce his presence did a technician enter the area from an adjacent room. Apparently, the door was kept open, even though constant surveillance was not provided, because deterioration of the hot lab floor necessitated extra effort to close the door. At the time, the entry to the hot lab was not in the line of sight of personnel in the other rooms that were occupied, because of ongoing construction in an area adjacent to the hot lab and a temporary wall built in the corridor in front of the hot lab. The NRC license issued to Boston City Hospital entrusts the licensee with the responsibility for - j maintaining control of access to licensed material so as to prevent the loss or theft of the material and unnecessary exposure of individuals to radiation. Although there was no loss or theft of the licensed radioactive material, and no unnecessary exposures, the failure to maintain - proper security created an opportunity for such events. This failure was particularly disturbing ; since the deterioration of the floor which resulted in the inability to keep the door closed was -known by your staff, but timely corrective actions were not taken. Therefore, in accordance. with the " General Statement of Policy and Procedure for NRC Enforcement Actions," ,(Enforcement Policy) 10 CFR Part 2, Appendix C, this violation is classified at Severity Level : 111 and is set forth in Section I of the enclosed Notice. I The NRC recognizes that subsequent to the inspection, prompt and comprehensive actions were, taken to correct the violation and prevent recurrence. These actions, which were described during the enforcement conference, included relocating the hot lab to a new room-on ; October 28,1993, and implementation of measures to ensure that security of the new hot lab,| door is maintained in that the door is self-locking with a combination lock. Notwithstanding these actions, to emphasize the need to maintain access control over licensed material at all times, and to assure that your corrective actions are long lasting, I have been ; authorized to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty ; j in the amount of $2,500 for this Severity Level III violation. The base amount of a civil penalty for a Severity Level III violation for medical institutions is $2,500. The civil penalty adjustment factors in the Enforcement Policy were considered. The base civil penalty was escalated by 50% because of NRC's identification of the violation, and | : mitigated 50% in view of your prompt and comprehensive corrective actions. In addition, with respect to your prior performance, although there were only four violations in the two previous ; inspections, which generally is good performance, no mitigation is warranted because the seven i violations in the enclosed Notice indicate a general decline in your recent performance. Therefore, on balance, no adjustment to the base civil penalty was made.. The other adjustment factors in the policy were considered and no further adjustment to the base civil penalty was; considered appropriate. Six other violations identified during the inspection are set forth in Sections II and III of the enclosed Notice. The violations in Section II are related to your failure to implement the Quality Management Program (QMP), and follow the requirements of the QMP. These violations also represent a failure of the Radiation Safety Officer (RSO) to ensure that radiation safety activities were being performed in accordance with approved procedures and requirements. Specifically, these violations include failure of the authorized user to complete written directives by signing the form so as to indicate review prior to administration; failure to instruct all supervised users on the requirements of the QMP; and failure to develop procedures ~for conducting a review of j the QMP. At the enforcement conference, you indicated that a review of the written directives, including the changes made to the initial directives, was performed by the authorized user via ; j conversation with the technicians, or by an actual review of the directive prior to administration. , The NRC notes that to ensure licensed material is administered as directed, a review of the : written directive by the authorized user is necessary on a!! occasions. Three other violations are set forth in Section III of the Notice and involve the failure to appropriately test the dose calibrator for linearity, failure to instruct all of the technicians in proper use of the survey instruments, and failure to notify the NRC when authorized users left the licensee's facility. In addition, regarding another apparent violation identified in the inspection report, related to a failure to include the date of birth and identification number in the
radiation records of two individuals, you stated at the enforcement conference the reasons for this apparent violation and your corrective actions to prevent recurrence. After considering this information, the NRC has determined that the apparent violation satisfied the criteria for enforcement discretion in paragraph VII.B.(1) of the Enforcement Policy in Appendix C of 10 CFR Part 2. Therefore, this violation is not being cited. Finally, the inspection report discussed an apparent violation for not adhering to a QMP requirement for submitting the written directives to the Radiation Safety Office prior to administration of iodine-131 in amounts greater than 30 microcuries. This apparent violation has been withdrawn based on your response that the 30 microcurie limit was a typographical error in the QMP. This limit, based on your statement at the enforcement conference, is 30 ; millicuries, and you also indicated that no administration reached this limit to require such a review. You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. In your response, you should document the specific actions taken and any additional actions you plan to prevent recurrence. After reviewing your response to this Notice, including your proposed corrective actions and the results of future inspections, the NRC will determine whether further NRC enforcement action is necessary to ensure compliance with NRC regulatory requirements. In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," a copy of this letter and its enclosure will be placed in the NRC Public Document Room. The responses directed by this letter and the enclosed Notice are not subject to the clearance procedures of the Office of Management and Budget as required by the Paperwork Reduction Act of 1980, Pub. L. No. 96-511.
Thomas T. Martin, Regional Administrator
Enclosures: 1. Notice of Violation and Proposed Imposition of Civil Penalty, 2. Enforcement Conference Report
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License No. 20-02215-01, Docket No. 030-01845, Control No. 119111
Boston University Medical Center :
ATTN: Victor Evdokimoff, Director Radiation Protection, 88 East Newton Street, Boston, Massachusetts 02118
Dear Mr. Evdokimoff: This refers to your license amendment request. Enclosed with this letter is the amended license authorizing incineration of waste from two closely , affiliated institutions. The amendment to approve your method of verifying ! that incineration ash is not radioactive is still under review. Please review the enclosed document carefully and be sure that you understand and fully implement all the Conditions incorporated into the amended license. If there are errors or questions, please notify the U.S. Nuclear Regulatory Commission, Region I office, the Licensing Assistance Section, (610) 337-5093 or 5239, so that we can provide appropriate corrections and answers. i Thank you for your cooperation. Sincerely, Original Signed By Keith D. Brown, Ph.D, Nuclear Materials Safety Branch, Division of Radiation Safety and Safeguards
Enclosure: Amendment No. 49
Boston University Medical Center :
ATTN: Victor Evdokimoff, Director Radiation Protection, 88 East Newton Street, Boston, Massachusetts 02118
Dear Mr. Evdokimoff: This refers to your license amendment request. Enclosed with this letter is the amended license authorizing incineration of waste from two closely , affiliated institutions. The amendment to approve your method of verifying ! that incineration ash is not radioactive is still under review. Please review the enclosed document carefully and be sure that you understand and fully implement all the Conditions incorporated into the amended license. If there are errors or questions, please notify the U.S. Nuclear Regulatory Commission, Region I office, the Licensing Assistance Section, (610) 337-5093 or 5239, so that we can provide appropriate corrections and answers. i Thank you for your cooperation. Sincerely, Original Signed By Keith D. Brown, Ph.D, Nuclear Materials Safety Branch, Division of Radiation Safety and Safeguards
Enclosure: Amendment No. 49
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| 1997_escrow_ml20141b476_pdf.pdf |
Nuclear Regulatory Commission, License Fee Management Branch, Washington, D.C. 20555, Attn: Mr. Allen S. Cabell
Dear Mr. Cabell: With reference to your letter of February 8, 1985 regarding information as to how or in what capacity the Boston City Hospital and' the Boston V.A. Medical Center are formally affiliated with the Boston University Medical Center, we enclose copies of a Memorandum of Agreement _( Affiliation) between the Boston University School of Medicine, a constituent member, with the University Hospital, of the Boston University Medical Center, and the two Institutions for which we wish to provide the service of receiving radioactive waste at a nominal charge by the Animal Science Center to cover expenses. You may note that in paragraph 2 d of the memorandum the Boston V.A. Medical Center will cooperate with the Boston University School of Medicine in the conduct of appropriate programs of education, training and research. Thank you for your attention to this matter, BELTON A. BURROWS, M.D. |
Director, Radiation Protection, Encl. (2) NRC letter dated 2/8/85, VA Memorandum of Agreement dated 5/1.3/75, BCH Contract with BU dated July 1982
Director (00/11) VA Hospital, 150 South Huntington Avenue, Boston, Massachusetts 02130
SUBJ: Memorandum of Agreement (Affiliation between the Veterans Administration Hospital, Boston, Massachusetts, and *The
Boston University and Tufts University Scheels of Medicine, Boston, Massachusetts (Our letter April 24, 1975). We are pleased to advise you that the subject Memorandum of Agreement has been approved by the General Counsel and signed by the Chief Medical Director. 2. The signed agreement is enclosed for your files. By direction of the Director, Field Operations, Region 1, Richard A. Livinson, M.D., Veterans Association Dept. of Medicine & Surgery
MEMEORANDUM OF AGREEMENT (AFFILIATION) BETWEEN THE VETERANS ADMINISTRATION HOSPITAL, BOSTON, MA, AND THE BOSTON UNIVERSITY AND TUFTS UNIVERSITY SCHOOLS OF MEDICINE, BOSTON, MA.
CONTRACT between City of Boston, acting by its Board of Health and Hospitals, and the Trustees of Boston University, acting for Boston University School of Medicine.
Dear Mr. Cabell: With reference to your letter of February 8, 1985 regarding information as to how or in what capacity the Boston City Hospital and' the Boston V.A. Medical Center are formally affiliated with the Boston University Medical Center, we enclose copies of a Memorandum of Agreement _( Affiliation) between the Boston University School of Medicine, a constituent member, with the University Hospital, of the Boston University Medical Center, and the two Institutions for which we wish to provide the service of receiving radioactive waste at a nominal charge by the Animal Science Center to cover expenses. You may note that in paragraph 2 d of the memorandum the Boston V.A. Medical Center will cooperate with the Boston University School of Medicine in the conduct of appropriate programs of education, training and research. Thank you for your attention to this matter, BELTON A. BURROWS, M.D. |
Director, Radiation Protection, Encl. (2) NRC letter dated 2/8/85, VA Memorandum of Agreement dated 5/1.3/75, BCH Contract with BU dated July 1982
Director (00/11) VA Hospital, 150 South Huntington Avenue, Boston, Massachusetts 02130
SUBJ: Memorandum of Agreement (Affiliation between the Veterans Administration Hospital, Boston, Massachusetts, and *The
Boston University and Tufts University Scheels of Medicine, Boston, Massachusetts (Our letter April 24, 1975). We are pleased to advise you that the subject Memorandum of Agreement has been approved by the General Counsel and signed by the Chief Medical Director. 2. The signed agreement is enclosed for your files. By direction of the Director, Field Operations, Region 1, Richard A. Livinson, M.D., Veterans Association Dept. of Medicine & Surgery
MEMEORANDUM OF AGREEMENT (AFFILIATION) BETWEEN THE VETERANS ADMINISTRATION HOSPITAL, BOSTON, MA, AND THE BOSTON UNIVERSITY AND TUFTS UNIVERSITY SCHOOLS OF MEDICINE, BOSTON, MA.
CONTRACT between City of Boston, acting by its Board of Health and Hospitals, and the Trustees of Boston University, acting for Boston University School of Medicine.
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| 1985_nrc_relationships_ml20100b587_opt2.pdf |
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| 1982_boston_and_bu_ml20100b587-6_pdf_bw.pdf |
Liquid Waste. Liquid byproduct material will either be disposed of via the sanitary sewer system in quantities not exceeding ten times the values listed in Appendix E, Table 1 Column 2 of Title 10, Part 20, Code of Federal Register or allowed to decay to background, monitored and disposed of via the sanitary sewer system or into the regular waste. A separate sink disposal list trill be kept at the sink to ensure that limits specified in Section 20.303 of 10 CFR20 are not exceeded
This letter is in response to IE Bulletin #79-19. NRC license #20-00275-08 does use radioactive waste barrels for disposal of low level radioactive waste. Attached is the protocol which you requested. September 11, 1979
Boston University Medical Center (BUMC) in Boston, MA.
BUMC is comprised of two entities: Boston University (BU), a Massachusetts nonprofit educational institution (which includes the Medical School), and Boston Medical Center (BMC), a privately owned hospital and the teaching affiliate for BU 's Medical School. But, the relationship goes beyond the teaching affiliation. The two entities work very closely together, share resources, and even share and co-own buildings and/or attach them via cat walks, etc., allowing seamless access to BMC and BU areas (dependent upon one's work function). Two resources shared by BMC and BU include the Public Safety and Radiation Safety departments. The Public Safety department provides security in all BMC and BU buildings and grounds, and they issue and rescind employee identification cards which are smart cards that provide/deny access to B.MC and BU buildings, based upon each employee work function and restrictions. In addition, all the BMC and BU buildings are on the same Radioactive Materials license, as the BUMC campus, issued by the Massachusetts Radiation Control Program, hence, radiation safety is administered under one common Radiation Safety department.
There is one building, the Fuller Building, along our contiguous area, which is owned and partially used by the Commonwealth of Massachusetts, and is also leased for use to BU and BMC. The Commonwealth of Massachusetts uses several floors of this building and provides their own security and access to this building, but radiation safety is provided by the common BU/BMC Radiation Safety depai1ment, and this building is on the BUMC Radioactive Materials license. Our plan is to use the private road which traverses between the Fuller Building and our BUMC campus to move the irradiator. Note that half this private road is owned by the BU.MC while the other half is owned by the State of Massachusetts. Our plan is to restrict the access (the public and uninvolved BUMC employees) on our side of the private road when moving the blood irradiator - on our side of this private road.
US DOT, March 13 2017, Reference No. 16-0134
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"radioactive dog carcasses"
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MASSACHUSETTS SCHOOLS CITED FOR CAVALIER' HANDLING OF RADIOACTIVE MATERIALS
April 16, 1995 By Associated Press
BOSTON, APRIL 15 -- Radioactive material is tossed into the trash and buried in a landfill. Eight people are unknowingly exposed when radioactive waste leaks from a container because someone forgot to put the plug in. Labs with radioactive materials are left unlocked and unsupervised. Cut through the 2024 election noise. Get The Campaign Moment newsletter. These incidents, and similar ones, occurred not at an irresponsible corporation or in a bad B-movie plot, but at Harvard, Boston University, the University of Massachusetts and other schools. Nuclear Regulatory Commission documents obtained under the Freedom of Information Act show that Massachusetts universities have what an NRC inspector called a "cavalier" attitude toward the handling and disposal of radioactive material. The inspector singled out Harvard University, which has been cited at least eight times in the last 10 years for violating NRC regulations. Harvard has changed its procedures and its packaging for radioactive waste, said Joe Ring, the university's radiation safety officer. He said faculty and students have responded to threats that their laboratories might be shut down because of violations, and the university's most recent NRC inspection last year found no violations. The documents showed that radioactive material has been illegally thrown into the trash at least seven times by four different Massachusetts institutions in the last eight years. Four of these instances occurred at the Boston University medical school, where a radiology instrument containing radioactive material was accidently thrown into a trash compactor in December 1987 and hauled to a landfill south of Boston. On March 13, 1989, radioactive material was discovered missing from a Boston University lab. Six months later, a vial containing radioactive phosphorous was left in a hallway trash pile and disposed of in an unknown landfill. And on Oct. 4, 1993, a housekeeping employee threw another container of radioactive phosphorus into the trash. Boston University's associate director of environmental health, James Bove, called the problems isolated incidents and said procedures have been changed. Robert Hallisey, director of the state's Radiation Control Program, called college students and professors "lackadaisical" about the issue. "People are in deep denial about the potential hazard to themselves and the potential harm that they are doing to completely unknowing people," said Mary Olson, who was accidentally exposed to radiation when she was a Yale University researcher. NRC documents show that in addition to inadequately disposing of radioactive waste, the universities violated safe handling rules and had several accidents. At Harvard, NRC officials found the doors to labs and storage rooms propped open and researchers working with radiation while wearing shorts, without required lab coats or monitoring badges. Students and professors at Boston College, Brandeis, Harvard and the University of Massachusetts-Amherst were discovered eating sandwiches and drinking coffee in labs where radioactive isotopes were present. Eating in a lab where there is radioactive material is illegal, since radiation can be rapidly absorbed into the body this way. Yet Brandeis lab workers kept a coffee pot on a lab bench where radioactive phosphorus was being used. Robin Bell, the Brandeis radiation safety officer, said eating in a lab "is plain and simple carelessness." Still, he added, "It's a problem you'll find virtually everywhere that radiation is used in universities." The documents revealed other accidents involving radioactive material: Eight people stepped in radioactive liquid at Harvard Medical School on Jan. 13, 1993, after someone forgot to put a plug in a container filled with radioactive waste. By the time the leak was detected, radioactivity had spread to all six floors and the building was evacuated. At UMass-Amherst last year, a visiting researcher spilled radioactive liquid in a lab. It was discovered five days later, after two university employees unwittingly stepped in the material and tracked it around.
https://www.washingtonpost.com/archive/politics/1995/04/16/massachusetts-schools-cited-for-cavalier-handling-of-radioactive-materials/4ac7a485-22f9-45ba-a72b-030df3428f48/
April 16, 1995 By Associated Press
BOSTON, APRIL 15 -- Radioactive material is tossed into the trash and buried in a landfill. Eight people are unknowingly exposed when radioactive waste leaks from a container because someone forgot to put the plug in. Labs with radioactive materials are left unlocked and unsupervised. Cut through the 2024 election noise. Get The Campaign Moment newsletter. These incidents, and similar ones, occurred not at an irresponsible corporation or in a bad B-movie plot, but at Harvard, Boston University, the University of Massachusetts and other schools. Nuclear Regulatory Commission documents obtained under the Freedom of Information Act show that Massachusetts universities have what an NRC inspector called a "cavalier" attitude toward the handling and disposal of radioactive material. The inspector singled out Harvard University, which has been cited at least eight times in the last 10 years for violating NRC regulations. Harvard has changed its procedures and its packaging for radioactive waste, said Joe Ring, the university's radiation safety officer. He said faculty and students have responded to threats that their laboratories might be shut down because of violations, and the university's most recent NRC inspection last year found no violations. The documents showed that radioactive material has been illegally thrown into the trash at least seven times by four different Massachusetts institutions in the last eight years. Four of these instances occurred at the Boston University medical school, where a radiology instrument containing radioactive material was accidently thrown into a trash compactor in December 1987 and hauled to a landfill south of Boston. On March 13, 1989, radioactive material was discovered missing from a Boston University lab. Six months later, a vial containing radioactive phosphorous was left in a hallway trash pile and disposed of in an unknown landfill. And on Oct. 4, 1993, a housekeeping employee threw another container of radioactive phosphorus into the trash. Boston University's associate director of environmental health, James Bove, called the problems isolated incidents and said procedures have been changed. Robert Hallisey, director of the state's Radiation Control Program, called college students and professors "lackadaisical" about the issue. "People are in deep denial about the potential hazard to themselves and the potential harm that they are doing to completely unknowing people," said Mary Olson, who was accidentally exposed to radiation when she was a Yale University researcher. NRC documents show that in addition to inadequately disposing of radioactive waste, the universities violated safe handling rules and had several accidents. At Harvard, NRC officials found the doors to labs and storage rooms propped open and researchers working with radiation while wearing shorts, without required lab coats or monitoring badges. Students and professors at Boston College, Brandeis, Harvard and the University of Massachusetts-Amherst were discovered eating sandwiches and drinking coffee in labs where radioactive isotopes were present. Eating in a lab where there is radioactive material is illegal, since radiation can be rapidly absorbed into the body this way. Yet Brandeis lab workers kept a coffee pot on a lab bench where radioactive phosphorus was being used. Robin Bell, the Brandeis radiation safety officer, said eating in a lab "is plain and simple carelessness." Still, he added, "It's a problem you'll find virtually everywhere that radiation is used in universities." The documents revealed other accidents involving radioactive material: Eight people stepped in radioactive liquid at Harvard Medical School on Jan. 13, 1993, after someone forgot to put a plug in a container filled with radioactive waste. By the time the leak was detected, radioactivity had spread to all six floors and the building was evacuated. At UMass-Amherst last year, a visiting researcher spilled radioactive liquid in a lab. It was discovered five days later, after two university employees unwittingly stepped in the material and tracked it around.
https://www.washingtonpost.com/archive/politics/1995/04/16/massachusetts-schools-cited-for-cavalier-handling-of-radioactive-materials/4ac7a485-22f9-45ba-a72b-030df3428f48/
US DOT, March 13 2017, Reference No. 16-0134
Boston University Medical Center (BUMC) in Boston, MA.
BUMC is comprised of two entities: Boston University (BU), a Massachusetts nonprofit educational institution (which includes the Medical School), and Boston Medical Center (BMC), a privately owned hospital and the teaching affiliate for BU 's Medical School. But, the relationship goes beyond the teaching affiliation. The two entities work very closely together, share resources, and even share and co-own buildings and/or attach them via cat walks, etc., allowing seamless access to BMC and BU areas (dependent upon one's work funct ion). Tvvo resources shared by BMC and BU include the Public Safety and Radiation Safety departments. The Public Safety department provides security in all BMC and BU buildings and grounds, and they issue and rescind employee identification cards which are smart cards that provide/deny access to B.MC and BU buildings, based upon each employee work function and restrictions. In addition, all the BMC and BU buildings are on the same Radioactive Materials license, as the BUMC campus, issued by the Massachusetts Radiation Control Program, hence, radiation safety is administered under one common Radiation Safety department. There is one building, the Fuller Building, along our contiguous area, which is owned and partially used by the Commonwealth of Massachusetts, and is also leased for use to BU and BMC. The Commonwealth of Massachusetts uses several floors of this building and provides their own security and access to this building, but radiation safety is provided by the common BU/BMC Radiation Safety depai1ment, and this building is on the BUMC Radioactive Materials license. Our plan is to use the private road which traverses between the Fuller Building and our BUMC campus to move the irradiator. Note that half this private road is owned by the BU.MC while the other half is owned by the State of Massachusetts. Our plan is to restrict the access (the public and uninvolved BUMC employees) on our side of the private road when moving the blood irradiator - on our side of this private road
Boston University Medical Center (BUMC) in Boston, MA.
BUMC is comprised of two entities: Boston University (BU), a Massachusetts nonprofit educational institution (which includes the Medical School), and Boston Medical Center (BMC), a privately owned hospital and the teaching affiliate for BU 's Medical School. But, the relationship goes beyond the teaching affiliation. The two entities work very closely together, share resources, and even share and co-own buildings and/or attach them via cat walks, etc., allowing seamless access to BMC and BU areas (dependent upon one's work funct ion). Tvvo resources shared by BMC and BU include the Public Safety and Radiation Safety departments. The Public Safety department provides security in all BMC and BU buildings and grounds, and they issue and rescind employee identification cards which are smart cards that provide/deny access to B.MC and BU buildings, based upon each employee work function and restrictions. In addition, all the BMC and BU buildings are on the same Radioactive Materials license, as the BUMC campus, issued by the Massachusetts Radiation Control Program, hence, radiation safety is administered under one common Radiation Safety department. There is one building, the Fuller Building, along our contiguous area, which is owned and partially used by the Commonwealth of Massachusetts, and is also leased for use to BU and BMC. The Commonwealth of Massachusetts uses several floors of this building and provides their own security and access to this building, but radiation safety is provided by the common BU/BMC Radiation Safety depai1ment, and this building is on the BUMC Radioactive Materials license. Our plan is to use the private road which traverses between the Fuller Building and our BUMC campus to move the irradiator. Note that half this private road is owned by the BU.MC while the other half is owned by the State of Massachusetts. Our plan is to restrict the access (the public and uninvolved BUMC employees) on our side of the private road when moving the blood irradiator - on our side of this private road
Boston_Evening_Transcript_1903_08_01_24
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Boston_Evening_Transcript_1891_12_31_8
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Boston City Hospital is authorized under NRC license No. 20-00275-08 to possess | byproduct material identified in 10 CFR Parts 35.100,35.200,35.300 and 35.400 for medical diagnostic and radiation therapy procedures. Additionally, the licensee is also authorized to possess several radioactive isotopes for non-human use in research and development. The licensee is also authorized to use radiopharmaceuticals i identified in 10 CFR 31.11 for in vitro studies. There are five authorized locations of 1 use of licensed material. However, the licensee stated that at the present time the licensed material is being used at only two of these authorized locations. In addition to the routine diagnostic procedures, therapy dosages of iodine-131 are also administered in the nuclear medicine department. There are two authorized users in the nuclear medicine area and three active researchers who are authorized to use small quantities of carbon-14, phosphorus-32, tritium, and sulphur-35.
Results: Nine apparent violations of NRC requirements were identified: (1) Failure to include pertinent data in the individuals' radiation exposure records (Section 3); (2) failure to keep licensed material under constant surveillance and immediate control (Section 4); (3) ; multiple failures to complete written directives prior to administration of iodine-131 dosages in quantities greater than 30 microcuries (Section 4); (4) failure to require supervised individuals to follow written quality management program (Section 4); (5) failure to instruct supervised individuals in the licensee's quality management program (Section 4); (6) multiple failures to follow written Quality Management Program procedures requiring a review of. written directives prior to administration of radiopharmaceuticals (Section 4); (7) failure to develop procedures for conducting a review to verify compliance with the quality management program (Section 4); (8) failure to test the dose calibrator for linearity over the entire range of use (Section 4); (9) failure to provide training to the nuclear medicine :technologists in the proper use of radiation survey meters (Section 4).
Licensee: Boston City Hospital | License No. 20-00275-08 | Docket No. 030-01807
Results: Nine apparent violations of NRC requirements were identified: (1) Failure to include pertinent data in the individuals' radiation exposure records (Section 3); (2) failure to keep licensed material under constant surveillance and immediate control (Section 4); (3) ; multiple failures to complete written directives prior to administration of iodine-131 dosages in quantities greater than 30 microcuries (Section 4); (4) failure to require supervised individuals to follow written quality management program (Section 4); (5) failure to instruct supervised individuals in the licensee's quality management program (Section 4); (6) multiple failures to follow written Quality Management Program procedures requiring a review of. written directives prior to administration of radiopharmaceuticals (Section 4); (7) failure to develop procedures for conducting a review to verify compliance with the quality management program (Section 4); (8) failure to test the dose calibrator for linearity over the entire range of use (Section 4); (9) failure to provide training to the nuclear medicine :technologists in the proper use of radiation survey meters (Section 4).
Licensee: Boston City Hospital | License No. 20-00275-08 | Docket No. 030-01807
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"In decommissioning medical research buildings at this institution, most areas surveyed were not contaminated above NRC 1993 release limits. Most contamination found was fixed. Wipe tests were inefficient at assessing removable contamination. An initial approach to surveying such a facility should begin with limited sampling emphasizing fixed contamination detection. Recent NRC guidance on decommissioning suggests that the requirements are becoming less stringent for medical facilities. This seems to support our limited decommissioning survey strategy for medical research buildings where radioisotopes have been used."
Addresses:
Evdokimoff, V. “Lessons learned in decommissioning medical facilities.” Health physics vol. 77,5 Suppl (1999): S77-80. doi:10.1097/00004032-199911001-00006
Addresses:
Evdokimoff, V. “Lessons learned in decommissioning medical facilities.” Health physics vol. 77,5 Suppl (1999): S77-80. doi:10.1097/00004032-199911001-00006
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To: NRC (1994)
Disposal of Radioactive Material by Release into Sanitary Sewers. Gentlemen: We are a large medical research institution using radio-isotopes for medical research and in patients. We are opposed to further rulemaking revising the current regulations disposal of radioactive material into the sanitary sewerage system proposed in the Feb. 25, 1994 Federal Register.
In Massachusetts we have been denied access of our low-level radioactive waste at the Barnwell disposal facility. Further restrictions on radwaste disposal via limitations on sanitary sewerage disposal will create further hardship in an already crisis situation. I have specific comments relating to this proposal.
Exemption of Patient Excreta: a) Attempts to control excreta from diagnostic patients administered radiopharmaceuticals seems ludicrous. Millions of patients are administered diagnostic radiopharmaceuticals. Having an institution trying to control for example urine from bone imaging patients either at the institution or having urine returned from their home to the institution is not a reasonable request. 1) Handling urine represents a potential biohazardous material. 2) The radionuclides administered are short-lived and thus the exposure potential to all is short lived including sewerage treatment facilities which appear to be remote operations.
Attempts to control excreta from therapy patients represent greater exposure potential to the institution than remote sewerage operations. The radionuclide of concern here is I-131.
Therapy Assessment:
1) We would have to store urine for decay up to 2 months. Would you want to handle 2 month old urine?
2) There is exposure potential to staff of having to handle and store large millicurie quantities of this potential biohazardous waste. Thus lead bricks will be needed to shield be carboy quantities of radioactive urine.
3) There is potential of radioactive volatility from opening when continually adding to a patient urine container.
4) There is a possibility of spilling radioactive urine during processing.
5) Receiving urine from radioiodine outpatients (hyperthyroidism treatment) doesn't appear to be ALARA to our institution. How
will the patients comply let alone try to shield this material?
6) Costs to patients will go up to provide further radiation safety precautions for stored urine. There is no net benefit from medical diagnosis and treatment with radiopharmaceuticals that exceeds any minuscule risk from controlling exposure potential from radioactive excreta to a small segment of sewer treatment personnel or sludge.
I have not addressed radioactivity in feces. Please!
c) Disposal of Soluble Aqueous Medical Research Waste. At our institution we dispose of trace levels of soluble radionuclide solutions down " hot sinks". The amounts disposed are trivial compared to radioactive excreta from patients. We have already stated the benefit for patient use of radiopharmaceuticals. There are benefits to using radionuclides in medical research since almost all grant recipients in this institution need to use radionuclides for their research. If radioactive disposal was limited or eliminated this severely this will affect our medical research since we will have no to get rid of certain classes of radwaste at our institution needed for medical research. We have millions of dollars in research grants.
From: Victor Evdokimoff, Director Radiation Protection, Boston University Medical Center
Disposal of Radioactive Material by Release into Sanitary Sewers. Gentlemen: We are a large medical research institution using radio-isotopes for medical research and in patients. We are opposed to further rulemaking revising the current regulations disposal of radioactive material into the sanitary sewerage system proposed in the Feb. 25, 1994 Federal Register.
In Massachusetts we have been denied access of our low-level radioactive waste at the Barnwell disposal facility. Further restrictions on radwaste disposal via limitations on sanitary sewerage disposal will create further hardship in an already crisis situation. I have specific comments relating to this proposal.
Exemption of Patient Excreta: a) Attempts to control excreta from diagnostic patients administered radiopharmaceuticals seems ludicrous. Millions of patients are administered diagnostic radiopharmaceuticals. Having an institution trying to control for example urine from bone imaging patients either at the institution or having urine returned from their home to the institution is not a reasonable request. 1) Handling urine represents a potential biohazardous material. 2) The radionuclides administered are short-lived and thus the exposure potential to all is short lived including sewerage treatment facilities which appear to be remote operations.
Attempts to control excreta from therapy patients represent greater exposure potential to the institution than remote sewerage operations. The radionuclide of concern here is I-131.
Therapy Assessment:
1) We would have to store urine for decay up to 2 months. Would you want to handle 2 month old urine?
2) There is exposure potential to staff of having to handle and store large millicurie quantities of this potential biohazardous waste. Thus lead bricks will be needed to shield be carboy quantities of radioactive urine.
3) There is potential of radioactive volatility from opening when continually adding to a patient urine container.
4) There is a possibility of spilling radioactive urine during processing.
5) Receiving urine from radioiodine outpatients (hyperthyroidism treatment) doesn't appear to be ALARA to our institution. How
will the patients comply let alone try to shield this material?
6) Costs to patients will go up to provide further radiation safety precautions for stored urine. There is no net benefit from medical diagnosis and treatment with radiopharmaceuticals that exceeds any minuscule risk from controlling exposure potential from radioactive excreta to a small segment of sewer treatment personnel or sludge.
I have not addressed radioactivity in feces. Please!
c) Disposal of Soluble Aqueous Medical Research Waste. At our institution we dispose of trace levels of soluble radionuclide solutions down " hot sinks". The amounts disposed are trivial compared to radioactive excreta from patients. We have already stated the benefit for patient use of radiopharmaceuticals. There are benefits to using radionuclides in medical research since almost all grant recipients in this institution need to use radionuclides for their research. If radioactive disposal was limited or eliminated this severely this will affect our medical research since we will have no to get rid of certain classes of radwaste at our institution needed for medical research. We have millions of dollars in research grants.
From: Victor Evdokimoff, Director Radiation Protection, Boston University Medical Center
Radioactive excreta from nuclear medicine patients can enter solid waste as common trash and medical biohazardous waste. Many landfills and transfer stations now survey these waste streams with scintillation detectors which may result in rejection of a hospital`s waste. Our survey indicated that on the average either or both of Boston University Medical Center Hospital`s waste streams can contain detectable radioactive excreta on a weekly basis. To avoid potential problems, radiation detectors were installed in areas where housekeepers carting trash and medical waste must pass through to ensure no radioactivity leaves the institution. 3 refs.
Evdokimoff, V, et al. "Potential for radioactive patient excreta in hospital trash and medical waste." Health Physics, vol. 66, no. 2, Jan. 1994. https://doi.org/10.1097/00004032-199402000-00013
Evdokimoff, V N. “Radioactive patient waste at landfills--regulatory impasse.” Health physics vol. 81,2 Suppl (2001): S3-4. doi:10.1097/00004032-200108001-00003
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Event Notification Report for April 30, 2025, U.S. Nuclear Regulatory Commission, Operations Center
EVENT REPORTS FOR 04/29/2025 - 04/30/2025 Agreement State Event Number: 57687 Rep Org: MA Radiation Control Program Licensee: Boston University and Medical Center Notification Date: 05/02/2025 Notification Time: 17:05 [ET] Event Date: 04/30/2025 Event Time: 10:00 [EDT]
The following information was provided by the Massachusetts Radioactive Material Unit (the Agency) viaemail: "On 4/30/25, four radioactive material packages were to be received by the licensee, Boston Universityand Boston Medical Center (MA license number 44-0062). Two packages showed up just after 1000 EDT,but one package containing 7mCi of S-35 and another package containing 0.5 mCi of P-32 were notreceived. The packages were shipped from Revvity Health Sciences, Inc. (MA license number 00-3200). "An investigation was opened with the common carrier, which is currently ongoing. "The reporting requirement is within 30 days and is of 105 CMR [Code of Massachusetts Regulations]120.281(A)(2), missing licensed radioactive materials in aggregate quantity equal to or greater than 10times quantity specified in 105 CMR 120.297, Appendix C. "The Agency considers this event to be open."
EVENT REPORTS FOR 04/29/2025 - 04/30/2025 Agreement State Event Number: 57687 Rep Org: MA Radiation Control Program Licensee: Boston University and Medical Center Notification Date: 05/02/2025 Notification Time: 17:05 [ET] Event Date: 04/30/2025 Event Time: 10:00 [EDT]
The following information was provided by the Massachusetts Radioactive Material Unit (the Agency) viaemail: "On 4/30/25, four radioactive material packages were to be received by the licensee, Boston Universityand Boston Medical Center (MA license number 44-0062). Two packages showed up just after 1000 EDT,but one package containing 7mCi of S-35 and another package containing 0.5 mCi of P-32 were notreceived. The packages were shipped from Revvity Health Sciences, Inc. (MA license number 00-3200). "An investigation was opened with the common carrier, which is currently ongoing. "The reporting requirement is within 30 days and is of 105 CMR [Code of Massachusetts Regulations]120.281(A)(2), missing licensed radioactive materials in aggregate quantity equal to or greater than 10times quantity specified in 105 CMR 120.297, Appendix C. "The Agency considers this event to be open."
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Large Medical Facilities (1,224 NRC licensees)
The investigation into NRC-licensed medical licensees was divided into three phases. In the first phase, the available and pertinent literature was reviewed. In the second phase, the information obtained from the review was validated and expanded upon by meetings and correspondence with Radiation Safety Officers (RSOs) at selected hospitals. In the third phase, information gathered in phases 1 and 2 was put into a form more useful for assessing the costs and benefits of the clearance alternatives.
2.5.4.1 Literature Review and Interviews
"Lessons Learned in Decommissioning Medical Facilities"
This paper, prepared by Victor Evdokimoff of Boston University Medical Center (BUMC) and published in The Radiation Protection Journal, Vol. 77, No. 5 Supplement, November 1999, describes the decontamination of two medical facilities. The first decontamination operation consisted of renovating seven floors of a 10-story hospital in 1994, where all existing structures and equipment were removed with only the exterior of the building remaining. Since this building had been used for 50 years, the cleanup activities involved contamination accumulated over a long period of time. The second decommissioning project involved the demolition of three buildings in 1997. The 1994 decommissioning was performed in accordance with NRC guidance provided in NUREG/CR-5 849, Manual for Conducting Radiological Surveys in Support of License Termination (NRC 1994). Since many of the MARSSIM concepts were first introduced in this guidance, the manual can be considered a precursor to MARSSIM. Unlike MARSSIM, the guidelines also incorporate specific cleanup criteria, as presented in Table 2-93. These levels are identical to those set forth in Regulatory Guide 1.86. In accordance with these guidelines, the seven floors of the building (about 60,000 square feet) were divided into affected and unaffected areas. An area was defined as either a room in a lab, a room with many labs, or even a piece of equipment within a room, such as a hood. A total of 291 affected areas were identified. Within these areas, 70 contaminated spots were found in 32 hoods, 70 were found on 28 bench tops, 66 were found on the floors of 23 rooms, and 31 were found in cabinets in nine rooms. The 290 unaffected areas identified were found to contain two contaminated spots. Out of 4,114 dry wipe tests taken, only 12 swipes indicated removable contamination above the release limits, and 5 of these were contaminated with tritium. It was determined that very little of the contamination was removable. The average level of contamination was 30,000 dpm/100 cm2 primarily from tritium and C-14. The authors concluded that about 14 percent of the total surface area of the floors was contaminated, and only 0.3 percent of the contaminated areas contained removable contamination.
The 1997 decommissioning was performed in accordance with MARSSIM guidance. A scoping survey was performed which surveyed 10 percent of the affected areas and 1 percent of the unaffected areas. The scoping survey found no contamination above background in Building 1, which was a four-story patient care facility abandoned 15 years prior to the survey. Building 2 was a four-story research building also abandoned 15 years prior to the survey. Out of 30 areas designated as affected, 4 contaminated spots were found. These consisted of H-3 and C- 14 on some animal cages, inside freezers, and on some counter tops. Since the scoping survey found some contamination, a 100-percent survey of Building 2 was performed, but no additional contamination was found. There was no contamination detected in the areas of Building 2 designated as unaffected. Building 3 was a six-story research building in use for 40 years and vacated several months prior to the survey. In the 21 areas designated as affected, seven contaminated spots were found on counter tops. As a result, a 100-percent survey was performed which uncovered no additional contamination. In the areas designated as unaffected, the scoping survey found Ra-226 contamination on the floor and under the floor tiles in a corridor. The contamination resulted from a 70 mCi spill and contaminated a 40 square foot area of concrete under the floor tiles. The contamination was removed with a jackhammer. As a result of this finding, a 100-percent survey was performed, but no additional contamination was found. The overall cost of the 1994 program was several hundred thousand dollars, while the overall cost of the 1997 program was tens of thousands of dollars. The primary difference in the costs was the result of MARSSIM protocols that reduced the number of samples required for analysis and the extent of the surveys. Interview with Victor Evdokimoff: In addition to his paper, Mr. Evdokimoiff supplied additional information in telephone interviews characterize more fully the potential impacts of the alternatives on medical facilities. Mr. Evdokimoff also answered several questions in writing. In the 1994 decontamination, the total floor area of the 7 floors was 60,000 square feet, which included an average of about 30 labs per floor, of which about half used radioactive materials. During the decontamination operation of these labs, 15 cubic feet of incinerator ash ( containing 10 μCi ofH-3/C-14), and 13.6 cubic feet of miscellaneous waste (containing 300 μCi of H-3/C-14) were disposed of as low-level waste. In addition, 30 linear feet of plumbing and drains contaminated with S-35 were placed in storage for radioactive decay. In the 1997 decommissioning, 22.5 cubic feet of scab bled concrete ( containing I 00 μCi of Ra-226) and 30 cubic feet of miscellaneous metal and other wastes ( containing 5.6 mCi of H-3/C-14) were disposed of as low-level radioactive waste.
Mr. Evdokimoff provided the following written comments:
1. Given sufficient time to allow for decay of 1-125, P-32 and S-35, most contaminants are weak beta emitters H-3, C-14.
2. Most contamination is fixed on floors, benchtops, hoods, cabinets and hot sinks. The contamination was easily removed from the surfaces saving considerably on radwaste costs. Wipe testingfor removable contamination is a waste of time and money.
3. Since H-3 is a major contaminant, institutions that only do wipe tests and count them in a LSC will miss fixed H-3 contamination. Most medical research facilities do not have a windowless Proportional counter which is able to detect H-3 on surfaces.
4. 1-125 release limits are exceedingly strict. Most institutions will not be able to meet the detection limit for free release of 20 dpm/100 cm sq removable.
5. Older medical facilities have labs that are separated from one another by doors. In my opinion this minimizes the spread of radioactive contamination. Today's medical facilities have open bench designs in which a floor could contain 30-50 benchtops one after another. This could result in declaring the whole floor an impacted area since many of these benchtops are radioactive use areas. 6. Most medical research institutions have competent and vigilant health physics staff that help keep contamination from researchers to a minimum. In my experience in reviewing thousands of lab surveys over 25 years at Boston University Medical Center (BUMC) and as a consultant, radioactive contamination in labs is very infrequent. In addition, if there is contamination, the micro to millicurie use levels contribute to low levels of contamination
7. 1 agree with many of the observations provided by my colleague Ken Miller at HMC (see Appendix C). Our institution is two to three times larger than HMC. I believe my decommissioning findings can be generalized to other medical research facilities. My findings are that most areas and equipment are not contaminated. What little contamination exists is fixed from weak beta emitters.
8. Medical research facilities do not have the financial resources to pay for decommissionings that turn up very little contamination prior to release. We paid $300, 000 for a contractor with 3 people working 7 months in the 1994 decommissioning alone.
9. Hospitals that utilize nuclear medicine should not be confused with medical research facilities at a university, hospital or biotech firm. Medical research utilizes "CHIPS". The most commonly used radionuclides today are P-32 and S-35. There is a declining use of H-3, C-14 and 1-125. Iodinations have declined and 1-125 RIA kits are almost never used.
10. In our experience, 30% of the total radioactive use labs are turned over in a year. The researcher moves to another building. Our researchers seem to be moving around the institution constantly. Some leave and new Principle Investigators come. Almost all researchers use some radionuclides. Their grants depend on the use of radioactive materials. If they could not use radionuclides, they could not do research. Money is very tight for researchers who have to provide their own funding to come AND REMAIN at a medical research facility. If they lose a grant, they usually have to leave.
Mr. Evdokimoff also commented on the clearance alternatives, as follows:
1. 1 mrem/yr, 0. 1 mrem/yr, and zero above background. These dose limits are not justified. The LLD to detect these levels cannot be
obtained. This effectively prevents release of materials that are probably not contaminated If we cannot survey, then these materials would have to go out as radioactive waste. No one could afford this. Actions of this sort would cause researchers not to use radioactive tracers even those that are decayable because labs cannot be used for certain lengths of time. [S-35, a common radionuclide, has a half-life of 90 days.] Grants would be affected and ultimately medical research.
2. Prohibition of release is not justified because of low risk, low contamination potential. The following are Mr. Evdokimoffs comments on NUREG /CR-1754 (the study of reference non-fuel-cycle facilities discussed in Section 2.5.3.1): 1. This guide is too old to be used at all for generic medical research facilities.
2. H-3 and C-14 are usually used on the same benchtop. No mention of P-32 and S35 use. No research facility uses unsealed Am-241 or Cs-137.
3. The contamination levels seem high. Most surveys yield negative results. Walls and ceilings were not found to be contaminated in our decommissionings.
4. Medical facilities do not use glove boxes or hot cells.
5. Hot sinks, benchtops, floors cabinets, hoods and animal cages do get contaminated. Iodination hoods and its ductwork can be contaminated with 1-125. Plumbing and hot sink traps also get contaminated.
Site Visit
In order to validate and supplement the information summarized in the literature review, Hershey Medical Center in Harrisburg, Pennsylvania, was visited. Appendix D summarizes the results of that visit. This summary was reviewed and approved by Ken Miller, RSO of Hershey Medical Center.
Subsequent to the visit, additional questions arose that helped to clarify some of the material provided in Appendix D. The first question dealt with lower limits of detection. Mr. Miller explained that the medical center employs 100 dpm/100 cm2 as the definition of "clean," and this is determined by counting wipe samples that can achieve the lower limits of detection necessary to demonstrate that a given surface meets tthe "clean" criteria. Surface scans using handheld survey instruments can observe contamination at the limits set forth in Regulatory Guide 1.86.
The investigation into NRC-licensed medical licensees was divided into three phases. In the first phase, the available and pertinent literature was reviewed. In the second phase, the information obtained from the review was validated and expanded upon by meetings and correspondence with Radiation Safety Officers (RSOs) at selected hospitals. In the third phase, information gathered in phases 1 and 2 was put into a form more useful for assessing the costs and benefits of the clearance alternatives.
2.5.4.1 Literature Review and Interviews
"Lessons Learned in Decommissioning Medical Facilities"
This paper, prepared by Victor Evdokimoff of Boston University Medical Center (BUMC) and published in The Radiation Protection Journal, Vol. 77, No. 5 Supplement, November 1999, describes the decontamination of two medical facilities. The first decontamination operation consisted of renovating seven floors of a 10-story hospital in 1994, where all existing structures and equipment were removed with only the exterior of the building remaining. Since this building had been used for 50 years, the cleanup activities involved contamination accumulated over a long period of time. The second decommissioning project involved the demolition of three buildings in 1997. The 1994 decommissioning was performed in accordance with NRC guidance provided in NUREG/CR-5 849, Manual for Conducting Radiological Surveys in Support of License Termination (NRC 1994). Since many of the MARSSIM concepts were first introduced in this guidance, the manual can be considered a precursor to MARSSIM. Unlike MARSSIM, the guidelines also incorporate specific cleanup criteria, as presented in Table 2-93. These levels are identical to those set forth in Regulatory Guide 1.86. In accordance with these guidelines, the seven floors of the building (about 60,000 square feet) were divided into affected and unaffected areas. An area was defined as either a room in a lab, a room with many labs, or even a piece of equipment within a room, such as a hood. A total of 291 affected areas were identified. Within these areas, 70 contaminated spots were found in 32 hoods, 70 were found on 28 bench tops, 66 were found on the floors of 23 rooms, and 31 were found in cabinets in nine rooms. The 290 unaffected areas identified were found to contain two contaminated spots. Out of 4,114 dry wipe tests taken, only 12 swipes indicated removable contamination above the release limits, and 5 of these were contaminated with tritium. It was determined that very little of the contamination was removable. The average level of contamination was 30,000 dpm/100 cm2 primarily from tritium and C-14. The authors concluded that about 14 percent of the total surface area of the floors was contaminated, and only 0.3 percent of the contaminated areas contained removable contamination.
The 1997 decommissioning was performed in accordance with MARSSIM guidance. A scoping survey was performed which surveyed 10 percent of the affected areas and 1 percent of the unaffected areas. The scoping survey found no contamination above background in Building 1, which was a four-story patient care facility abandoned 15 years prior to the survey. Building 2 was a four-story research building also abandoned 15 years prior to the survey. Out of 30 areas designated as affected, 4 contaminated spots were found. These consisted of H-3 and C- 14 on some animal cages, inside freezers, and on some counter tops. Since the scoping survey found some contamination, a 100-percent survey of Building 2 was performed, but no additional contamination was found. There was no contamination detected in the areas of Building 2 designated as unaffected. Building 3 was a six-story research building in use for 40 years and vacated several months prior to the survey. In the 21 areas designated as affected, seven contaminated spots were found on counter tops. As a result, a 100-percent survey was performed which uncovered no additional contamination. In the areas designated as unaffected, the scoping survey found Ra-226 contamination on the floor and under the floor tiles in a corridor. The contamination resulted from a 70 mCi spill and contaminated a 40 square foot area of concrete under the floor tiles. The contamination was removed with a jackhammer. As a result of this finding, a 100-percent survey was performed, but no additional contamination was found. The overall cost of the 1994 program was several hundred thousand dollars, while the overall cost of the 1997 program was tens of thousands of dollars. The primary difference in the costs was the result of MARSSIM protocols that reduced the number of samples required for analysis and the extent of the surveys. Interview with Victor Evdokimoff: In addition to his paper, Mr. Evdokimoiff supplied additional information in telephone interviews characterize more fully the potential impacts of the alternatives on medical facilities. Mr. Evdokimoff also answered several questions in writing. In the 1994 decontamination, the total floor area of the 7 floors was 60,000 square feet, which included an average of about 30 labs per floor, of which about half used radioactive materials. During the decontamination operation of these labs, 15 cubic feet of incinerator ash ( containing 10 μCi ofH-3/C-14), and 13.6 cubic feet of miscellaneous waste (containing 300 μCi of H-3/C-14) were disposed of as low-level waste. In addition, 30 linear feet of plumbing and drains contaminated with S-35 were placed in storage for radioactive decay. In the 1997 decommissioning, 22.5 cubic feet of scab bled concrete ( containing I 00 μCi of Ra-226) and 30 cubic feet of miscellaneous metal and other wastes ( containing 5.6 mCi of H-3/C-14) were disposed of as low-level radioactive waste.
Mr. Evdokimoff provided the following written comments:
1. Given sufficient time to allow for decay of 1-125, P-32 and S-35, most contaminants are weak beta emitters H-3, C-14.
2. Most contamination is fixed on floors, benchtops, hoods, cabinets and hot sinks. The contamination was easily removed from the surfaces saving considerably on radwaste costs. Wipe testingfor removable contamination is a waste of time and money.
3. Since H-3 is a major contaminant, institutions that only do wipe tests and count them in a LSC will miss fixed H-3 contamination. Most medical research facilities do not have a windowless Proportional counter which is able to detect H-3 on surfaces.
4. 1-125 release limits are exceedingly strict. Most institutions will not be able to meet the detection limit for free release of 20 dpm/100 cm sq removable.
5. Older medical facilities have labs that are separated from one another by doors. In my opinion this minimizes the spread of radioactive contamination. Today's medical facilities have open bench designs in which a floor could contain 30-50 benchtops one after another. This could result in declaring the whole floor an impacted area since many of these benchtops are radioactive use areas. 6. Most medical research institutions have competent and vigilant health physics staff that help keep contamination from researchers to a minimum. In my experience in reviewing thousands of lab surveys over 25 years at Boston University Medical Center (BUMC) and as a consultant, radioactive contamination in labs is very infrequent. In addition, if there is contamination, the micro to millicurie use levels contribute to low levels of contamination
7. 1 agree with many of the observations provided by my colleague Ken Miller at HMC (see Appendix C). Our institution is two to three times larger than HMC. I believe my decommissioning findings can be generalized to other medical research facilities. My findings are that most areas and equipment are not contaminated. What little contamination exists is fixed from weak beta emitters.
8. Medical research facilities do not have the financial resources to pay for decommissionings that turn up very little contamination prior to release. We paid $300, 000 for a contractor with 3 people working 7 months in the 1994 decommissioning alone.
9. Hospitals that utilize nuclear medicine should not be confused with medical research facilities at a university, hospital or biotech firm. Medical research utilizes "CHIPS". The most commonly used radionuclides today are P-32 and S-35. There is a declining use of H-3, C-14 and 1-125. Iodinations have declined and 1-125 RIA kits are almost never used.
10. In our experience, 30% of the total radioactive use labs are turned over in a year. The researcher moves to another building. Our researchers seem to be moving around the institution constantly. Some leave and new Principle Investigators come. Almost all researchers use some radionuclides. Their grants depend on the use of radioactive materials. If they could not use radionuclides, they could not do research. Money is very tight for researchers who have to provide their own funding to come AND REMAIN at a medical research facility. If they lose a grant, they usually have to leave.
Mr. Evdokimoff also commented on the clearance alternatives, as follows:
1. 1 mrem/yr, 0. 1 mrem/yr, and zero above background. These dose limits are not justified. The LLD to detect these levels cannot be
obtained. This effectively prevents release of materials that are probably not contaminated If we cannot survey, then these materials would have to go out as radioactive waste. No one could afford this. Actions of this sort would cause researchers not to use radioactive tracers even those that are decayable because labs cannot be used for certain lengths of time. [S-35, a common radionuclide, has a half-life of 90 days.] Grants would be affected and ultimately medical research.
2. Prohibition of release is not justified because of low risk, low contamination potential. The following are Mr. Evdokimoffs comments on NUREG /CR-1754 (the study of reference non-fuel-cycle facilities discussed in Section 2.5.3.1): 1. This guide is too old to be used at all for generic medical research facilities.
2. H-3 and C-14 are usually used on the same benchtop. No mention of P-32 and S35 use. No research facility uses unsealed Am-241 or Cs-137.
3. The contamination levels seem high. Most surveys yield negative results. Walls and ceilings were not found to be contaminated in our decommissionings.
4. Medical facilities do not use glove boxes or hot cells.
5. Hot sinks, benchtops, floors cabinets, hoods and animal cages do get contaminated. Iodination hoods and its ductwork can be contaminated with 1-125. Plumbing and hot sink traps also get contaminated.
Site Visit
In order to validate and supplement the information summarized in the literature review, Hershey Medical Center in Harrisburg, Pennsylvania, was visited. Appendix D summarizes the results of that visit. This summary was reviewed and approved by Ken Miller, RSO of Hershey Medical Center.
Subsequent to the visit, additional questions arose that helped to clarify some of the material provided in Appendix D. The first question dealt with lower limits of detection. Mr. Miller explained that the medical center employs 100 dpm/100 cm2 as the definition of "clean," and this is determined by counting wipe samples that can achieve the lower limits of detection necessary to demonstrate that a given surface meets tthe "clean" criteria. Surface scans using handheld survey instruments can observe contamination at the limits set forth in Regulatory Guide 1.86.
| nrc_lesson_learned_bu.pdf |
LLRW in the Sewers & Stormwater
"BUMC is located in Boston’s historic South End, and includes 33 Boston University Medical Center owned or controlled buildings, a helipad and development parcels that are individually-owned or controlled, as well as shared facilities associated with each or both of the institutions. In addition to the property owned or controlled by the Proponent, each institution also leases office, instructional, and/or clinical space in 8 buildings located on and/or proximate to the campus. Buildings range from 2 to 14 stories in height above ground. The buildings were built between 1864 (BCD/FGH), 2011 (Carl J. and Ruth Shapiro Ambulatory Care Center), and 2012 (Albany Fellows Phase 1 BU Medical Campus Graduate Student Housing). The Dr. Solomon Carter Fuller Mental Health Center, a state mental health facility, is also located on the BUMC Campus. BUMC is currently served by approximately 3,420 parking spaces. Of these spaces, approximately 2,665 are located in on-site garages, with the remaining spaces located at surface lots and off-site garages."
"There are existing BWSC storm drain mains in East Newton Street and Albany Street. There is a 30-inch x 52-inch BWSC storm drain main in Albany Street, which flows in a northeasterly direction before ultimately connecting to the Roxbury Canal. Conduit. There is a 15-inch storm drain that increases to an 18-inch BWSC storm drain main flowing in a southeasterly direction in East Newton Street and connects to the 30-inch by 52-inch storm drain main in Albany Street. Stormwater in East Newton Street is collected in existing BWSC catch basins, which flow to the existing 15-inch to 18-inch BWSC storm drain main in East Newton Street. Stormwater in Albany Street is collected in existing BWSC catch basins, which flow to the existing 30-inch x 52-inch BWSC storm drain main in Albany Street."
Boston University Goldman School of Dental Medicine, Boston, Massachusetts, Expanded Project Notification Form May 15, 2017
"There are existing BWSC storm drain mains in East Newton Street and Albany Street. There is a 30-inch x 52-inch BWSC storm drain main in Albany Street, which flows in a northeasterly direction before ultimately connecting to the Roxbury Canal. Conduit. There is a 15-inch storm drain that increases to an 18-inch BWSC storm drain main flowing in a southeasterly direction in East Newton Street and connects to the 30-inch by 52-inch storm drain main in Albany Street. Stormwater in East Newton Street is collected in existing BWSC catch basins, which flow to the existing 15-inch to 18-inch BWSC storm drain main in East Newton Street. Stormwater in Albany Street is collected in existing BWSC catch basins, which flow to the existing 30-inch x 52-inch BWSC storm drain main in Albany Street."
Boston University Goldman School of Dental Medicine, Boston, Massachusetts, Expanded Project Notification Form May 15, 2017
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BOSTON MEDICAL CENTER - MAIN ENTRYWAY, BOSTON, 02118
NPDES IDMAG912162
FRS ID110071814710
Pollutant Name Total Pounds (lb/yr) Max Allowable Load (lb/yr)
Solids, total dissolved 21,296
Chloride 11,383
Solids, total suspended 40.39 45.90
Nitrogen 4.41 15.30
https://echo.epa.gov/trends/loading-tool/reports/dmr-pollutant-loading?permit_id=MAG912162&year=2024
NPDES IDMAG912162
FRS ID110071814710
Pollutant Name Total Pounds (lb/yr) Max Allowable Load (lb/yr)
Solids, total dissolved 21,296
Chloride 11,383
Solids, total suspended 40.39 45.90
Nitrogen 4.41 15.30
https://echo.epa.gov/trends/loading-tool/reports/dmr-pollutant-loading?permit_id=MAG912162&year=2024
BMC is top discharger in 02118 zip code.
https://echo.epa.gov/trends/loading-tool/water-pollution-search/results?s=49fc1daf666cba609426d0462269436ca01edcb4
https://echo.epa.gov/trends/loading-tool/water-pollution-search/results?s=49fc1daf666cba609426d0462269436ca01edcb4
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| sewer_ml20069e852_pdf.pdf |
Infectious Disease & Pathogens
In 1957, at the Boston City Hospital, an increase of incidence of isolations of the Serratia organism was noted. In fact, the study indicated again that the nonpigment strain was more common in clinical disease than the typical red variety, and many laboratories around the country were unable to correctly identify this form 260 (1977) Biological testing involving human subjects by the Department of Defense, 1977 : hearings before the Subcommittee on Health and Scientific Research of the Committee on Human Resources, United States Senate, Ninety-fifth Congress, first session ... March 8 and May 23, 1977
The emergence of antibiotic-resistant strains of certain Gram-positive organisms (meningococcus, gonococcus, and
Staphylococcus, for example) has been noted by many investigators but appears to pose less of a problem than that of the increasing incidence of Gram-negative infections. Finland,, in analyzing his experience at Boston City Hospital, found that there has been a steady increase in the number of bacteremia patients (especially those with Gram-negative organisms), with an 80o increase from 1957 to 1965 (the last year of the study). In addition, he found that the case-fatality rate among all bacteremia patients showed a dramatic decline following the introduction. and use of the sulfonamides and another, but less striking, drop by 1947, after penicillin and streptomycin had achieved widespread use. However, in the ensuing years, in spite of the successive introduction of the many broad-spectrum and anti staphylococcal antibiotics, the
mortality has increased slowly but steadily so that by 1965, the mortality (35%) was still nearly the same as that observed in 1941 before penicillin first became available. Finland presumes that the major factor responsible for the changing ecology of the serious bacterial infections and for the marked increase in their occurrence, at least at Boston City Hospital. is the selective pressure of the antibiotics so widely and intensively used in therapy and especially for prophylaxis
"Examination of the pharmaceutical industry, 1973-74 : hearings before the Subcommittee on Health of the Committee on Labor and Public Welfare, United States Senate, Ninety-third Congress, first and second sessions, on S. 3441 and S. 966 .. Part 2." Examination of the pharmaceutical industry, 1973-74 : hearings before the Subcommittee on Health of the Committee on Labor and Public Welfare, United States Senate, Ninety-third Congress, first and second sessions, on S. 3441 and S. 966 .. Part 2, , 1973, pp. I-718.
The emergence of antibiotic-resistant strains of certain Gram-positive organisms (meningococcus, gonococcus, and
Staphylococcus, for example) has been noted by many investigators but appears to pose less of a problem than that of the increasing incidence of Gram-negative infections. Finland,, in analyzing his experience at Boston City Hospital, found that there has been a steady increase in the number of bacteremia patients (especially those with Gram-negative organisms), with an 80o increase from 1957 to 1965 (the last year of the study). In addition, he found that the case-fatality rate among all bacteremia patients showed a dramatic decline following the introduction. and use of the sulfonamides and another, but less striking, drop by 1947, after penicillin and streptomycin had achieved widespread use. However, in the ensuing years, in spite of the successive introduction of the many broad-spectrum and anti staphylococcal antibiotics, the
mortality has increased slowly but steadily so that by 1965, the mortality (35%) was still nearly the same as that observed in 1941 before penicillin first became available. Finland presumes that the major factor responsible for the changing ecology of the serious bacterial infections and for the marked increase in their occurrence, at least at Boston City Hospital. is the selective pressure of the antibiotics so widely and intensively used in therapy and especially for prophylaxis
"Examination of the pharmaceutical industry, 1973-74 : hearings before the Subcommittee on Health of the Committee on Labor and Public Welfare, United States Senate, Ninety-third Congress, first and second sessions, on S. 3441 and S. 966 .. Part 2." Examination of the pharmaceutical industry, 1973-74 : hearings before the Subcommittee on Health of the Committee on Labor and Public Welfare, United States Senate, Ninety-third Congress, first and second sessions, on S. 3441 and S. 966 .. Part 2, , 1973, pp. I-718.
Acquisition of infection within the hospital is being recognized as an increasingly serious problem [1-3]. Bacteremia accompanying such infection not only is one of the best criteria of severity but also offers the most reliable means of identification of the etiologic agent. Changes in the occurrence of and mortality rate from all bac- teremic infections at Boston City Hospital dur- ing the antimicrobial era were first reported in 1959 [4] based on data for seven selected years between 1935 and 1957. The observations were subsequently extended to include three of the next eight years [5]; more recently, some features of cases from some of the same years and for 1969 were also reported [6]. The number of admissions to Boston City Hospital had been declining slowly but steadily since 1950 and more rapidly since 1965.
In 1973 the bed capacity in the main hospital was deliberately reduced to 500, and professional care of patients was delegated to a single medical school (three Boston schools had previously been in- volved). In this paper we will present first an analysis of the cases of bacteremic infection at Boston City Hospital in 1972, the last full year of operation under the former regime. The data for 12 selected years from 1935 to 1972 will then be presented and analyzed in relation to age of the patients, their admission to medical or surgical services, and acquisition of infection in the community or in the hospital. The results will thus reflect the changes that occurred throughout the antibiotic era and the results of the use of the various antibacterial agents as they became This work was aided in part by grants no. 5R01-AI-23 and 2T01-AI-68 from the National Institute of Allergy and Infectious Diseases. Please address requests for reprints to Dr. Maxwell Fin- land, Channing Laboratory, Boston City Hospital, Boston, Massachusetts 02118. * Present address: Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia 30303. t Distinguished Physician, U.S. Veterans Administration. available and were used intensively within the hospital and in the community.
The most striking difference between the 1967 and 1970 surveys was the increase in the pro- portion of nosocomial infections associated with gram-negative bacilli (table 15). Nearly 40% of the nosocomial infections in 1970 yielded gram- negative bacilli. Furthermore, gram-negative bacilli other than E. coli comprised 80% of the isolates from nosocomial infections in 1970, as compared with 47% in 1967. The most significant increases were noted in the number of isolates of Klebsiella-Enterobacter and Pseudomonas aeruginosa. In both surveys gram-negative bacilli ac- counted for approximately 20% of isolates from community-acquired infections.
McGowan, Barnes & Finland, Bacteremia at Boston City Hospital: Occurrence and Mortality during 12 Selected Years (1935-1972), with Special Reference to Hospital-Acquired Cases, The Journal of Infectious Diseases , Sep., 1975, Vol. 132, No. 3 (Sep., 1975), pp. 316-335
In 1972, the incidence of bacteremic infections (but not the case-fatality ratio) was significantly higher in males than in females. Bacteremic infections were more than twice as frequent on the medical than on the surgical services, but the case-fatality ratio was slightly but not significantly higher on the surgical services. Bacteremia was most frequent in the youngest (birth through nine years) and the oldest (>60 years) age groups, whereas the case-fatality ratio was lowest in the youngest group and increased with each decade of life. Streptococcus pneumoniae was the most frequent organism causing bacteremia; next were Escherichia coli, Klebsiella-Enterobacter, and Staphylococ- cus aureus, in that order. The case-fatality ratio was lowest in cases due to S. pneumoniae and highest in those caused by Pseudomonas aeruginosa, Proteus, and Klebsiella-Enterobacter.
The data for all 12 selected years indicate a rising incidence of bacteremic infections during the 1950s and most of the 1960s, with evidence of decline in 1969 and 1972. The greatest proportion of bacteremic cases on the medical services were community-acquired, whereas the majority of those on the surgical services were hospital-acquired; on both the medical and the surgical services, the rates of hospital-acquired infections continued to increase, and most of the recent decrease was in community-acquired cases on medical services.
Case-fatality ratios were significantly higher among those with hospital-acquired infections than among those with community-acquired infections in all instances. In 1935 about one-fifth of all cases of bacteremic infection and about 30% of deaths from such infections were in patients -60 years old. The remaining cases were about equally divided among those <30 years old and those 30-59 years old, but one-half of all deaths were among the latter age group. In the ensuing years the proportion of cases (and particularly of deaths) in those <30 years old declined sharply, whereas cases and deaths in patients >60 years old increased to about one-half of all cases and to more than 60% (up to three-fourths) of all deaths.
More than one organism was grown from blood of 84 patients (generally at different times): two from 55 patients and from 29 patients. The total number of organisms thus exceeds the total number of patients. Except for number of admissions distribution by sex and age, "case" refers to infection with one organism.
Hospital admissions and deaths. The total number of patients hospitalized at Boston City Hospital and the number of bacteremic patients during the 12 years between 1935 and 1972 selected for study are shown in table 3. The number of deaths and the mortality rate (C FR) and the rates of bacteremic patients per 1,000 admis- sions and per 100 hospital deaths for each year also shown. The total number of admissions and of deaths declined steadily in each of the years of study after 1951, and the decline accelerated after 1965. The steadily declining CFR for all hos- pitalized patients since 1955 is also evident from these figures.
The number and rate of all cases of bacteremic infection rose steadily during the successive years of this study through 1965 and dropped considerably during the last two years. The number and rate of deaths from bacteremic infec- tion and the CFR in all bacteremic cases de- clined in 1941 after the sulfonamides came into general use and dropped still further in 1947 fol- lowing the availability and widespread use of penicillin and streptomycin. After that year, the number and rate of deaths among bacteremic pa- tients climbed steadily in successive years through 1965, despite the declining total number of hospital admissions and deaths and the declin- ing death rate among all patients in the hospital; however, numbers and rates of bacteremic cases declined in 1969 and 1972. The CFR for all bac- teremias dropped considerably in 1941 and again in 1947, but after that remained fairly steady (35%-40%), with an apprieciable drop only in 1972
Bacterial etiology. The changing ecology of serious bacterial infections at Boston City Hospi- tal was reviewed in general terms in the papers referred to earlier [4, 5]. Similar data concerning the changing etiology of bacterial endocarditis for the same selected years through 1965 have also been reviewed [7]. The number of cases of C-A and H-A bacteremic infection and the mor- tality rate among those cases for the 12 years are shown for selected gram-positive bacteria in table 9 and for some of the gram-negative bacilli and Candida in table 10. The incidence of cases per 1,000 hospital admissions is shown graphi- cally in figure 1 for both C-A and H-A cases due to the same organisms
McGowan, Barnes & Finland, Bacteremia at Boston City Hospital: Occurrence and Mortality during 12 Selected Years (1935-1972), with Special Reference to Hospital-Acquired Cases, The Journal of Infectious Diseases , Sep., 1975, Vol. 132, No. 3 (Sep., 1975), pp. 316-335
In 1973 the bed capacity in the main hospital was deliberately reduced to 500, and professional care of patients was delegated to a single medical school (three Boston schools had previously been in- volved). In this paper we will present first an analysis of the cases of bacteremic infection at Boston City Hospital in 1972, the last full year of operation under the former regime. The data for 12 selected years from 1935 to 1972 will then be presented and analyzed in relation to age of the patients, their admission to medical or surgical services, and acquisition of infection in the community or in the hospital. The results will thus reflect the changes that occurred throughout the antibiotic era and the results of the use of the various antibacterial agents as they became This work was aided in part by grants no. 5R01-AI-23 and 2T01-AI-68 from the National Institute of Allergy and Infectious Diseases. Please address requests for reprints to Dr. Maxwell Fin- land, Channing Laboratory, Boston City Hospital, Boston, Massachusetts 02118. * Present address: Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia 30303. t Distinguished Physician, U.S. Veterans Administration. available and were used intensively within the hospital and in the community.
The most striking difference between the 1967 and 1970 surveys was the increase in the pro- portion of nosocomial infections associated with gram-negative bacilli (table 15). Nearly 40% of the nosocomial infections in 1970 yielded gram- negative bacilli. Furthermore, gram-negative bacilli other than E. coli comprised 80% of the isolates from nosocomial infections in 1970, as compared with 47% in 1967. The most significant increases were noted in the number of isolates of Klebsiella-Enterobacter and Pseudomonas aeruginosa. In both surveys gram-negative bacilli ac- counted for approximately 20% of isolates from community-acquired infections.
McGowan, Barnes & Finland, Bacteremia at Boston City Hospital: Occurrence and Mortality during 12 Selected Years (1935-1972), with Special Reference to Hospital-Acquired Cases, The Journal of Infectious Diseases , Sep., 1975, Vol. 132, No. 3 (Sep., 1975), pp. 316-335
In 1972, the incidence of bacteremic infections (but not the case-fatality ratio) was significantly higher in males than in females. Bacteremic infections were more than twice as frequent on the medical than on the surgical services, but the case-fatality ratio was slightly but not significantly higher on the surgical services. Bacteremia was most frequent in the youngest (birth through nine years) and the oldest (>60 years) age groups, whereas the case-fatality ratio was lowest in the youngest group and increased with each decade of life. Streptococcus pneumoniae was the most frequent organism causing bacteremia; next were Escherichia coli, Klebsiella-Enterobacter, and Staphylococ- cus aureus, in that order. The case-fatality ratio was lowest in cases due to S. pneumoniae and highest in those caused by Pseudomonas aeruginosa, Proteus, and Klebsiella-Enterobacter.
The data for all 12 selected years indicate a rising incidence of bacteremic infections during the 1950s and most of the 1960s, with evidence of decline in 1969 and 1972. The greatest proportion of bacteremic cases on the medical services were community-acquired, whereas the majority of those on the surgical services were hospital-acquired; on both the medical and the surgical services, the rates of hospital-acquired infections continued to increase, and most of the recent decrease was in community-acquired cases on medical services.
Case-fatality ratios were significantly higher among those with hospital-acquired infections than among those with community-acquired infections in all instances. In 1935 about one-fifth of all cases of bacteremic infection and about 30% of deaths from such infections were in patients -60 years old. The remaining cases were about equally divided among those <30 years old and those 30-59 years old, but one-half of all deaths were among the latter age group. In the ensuing years the proportion of cases (and particularly of deaths) in those <30 years old declined sharply, whereas cases and deaths in patients >60 years old increased to about one-half of all cases and to more than 60% (up to three-fourths) of all deaths.
More than one organism was grown from blood of 84 patients (generally at different times): two from 55 patients and from 29 patients. The total number of organisms thus exceeds the total number of patients. Except for number of admissions distribution by sex and age, "case" refers to infection with one organism.
Hospital admissions and deaths. The total number of patients hospitalized at Boston City Hospital and the number of bacteremic patients during the 12 years between 1935 and 1972 selected for study are shown in table 3. The number of deaths and the mortality rate (C FR) and the rates of bacteremic patients per 1,000 admis- sions and per 100 hospital deaths for each year also shown. The total number of admissions and of deaths declined steadily in each of the years of study after 1951, and the decline accelerated after 1965. The steadily declining CFR for all hos- pitalized patients since 1955 is also evident from these figures.
The number and rate of all cases of bacteremic infection rose steadily during the successive years of this study through 1965 and dropped considerably during the last two years. The number and rate of deaths from bacteremic infec- tion and the CFR in all bacteremic cases de- clined in 1941 after the sulfonamides came into general use and dropped still further in 1947 fol- lowing the availability and widespread use of penicillin and streptomycin. After that year, the number and rate of deaths among bacteremic pa- tients climbed steadily in successive years through 1965, despite the declining total number of hospital admissions and deaths and the declin- ing death rate among all patients in the hospital; however, numbers and rates of bacteremic cases declined in 1969 and 1972. The CFR for all bac- teremias dropped considerably in 1941 and again in 1947, but after that remained fairly steady (35%-40%), with an apprieciable drop only in 1972
Bacterial etiology. The changing ecology of serious bacterial infections at Boston City Hospi- tal was reviewed in general terms in the papers referred to earlier [4, 5]. Similar data concerning the changing etiology of bacterial endocarditis for the same selected years through 1965 have also been reviewed [7]. The number of cases of C-A and H-A bacteremic infection and the mor- tality rate among those cases for the 12 years are shown for selected gram-positive bacteria in table 9 and for some of the gram-negative bacilli and Candida in table 10. The incidence of cases per 1,000 hospital admissions is shown graphi- cally in figure 1 for both C-A and H-A cases due to the same organisms
McGowan, Barnes & Finland, Bacteremia at Boston City Hospital: Occurrence and Mortality during 12 Selected Years (1935-1972), with Special Reference to Hospital-Acquired Cases, The Journal of Infectious Diseases , Sep., 1975, Vol. 132, No. 3 (Sep., 1975), pp. 316-335
"In 1967, the bacteriology labo- ratory at the hospital was reporting the isolation of S. marcescens from clinical specimens with increasing frequency" & "1967. The immediate mortality was 36%"
Klebsiella-Enterobacter-Serratia. Dr. Eickhoff, who at the time was an epidemiologist of the Communicable Disease Center (CDC), initiated a more detailed study of this group of organisms, focusing particularly on Klebsiella, for which specific capsular typing sera were available at the CDC. It was hoped that specific identification of these organisms might prove useful in tracing the sources of hospital-acquired infection with these organisms. With Dr. Steinhauer, we collected 257 strains of K. pneumoniae from patients seen in the hospital during the last half of 1964. The bio- chemical and serologic characteristics of these strains and their susceptibility to available anti- biotics were studied [120], as were the clinical and epidemiological aspects of the infections associated with them [121].
Finland, M., Excursions into Epidemiology: Selected Studies during the past Four Decades at Boston City Hospital, The Journal of Infectious Diseases, Vol. 128, No. 1 (Jul., 1973), pp. 76-124
Klebsiella-Enterobacter-Serratia. Dr. Eickhoff, who at the time was an epidemiologist of the Communicable Disease Center (CDC), initiated a more detailed study of this group of organisms, focusing particularly on Klebsiella, for which specific capsular typing sera were available at the CDC. It was hoped that specific identification of these organisms might prove useful in tracing the sources of hospital-acquired infection with these organisms. With Dr. Steinhauer, we collected 257 strains of K. pneumoniae from patients seen in the hospital during the last half of 1964. The bio- chemical and serologic characteristics of these strains and their susceptibility to available anti- biotics were studied [120], as were the clinical and epidemiological aspects of the infections associated with them [121].
Finland, M., Excursions into Epidemiology: Selected Studies during the past Four Decades at Boston City Hospital, The Journal of Infectious Diseases, Vol. 128, No. 1 (Jul., 1973), pp. 76-124
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Publications of the Medical and Surgical Staff. Following is a list of the scientific papers published by members of the Hospital Staff from February 1, 1925 to December 31, 1925, inclusive:
“Radium Therapy in Non-Malignant Eye Conditions,” by Dr. Jeremiah J. Corbett. Medical Review of Reviews, July, 1925.
“Studies on Filterable Viruses I.,” “Studies on Filterable Viruses II.,” by Drs. Frederic Parker, Jr., and Robert N. Nye. American Journal of Pathology, 1925, I., 325 and 337.
“Phagocytosis of Erythrocytes in the Bone Marrow, with Special Reference to Pernicious Anemia,” by Dr. Francis W. Peabody with Dr. G. 0. Broun. American Journal of Pathology, 1925,1, 169.
“Antimonials as Therapeutic Agents,” by Dr. George C. Shattuck. Chapter 6 of a monograph entitled “Organic Derivatives of Antimony,” by Walter G. Christianson. The Chemical Catalogue Company, Inc., 1925.
“Ethylene,” by Dr. Lincoln F. Sise. Boston Medical and Surgical Journal, February 2, 1925
“The Fate of Reacting Leucocytes in the Tuberculin and Reinfection Reactions,” by Drs. F. W. Stewart, P. H. Long and John Bradley. American Journal of Pathology (in press).
“Testicle Infection in Guinea Pigs Sensitized with Killed Tubercle Bacilli,” by Dr. F. W. Stewart. Journal of Immunol¬ ogy (in press).
“Dermal Spirochaetosis,” by Dr. Richard P. Strong. Trans¬ actions of the Association of American Physicians, 1925, Vol. XL., page 427.
“The Relationship of Certain “Free-Living” and Sapro¬ phytic Micro-organisms to Disease,” by Dr. Richard P. Strong. Science, January 30, 1925, LXI, No. 1570, page 97.
“Amoebic Dysentery,” by Dr. Richard P. Strong. Osier’s Modern Medicine, McCrae, N. Y., 1925 Vol. II, page 221, third edition revised.
“Diphtheria of the Skin,” by Drs. Shields Warren and I;. Sutton. Journal of the American Medical Association, 1925, 84, 1983.
“Radium in Some Diseases of the Eye as Illustrated by its use in Opacity of the Cornea,” by Dr. Francis H. Williams. Transactions of the Association of American Physicians, 1925, Vol. XL, page 348.
“Acute Epidemic Encephalitis,” a paper read by Dr. Eli Friedman before the North Shore Medical Society, June, 1925.
“Intravenous Use of Anti-Toxin in Diphtheria,” a paper read by Dr. Eli Friedman before the Fall River Medical Society, February, 1925.
Lectures on “Radium Therapy,” given by Dr. Isaac Gerber before the fourth year class of Tufts Medical School, January 8 and 13, 1925.
“X-Ray Treatment of Carbuncles and other Pyogenic Infec¬ tions,” a paper read by Dr. Isaac Gerber before the New England Roentgen Ray Society, Boston, January 16, 1925.
“X-Ray Treatment of Superficial Skin Infections,” a paper read by Dr. Isaac Gerber before The Boston City Hospital Alumni, April 25,1925.
“X-Ray Treatment of Various Benign Diseases,” a paper read by Dr, Isaac Gerber at the Brockton Hospital, May 5, 1925.
“X-Ray Treatment of Bronchial Asthma and Chronic Bron¬ chitis,” a paper read by Dr. Isaac Gerber before the American Medical Association, Atlantic City, N. J., May 29, 1925.
“X-Ray Treatment of Pyogenic Infections, Particularly of the Skin,” a paper read by Dr. Isaac Gerber at the International Congress of Radiology, London,England, July 3, 1925.
“X-Ray Treatment of Whooping Cough, Asthma and Chronic Bronchitis,” a paper read by Dr. Isaac Gerber before the Fall River Medical Society, October 14, 1925.
“X-Ray Treatment of Pyogenic Infections,” a paper read by Dr. Isaac Gerber before the Providence Medical Association November 2, 1925.
“The Development and Present Status of Deep X-Ray Therapy,” a paper read by Dr. Isaac Gerber before the Rhode Island Medical Society, December 3, 1925.
“Choice of X-Ray Treatment in Chest Malignancy,” a paper read by Dr. Isaac Gerber before the New England Roentgen Ray Society, Boston, December 18, 1925.
“Hemochromatosis and Chronic Poisoning with Copper,” read as the Mellon lecture by Dr. F. B. Mallory before the Biological Society at Pittsburgh, Pa., April 30, 1925 and as the Hanna lecture before the Academy of Medicine of Cleve¬ land, Ohio, May 1, 1925.
“Medical Legislation,” a paper read by Dr. Thomas J. O’Brien before the Essex North District Medical Society at Danvers State Hospital, August 25, 1925.
“The Legal Status of Medicine in Massachusetts,” a paper read bv Dr. Thomas J. O’Brien before the Essex South District Medical Society, December 2, 1925.
“Studies on Filterable Viruses I,” and “Studies on Filterable Viruses II.” read in part by Dr. Frederic Parker, Jr., before the American Society for Clinical Investigation at Washington, D. C., May 4, 1925.
An address and demonstration of the “Technique of Ultra¬ violet Ray Therapy in general with special attention to the method of closing up pus discharging Sinuses,” by Dr. Joseph Resnik before the Alumni of The Boston City Hospital, April 25, 1925.
“Tropical Diseases,” an address given by Dr. George C. Shattuck at The Boston City Hospital, October 20, 1925 and before the District Health Officers for the State Department of Health, November 20, 1925.
“Travel and Research in Brazil,” a lecture given by Dr. Richard P. Strong at the St. Botolph Club, April 1, 1925.
“Dermal Spirochaetosis,” an address given by Dr. Richard P. Strong at a meeting of the Association of American Physi¬ cians, Washington, D. C., May 4 to 7, 1925.
“The Medical Results of the Amazon Expedition in 1924,” an address by Dr. Richard P. Strong at a meeting of the Ameri¬ can Society of Tropical Medicine, Washington, D. C., May 5 to 7, 1925.
“ Spirochaetal Infections of Man,” an address by Dr. Richard P. Strong at a meeting of the Medical Society of the State of Pennsylvania, at Harrisburg, Pa., October 6 to 8, 1925.
City Document No. 14. Hospital Department. 1927.
“Radium Therapy in Non-Malignant Eye Conditions,” by Dr. Jeremiah J. Corbett. Medical Review of Reviews, July, 1925.
“Studies on Filterable Viruses I.,” “Studies on Filterable Viruses II.,” by Drs. Frederic Parker, Jr., and Robert N. Nye. American Journal of Pathology, 1925, I., 325 and 337.
“Phagocytosis of Erythrocytes in the Bone Marrow, with Special Reference to Pernicious Anemia,” by Dr. Francis W. Peabody with Dr. G. 0. Broun. American Journal of Pathology, 1925,1, 169.
“Antimonials as Therapeutic Agents,” by Dr. George C. Shattuck. Chapter 6 of a monograph entitled “Organic Derivatives of Antimony,” by Walter G. Christianson. The Chemical Catalogue Company, Inc., 1925.
“Ethylene,” by Dr. Lincoln F. Sise. Boston Medical and Surgical Journal, February 2, 1925
“The Fate of Reacting Leucocytes in the Tuberculin and Reinfection Reactions,” by Drs. F. W. Stewart, P. H. Long and John Bradley. American Journal of Pathology (in press).
“Testicle Infection in Guinea Pigs Sensitized with Killed Tubercle Bacilli,” by Dr. F. W. Stewart. Journal of Immunol¬ ogy (in press).
“Dermal Spirochaetosis,” by Dr. Richard P. Strong. Trans¬ actions of the Association of American Physicians, 1925, Vol. XL., page 427.
“The Relationship of Certain “Free-Living” and Sapro¬ phytic Micro-organisms to Disease,” by Dr. Richard P. Strong. Science, January 30, 1925, LXI, No. 1570, page 97.
“Amoebic Dysentery,” by Dr. Richard P. Strong. Osier’s Modern Medicine, McCrae, N. Y., 1925 Vol. II, page 221, third edition revised.
“Diphtheria of the Skin,” by Drs. Shields Warren and I;. Sutton. Journal of the American Medical Association, 1925, 84, 1983.
“Radium in Some Diseases of the Eye as Illustrated by its use in Opacity of the Cornea,” by Dr. Francis H. Williams. Transactions of the Association of American Physicians, 1925, Vol. XL, page 348.
“Acute Epidemic Encephalitis,” a paper read by Dr. Eli Friedman before the North Shore Medical Society, June, 1925.
“Intravenous Use of Anti-Toxin in Diphtheria,” a paper read by Dr. Eli Friedman before the Fall River Medical Society, February, 1925.
Lectures on “Radium Therapy,” given by Dr. Isaac Gerber before the fourth year class of Tufts Medical School, January 8 and 13, 1925.
“X-Ray Treatment of Carbuncles and other Pyogenic Infec¬ tions,” a paper read by Dr. Isaac Gerber before the New England Roentgen Ray Society, Boston, January 16, 1925.
“X-Ray Treatment of Superficial Skin Infections,” a paper read by Dr. Isaac Gerber before The Boston City Hospital Alumni, April 25,1925.
“X-Ray Treatment of Various Benign Diseases,” a paper read by Dr, Isaac Gerber at the Brockton Hospital, May 5, 1925.
“X-Ray Treatment of Bronchial Asthma and Chronic Bron¬ chitis,” a paper read by Dr. Isaac Gerber before the American Medical Association, Atlantic City, N. J., May 29, 1925.
“X-Ray Treatment of Pyogenic Infections, Particularly of the Skin,” a paper read by Dr. Isaac Gerber at the International Congress of Radiology, London,England, July 3, 1925.
“X-Ray Treatment of Whooping Cough, Asthma and Chronic Bronchitis,” a paper read by Dr. Isaac Gerber before the Fall River Medical Society, October 14, 1925.
“X-Ray Treatment of Pyogenic Infections,” a paper read by Dr. Isaac Gerber before the Providence Medical Association November 2, 1925.
“The Development and Present Status of Deep X-Ray Therapy,” a paper read by Dr. Isaac Gerber before the Rhode Island Medical Society, December 3, 1925.
“Choice of X-Ray Treatment in Chest Malignancy,” a paper read by Dr. Isaac Gerber before the New England Roentgen Ray Society, Boston, December 18, 1925.
“Hemochromatosis and Chronic Poisoning with Copper,” read as the Mellon lecture by Dr. F. B. Mallory before the Biological Society at Pittsburgh, Pa., April 30, 1925 and as the Hanna lecture before the Academy of Medicine of Cleve¬ land, Ohio, May 1, 1925.
“Medical Legislation,” a paper read by Dr. Thomas J. O’Brien before the Essex North District Medical Society at Danvers State Hospital, August 25, 1925.
“The Legal Status of Medicine in Massachusetts,” a paper read bv Dr. Thomas J. O’Brien before the Essex South District Medical Society, December 2, 1925.
“Studies on Filterable Viruses I,” and “Studies on Filterable Viruses II.” read in part by Dr. Frederic Parker, Jr., before the American Society for Clinical Investigation at Washington, D. C., May 4, 1925.
An address and demonstration of the “Technique of Ultra¬ violet Ray Therapy in general with special attention to the method of closing up pus discharging Sinuses,” by Dr. Joseph Resnik before the Alumni of The Boston City Hospital, April 25, 1925.
“Tropical Diseases,” an address given by Dr. George C. Shattuck at The Boston City Hospital, October 20, 1925 and before the District Health Officers for the State Department of Health, November 20, 1925.
“Travel and Research in Brazil,” a lecture given by Dr. Richard P. Strong at the St. Botolph Club, April 1, 1925.
“Dermal Spirochaetosis,” an address given by Dr. Richard P. Strong at a meeting of the Association of American Physi¬ cians, Washington, D. C., May 4 to 7, 1925.
“The Medical Results of the Amazon Expedition in 1924,” an address by Dr. Richard P. Strong at a meeting of the Ameri¬ can Society of Tropical Medicine, Washington, D. C., May 5 to 7, 1925.
“ Spirochaetal Infections of Man,” an address by Dr. Richard P. Strong at a meeting of the Medical Society of the State of Pennsylvania, at Harrisburg, Pa., October 6 to 8, 1925.
City Document No. 14. Hospital Department. 1927.
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Maxwell Finland, Gaps in Therapy for Infectious Diseases: A Historical Perspective, The Journal of Infectious Diseases , Mar., 1982, Vol. 145, No. 3 (Mar., 1982), pp. 401-407, Published by: Oxford University Press
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Instead, I wish here to review some of the important changes in the patterns of resistance observed mostly in hos- pitals, particularly at the Boston City Hospital and in the last two decades, although some of this material was presented in 1972 [3]. Great advances have been made in recent years in elu- cidating the mechanisms of resistance
The first group of strains of enterococci that we tested-those isolated at Boston City Hospital be- fore 1950-were classified largely on the basis of resistance to heat (60 C for 30 min). The MICs of penicillin, streptomycin, and bacitracin for these strains each showed a bimodal distribu- tion [18]. In subsequent studies the enterococci were more fully differentiated by their biochemi- cal reactions and were generally identified to be of serogroup D, strains were resistant to chloramphenicol. It is of interest that among more than 100,000 distinct clinical strains of the six more common species isolated at Massachusetts General Hospi- tal during the six years 1971-1976, only the enterococci showed a distinct decline in the per- centage of strains susceptible to cephalothin- from about 30% in 1971 to 9% in 1976 [37]. Nonenterococcal Group D Streptococci During the past few years, various numbers of strains of group D streptococci from human in- fections have been identified and classified as nonenterococci [38]. Strains of these species, Streptococcus bovis and Streptococcus mutans, are of special interest because they are the cause of appreciable proportions of cases of group D streptococcal endocarditis [39, 40]. Moreover, their patterns of susceptibility to antibiotics are similar to those of viridans streptococci rather than to those of enterococci [39-41]. However, strains of S. bovis from two patients with infec- tive endocarditis, although susceptible to pen- icillin G, oxacillin, and cephalothin in disk dif- fusion tests, were found to be resistant to the lethal effects of penicillin G, cefazolin, and van- comycin [42 Staphylococcus Strains of Staphylococcus aureus isolated from patients with infections at Boston City Hospital at various intervals through 1974 were tested for susceptibility to increasing numbers of anti- biotics as those antibiotics became available. The strains isolated before 1950 and tested with seven
Antibiotics already show a wide range of MICS and stepto mycin with bimodal distribution. Among these strains, 85% of those isolated before 1946 were highly sensitive to penicillin G within a narrow range; the rest required increasing concentra- tions (-25 ,ug/ml). By contrast, of strains isolated in 1946-1949, only a small proportion were high- ly sensitive to penicillin G, and the others were inhibited by increasing concentrations over the entire range tested (up to -250 /g/ml) [43]. Over the next three years, more clearly defined bi- modal distributions of MICs of penicillin be- came evident with various proportions of highly resistant strains, depending on the source of the strains [44].
Strains of S. aureus isolated at Boston Hospital in 1955 showed a clearly tribution of MICs of erythromycin the related macrolide, oleandomycin, the latter had not been used in the treatment of patients in that hospital. The proportions of strains resistant to penicillin, streptomycin, and tetracycline had also increased over those ob- served in earlier studies. On the other hand, the 1955 strains were uniformly susceptible to 10 an- tibiotics that were new, that were not closely re- lated chemically to antibiotics previously in com- mon use, or that had been available but used only rarely. Chloramphenicol was the only wide- ly used antibiotic to which few of the strains were resistant
Further tests were done with staphylococci isolated from patients at Boston City Hospital in the fall of 1958; these isolates included strains obtained from outpatients. A smaller proportion of the latter strains were resistant to the antibiotics most commonly used within the hospital and the proportion of strains resistant to each of those antibiotics increased with increasing length of stay of the hospitalized patient before the sample was obtained for culture. Clear correlations of phage patterns and proportions of strains resistant to various antibiotics were again demonstrated [51].
A more extensive study involving 1,550 strains of S. aureus, most of them isolated in previous years but 40% of them isolated in 1959-1960, was carried out by Wallmark and Finland [52]. In this study the results of tests for susceptibility were correlated with the years the strains were isolated, their phage type, isolation from outpatients or hospitalized patients, duration of hospitalization
before the culture was made, and prior treatment of the patient with antibiotics. A definite relationship was shown between the
proportion of antibiotic-resistant strains and the length of previous hospitalization of the patients from whom the strains were obtained; the proportion increased with length of hospital stay and was highest in strains isolated at autopsy. The differences in proportions of resistant strains were shown to be related to the frequency, duration, and intensity of treatment with antibiotics,
although the resistance of individual strains was not specifically related to the particular antibiotic(s) used to treat the patients from
whom the strains were obtained. Changes in proportions of resistant strains were also related to changes in the prevalence of strains of various phage patterns from both outpatients and hospitalized patients.
These data were compatible with the concept that the increased prevalence of antibiotic-resistant staphylococci resulted in the reduction or elimination of sensitive staphylococci by antibiotic therapy, permitting resistant ones to persist and multiply. Increases in resistance of originally sensitive strains directed specifically to the antibiotic(s) that the patient was receiving could be demonstrated only infrequently
Serious staphylococcal infections with bacteremia, both community-acquired and hospital-acquired, had increased markedly in incidence at Boston City Hospital during the 1950s [53]. This trend was reversed during the 1960s, as was the increasing resistance of S. aureus to the antibiot ic that had been in common use; these reversals were associated with the introduction and increasing
use of methicillin and other semisynthetic, penicillinase-resistant penicillins and later the cephalosporins [54]. At Boston City Hospital [54], in the University Hospital in Seattle, Wash. [55], and in hospitals in England [56], although the proportion of strains resistant to penicillin continued to be high, the proportion of strains also resistant to other antibiotics declined markedly among isolates from infections in hospitalized patients, whereas the prevalence of resistance in strains from community-acquired infections,
which previously had been much less than the prevalence of resistance in hospital strains, increased [54, 55]. These changes in resistance of the staphylococci were associated with shifts in the prevalence of strains with various phage patterns [54, 56].
Maxwell Finland, Antibiotic Resistance in Hospitals, 1935-1975 [with Discussion], Reviews of Infectious Diseases , Jan. - Feb., 1979, Vol. 1, No. 1, Cefoxitin: Biochemical, Pharmacologic, Microbiologic and Clinical Properties (Jan. - Feb., 1979), pp. 4-22
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INTENSIVE studies of epidemics of viral hepatitis have revealed multiple epidemiologic patterns of disease spread. Person-to-person contact is thought to be the most common type of transmission. Extensive common-source outbreaks of infectious hepatitis, although infrequent, have been traced to contaminated water, milk and other foods.
In 1961 raw clams and raw oysters were incriminated for the first time in the United States. This pattern of shellfish associated disease has recurred in 2 subsequent epidemics along the Atlantic seacoast. A significant risk of hepatitis has been recognized in animal handlers in contact with newly imported subhuman primates. Illicit use of habituating drugs...
Koff et al, Viral Hepatitis in a Group of Boston Hospitals — Importance of Exposure to Shellfish in a Nonepidemic Period N Engl J Med 1967;276:703-710
In 1961 raw clams and raw oysters were incriminated for the first time in the United States. This pattern of shellfish associated disease has recurred in 2 subsequent epidemics along the Atlantic seacoast. A significant risk of hepatitis has been recognized in animal handlers in contact with newly imported subhuman primates. Illicit use of habituating drugs...
Koff et al, Viral Hepatitis in a Group of Boston Hospitals — Importance of Exposure to Shellfish in a Nonepidemic Period N Engl J Med 1967;276:703-710
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DOE Human Experiment List:
BU:
OT-36. Analysis of Red Blood-Cell Survival in the Body UsingChromium-51
OT-37. Blood Volume Studies Using Chromium-51
OT-38. Studies of Stable Iodine Uptake Using Iodine-131 as a Tracer
OT-39. Studies of Iron Metabolism, Anemia, and Cancer Using Iron-59 and Chromium-51
OT-40. Studies of Iron Metabolism, Anemia, and Rheumatoid Arthritis Using Iron-59
OT-41. Iron Absorption Studies Using Iron-59
BCH:
OT-45. Iodine Metabolism Studies in Graves Disease Using Iodine-131
https://ehss.energy.gov/OHRE/roadmap/experiments/0491doc.html
BU:
OT-36. Analysis of Red Blood-Cell Survival in the Body UsingChromium-51
OT-37. Blood Volume Studies Using Chromium-51
OT-38. Studies of Stable Iodine Uptake Using Iodine-131 as a Tracer
OT-39. Studies of Iron Metabolism, Anemia, and Cancer Using Iron-59 and Chromium-51
OT-40. Studies of Iron Metabolism, Anemia, and Rheumatoid Arthritis Using Iron-59
OT-41. Iron Absorption Studies Using Iron-59
BCH:
OT-45. Iodine Metabolism Studies in Graves Disease Using Iodine-131
https://ehss.energy.gov/OHRE/roadmap/experiments/0491doc.html
Experimental Myocardial Infarction
VI. EFFICACY AND TOXICITY OF DIGITALIS IN ACUTE AND HEALING PHASE IN INTACT CONSCIOUS DOGS
RAJ KUMAR, WILLIAM B. HOOD, JR., JUI1O JOISON, DAVID P. GILMOUR, JOHN C. NORMAN, and WALT H. ABELMANN
From the Thorndike Memorial Laboratory, Harvard (Second and Fourth)
Medical Services, and Sears Surgical Laboratory, Harvard Surgical Service,
Boston City Hospital, and the Departments of Medicine and Surgery, Harvard
Medical School, Boston, Massachusetts 02130
The Journal of Clinical Investigation Volume 49 1970
A B S T R A C T Use of digitalis in myocardial infarction is controversial. To determine the efficacy and toxic threshold, serial infusions of 3 jg/kg per min of acetylstrophanthidin were given to six intact conscious dogs 24 hr before and 1 hr, 2 days, and 7 days after myocardial infarction induced by inflation of a balloon cuff implanted on the left anterior descending coronary
artery. Within 1 hr after myocardial infarction, heart rate increased by 28%. Left ventricular end-diastolic pressure increased from 7 to 20 mm Hg, and stroke volume decreased by 25%. At this time acetylstrophanthidin caused no beneficial hemodynamic change. 1 wk
later, the heart rate and left ventricular end-diastolic pressure had declined toward normal but remained elevated. At this time, acetylstrophanthidin lowered left ventricular end-diastolic pressure by 25%, and increased the stroke volume and cardiac output by 25% and 21% respectively, without any change in heart rate or aortic pressure. Tolerance to acetylstrophanthidin, defined as appearance of ventricular tachycardia, declined the 1st hr after myocardial infarction by 24% (P < 0.05) from the control level of 43 ±4 jig/kg (SEM), but subsequently returned to control. Thus, immediately after myocardial infarction, tolerance to acetylstrophanthidin was reduced, and left ventricular failure was not ameliorated. 1 wk later in the healing phase of myocardial infarction, tolerance to acetylstrophanthidin returned to normal and left ventricular performance was improved by this drug. The
study suggests a limited therapeutic role for digitalis in the treatment of left ventricular failure in the acute phase immediately after myocardial infarction, but beneficial effects may occur in the healing phase 1 wk later.
VI. EFFICACY AND TOXICITY OF DIGITALIS IN ACUTE AND HEALING PHASE IN INTACT CONSCIOUS DOGS
RAJ KUMAR, WILLIAM B. HOOD, JR., JUI1O JOISON, DAVID P. GILMOUR, JOHN C. NORMAN, and WALT H. ABELMANN
From the Thorndike Memorial Laboratory, Harvard (Second and Fourth)
Medical Services, and Sears Surgical Laboratory, Harvard Surgical Service,
Boston City Hospital, and the Departments of Medicine and Surgery, Harvard
Medical School, Boston, Massachusetts 02130
The Journal of Clinical Investigation Volume 49 1970
A B S T R A C T Use of digitalis in myocardial infarction is controversial. To determine the efficacy and toxic threshold, serial infusions of 3 jg/kg per min of acetylstrophanthidin were given to six intact conscious dogs 24 hr before and 1 hr, 2 days, and 7 days after myocardial infarction induced by inflation of a balloon cuff implanted on the left anterior descending coronary
artery. Within 1 hr after myocardial infarction, heart rate increased by 28%. Left ventricular end-diastolic pressure increased from 7 to 20 mm Hg, and stroke volume decreased by 25%. At this time acetylstrophanthidin caused no beneficial hemodynamic change. 1 wk
later, the heart rate and left ventricular end-diastolic pressure had declined toward normal but remained elevated. At this time, acetylstrophanthidin lowered left ventricular end-diastolic pressure by 25%, and increased the stroke volume and cardiac output by 25% and 21% respectively, without any change in heart rate or aortic pressure. Tolerance to acetylstrophanthidin, defined as appearance of ventricular tachycardia, declined the 1st hr after myocardial infarction by 24% (P < 0.05) from the control level of 43 ±4 jig/kg (SEM), but subsequently returned to control. Thus, immediately after myocardial infarction, tolerance to acetylstrophanthidin was reduced, and left ventricular failure was not ameliorated. 1 wk later in the healing phase of myocardial infarction, tolerance to acetylstrophanthidin returned to normal and left ventricular performance was improved by this drug. The
study suggests a limited therapeutic role for digitalis in the treatment of left ventricular failure in the acute phase immediately after myocardial infarction, but beneficial effects may occur in the healing phase 1 wk later.
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EXPERIMENTS IN INTRACARDIAC SURGERY 1. BACTERIAL ENDOCARDITIS
DWIGHT E. HARKEN,· M.D. BOSTON, MASS.
Assistant in Surgery, Harvard Medical School. Resident, Fifth (Harvard) Surgical Service, Boston City Hospital.
From. the Surgical Research Laboratories of the Boston City Hospital. Dr. Stephen; Maddock, Director. Received for publication, Nov. 5. 1941
RE CENT advances in thoracic surgery suggest that it is time to take up experimental intracardiac surgery. Weare interested in such experimental surgery primarily as it pertains to the treatment of human disease. No attempt is made here to review the experimental and clinical background of this field. It may suffice to say that the most significant work has been contributed by Cushing;' Bernheim," Carrel," 'I'uffier," Coryl10s, 5 Cutler and Beck," Graham and Allen,' and Powers." Recently an opportunity has been provided in this laboratory for the conduct of intracardiac surgical maneuvers which have been directed principally at the production of valvular lesions, intracardiac visualization, and the production and local treatment of bacterial endocarditis.
A SURVEY OF REPORTED METHODS OF EXPERIMENTAL PRODUCTION OF BACTERIAL ENDOCARDITIS
Although not primarily interested in the production of bacterial endocarditis, Rosenbach'? in 1878, was apparently the first to produce the experimental disease. In this instance, the disease developed in dogs and rabbits on valves that had been injured by passing a rod down the carotid artery. Ribbert-' in 1885 probably was the first to produce the disease intentionally. His method has, in principle, had repeated recent trials (Dietrich-") and was directed at wounding the valves by the injection of staphylococcal suspensions containing starch granules from potato cultures. Dreschfeld.P in 1887, was the first to transmit the disease from a human case to an experimental animal. Since these early efforts a great variety of successful techniques have been presented. These various methods have been conveniently grouped by Blahd, Frank and Saphir> into four general types: (1) mechanical procedures directed at leaflet damage with subsequent intravenous introduction of virulent bacteria, (2) simple intravenous injection of bacteria, (3) production of a bacterial focus in the body, and (4) preliminary injection of predisposing substances, with subsequent intravenous injection of virulent organisms.
The first general method, embracing mechanical injury of the leaflets, followed by spontaneous or induced infection of these lesions has represented the most common as well as the first consistently successful method. The early work of Rosenbach10 has already been mentioned. The modern controlled counterpart is to be found in the excellent work of Kinsella and Hayes'" and Kinsella and Meuther." In this last article these workers reported that their animals with damaged leaflets developed bacterial endocarditis after bacterial feedings. Other ingenious mechanical methods have been sought out by Blahd and his associates" and consist of intravenous injections of bacteria in particulate media, such as pulverized carbon," an emulsion of carcinomatous cells," and sterile flour." Finally we must add perhaps the most elaborate procedure of this group, the preliminary fulguration of the mitral valve and subsequent infection of these vulnerable leaflets by the intravenous injection of Streptococcus uiridam«, This last method was devised by Powers." A similar, even more precise technique of fulguration under vision has been devised by Keith.:"
In principle and practice the first general method has appealed to us as comprehending the most dependable means of producing the experimental disease. It is the method of choice for our purposes also because we are primarily interested in developing a surgical technique that attacks the local lesion rather than the much discussed immunologic, bacteriologic and physiopathologic aspects of the disease. The second general group, consisting of simple intravenous injection of bacteria, has had abundant trial and inconstant results. It will be recalled that the early and important contributions of Horder'" and Rosenow" were of this type. Later, Lanfranehi'" and Fox24and still more recently, Cornil, Mosinger and Haimovici," MacNeal and his associates" and Lloyd-Jones" have used this simple but tedious method with variable results. In general, this approach has been used in work on rabbits, in which instances the disease was produced with ease, and, in those few instances of the injection of dogs, the experimental lesions were produced only with considerable difficulty. Worthy of special comment is the study of Blahd, Frank and Saphir," who used a beta hemolytic streptococcus strain isolated from a spontaneous vegetative endocarditis, discovered by chance, in a dog. This strain reproduced the valvular disease in ten of twenty-five animals into which it was injected.
The third general method aims at the production of bacterial endocarditis by the establishment of a bacterial focus in the body. Most
ingenious and most worth while from our point of view has been the work of Friedman, Katz, and Howell,28 who anchored bakelite bacteriacontaining capsules in various places in the heart and great vessels of dogs. To produce the cardiac lesions, the capsules were introduced through the chest wall and myocardium by means of a trocar. This method is somewhat hazardous to animals and cannot be relied upon for precise localization of the capsule; however, it served the purposes of these investigators admirably. This work should be reviewed by those contemplating studies in this field. Welch, Murdock, and Ferguson" planted Streptococcus viridans about the teeth of rabbits, sprayed the rabbits ', throats with influenza bacilli, and again produced the disease. The fourth general method comprehends preparatory injections of various substances such as pitressin as used by Nedzel,30 or other bacterial strains as demonstrated by Freifeld." Dietrich" sensitized rabbits with horse serum, a solution containing casein 5 per cent, colon bacillus and histamine; after sensitization he injected staphylococci and colon bacilli intravenously repeatedly. In his killed animals, all rabbits, he found early lesions. This general approach to the problem has perhaps the most promising possibilities for immunologists, bacteriologists, and physiologists.l- After reviewing the literature, or even the above brief survey, one is impressed by the multiplicity of relationships between rabbits and bacteria that result in endocarditis for the former. Furthermore, one is confronted by the fact that, aside from the pathologic picture, the experimental disease so produced bears little similarity to its human counterpart. To us it appears that these factors tend to invalidate the rabbit as a suitable experimental animal in this work. When one's object is, as ours, to approach the problem from a local surgical point of view, the size of the rabbits' mitral leaflets completes the invalidation.
The above-described methods for the production of experimental bacterial
endocarditis are of interest in pathologic studies. They also lend to our understanding of the mechanism of origin and perpetuation of this disease. However; they are tedious procedures; they are somewhat uncertain; and the disease as produced in some animals lacks clinical similarity to its human counterpart. These features delay or preclude the phase of investigative work which appears to us to be of prime importance, namely, the treatment of the human disease. In short, the prelude to investigations of therapy in bacterial endocarditis is so expensive in time and animals that few are able to see the program through. The human lesion is well mapped; it does seem to be the distributing point of the lesions that cause the death, and therefore the destruction or removal of the vegetations or their contained bacteria should cure the sufferer. Any experimental therapeutic technique directed at the local lesion,
that we can now imagine, requires lesions on heart leaflets large enough for surgical approach. The hearts of large dogs are the most practical source available. Our specifications then resolve themselves into: a fatal disease not too fulminating for therapeutic intervention, that is, the animals should live more than two weeks; this fatal disease should not be so slow in terminating as to render therapeutic assay difficult. The clinical course of the experimental disease should resemble the course of the disease in human beings. The fatal issue must be secondary to leaflet vegetations of bacterial nature. This disease must be produced in animals sufficiently large to permit maneuvers of visualization, excision and/or sterilization. The condition must be technically easy to produce and have a low production mortality
DWIGHT E. HARKEN,· M.D. BOSTON, MASS.
Assistant in Surgery, Harvard Medical School. Resident, Fifth (Harvard) Surgical Service, Boston City Hospital.
From. the Surgical Research Laboratories of the Boston City Hospital. Dr. Stephen; Maddock, Director. Received for publication, Nov. 5. 1941
RE CENT advances in thoracic surgery suggest that it is time to take up experimental intracardiac surgery. Weare interested in such experimental surgery primarily as it pertains to the treatment of human disease. No attempt is made here to review the experimental and clinical background of this field. It may suffice to say that the most significant work has been contributed by Cushing;' Bernheim," Carrel," 'I'uffier," Coryl10s, 5 Cutler and Beck," Graham and Allen,' and Powers." Recently an opportunity has been provided in this laboratory for the conduct of intracardiac surgical maneuvers which have been directed principally at the production of valvular lesions, intracardiac visualization, and the production and local treatment of bacterial endocarditis.
A SURVEY OF REPORTED METHODS OF EXPERIMENTAL PRODUCTION OF BACTERIAL ENDOCARDITIS
Although not primarily interested in the production of bacterial endocarditis, Rosenbach'? in 1878, was apparently the first to produce the experimental disease. In this instance, the disease developed in dogs and rabbits on valves that had been injured by passing a rod down the carotid artery. Ribbert-' in 1885 probably was the first to produce the disease intentionally. His method has, in principle, had repeated recent trials (Dietrich-") and was directed at wounding the valves by the injection of staphylococcal suspensions containing starch granules from potato cultures. Dreschfeld.P in 1887, was the first to transmit the disease from a human case to an experimental animal. Since these early efforts a great variety of successful techniques have been presented. These various methods have been conveniently grouped by Blahd, Frank and Saphir> into four general types: (1) mechanical procedures directed at leaflet damage with subsequent intravenous introduction of virulent bacteria, (2) simple intravenous injection of bacteria, (3) production of a bacterial focus in the body, and (4) preliminary injection of predisposing substances, with subsequent intravenous injection of virulent organisms.
The first general method, embracing mechanical injury of the leaflets, followed by spontaneous or induced infection of these lesions has represented the most common as well as the first consistently successful method. The early work of Rosenbach10 has already been mentioned. The modern controlled counterpart is to be found in the excellent work of Kinsella and Hayes'" and Kinsella and Meuther." In this last article these workers reported that their animals with damaged leaflets developed bacterial endocarditis after bacterial feedings. Other ingenious mechanical methods have been sought out by Blahd and his associates" and consist of intravenous injections of bacteria in particulate media, such as pulverized carbon," an emulsion of carcinomatous cells," and sterile flour." Finally we must add perhaps the most elaborate procedure of this group, the preliminary fulguration of the mitral valve and subsequent infection of these vulnerable leaflets by the intravenous injection of Streptococcus uiridam«, This last method was devised by Powers." A similar, even more precise technique of fulguration under vision has been devised by Keith.:"
In principle and practice the first general method has appealed to us as comprehending the most dependable means of producing the experimental disease. It is the method of choice for our purposes also because we are primarily interested in developing a surgical technique that attacks the local lesion rather than the much discussed immunologic, bacteriologic and physiopathologic aspects of the disease. The second general group, consisting of simple intravenous injection of bacteria, has had abundant trial and inconstant results. It will be recalled that the early and important contributions of Horder'" and Rosenow" were of this type. Later, Lanfranehi'" and Fox24and still more recently, Cornil, Mosinger and Haimovici," MacNeal and his associates" and Lloyd-Jones" have used this simple but tedious method with variable results. In general, this approach has been used in work on rabbits, in which instances the disease was produced with ease, and, in those few instances of the injection of dogs, the experimental lesions were produced only with considerable difficulty. Worthy of special comment is the study of Blahd, Frank and Saphir," who used a beta hemolytic streptococcus strain isolated from a spontaneous vegetative endocarditis, discovered by chance, in a dog. This strain reproduced the valvular disease in ten of twenty-five animals into which it was injected.
The third general method aims at the production of bacterial endocarditis by the establishment of a bacterial focus in the body. Most
ingenious and most worth while from our point of view has been the work of Friedman, Katz, and Howell,28 who anchored bakelite bacteriacontaining capsules in various places in the heart and great vessels of dogs. To produce the cardiac lesions, the capsules were introduced through the chest wall and myocardium by means of a trocar. This method is somewhat hazardous to animals and cannot be relied upon for precise localization of the capsule; however, it served the purposes of these investigators admirably. This work should be reviewed by those contemplating studies in this field. Welch, Murdock, and Ferguson" planted Streptococcus viridans about the teeth of rabbits, sprayed the rabbits ', throats with influenza bacilli, and again produced the disease. The fourth general method comprehends preparatory injections of various substances such as pitressin as used by Nedzel,30 or other bacterial strains as demonstrated by Freifeld." Dietrich" sensitized rabbits with horse serum, a solution containing casein 5 per cent, colon bacillus and histamine; after sensitization he injected staphylococci and colon bacilli intravenously repeatedly. In his killed animals, all rabbits, he found early lesions. This general approach to the problem has perhaps the most promising possibilities for immunologists, bacteriologists, and physiologists.l- After reviewing the literature, or even the above brief survey, one is impressed by the multiplicity of relationships between rabbits and bacteria that result in endocarditis for the former. Furthermore, one is confronted by the fact that, aside from the pathologic picture, the experimental disease so produced bears little similarity to its human counterpart. To us it appears that these factors tend to invalidate the rabbit as a suitable experimental animal in this work. When one's object is, as ours, to approach the problem from a local surgical point of view, the size of the rabbits' mitral leaflets completes the invalidation.
The above-described methods for the production of experimental bacterial
endocarditis are of interest in pathologic studies. They also lend to our understanding of the mechanism of origin and perpetuation of this disease. However; they are tedious procedures; they are somewhat uncertain; and the disease as produced in some animals lacks clinical similarity to its human counterpart. These features delay or preclude the phase of investigative work which appears to us to be of prime importance, namely, the treatment of the human disease. In short, the prelude to investigations of therapy in bacterial endocarditis is so expensive in time and animals that few are able to see the program through. The human lesion is well mapped; it does seem to be the distributing point of the lesions that cause the death, and therefore the destruction or removal of the vegetations or their contained bacteria should cure the sufferer. Any experimental therapeutic technique directed at the local lesion,
that we can now imagine, requires lesions on heart leaflets large enough for surgical approach. The hearts of large dogs are the most practical source available. Our specifications then resolve themselves into: a fatal disease not too fulminating for therapeutic intervention, that is, the animals should live more than two weeks; this fatal disease should not be so slow in terminating as to render therapeutic assay difficult. The clinical course of the experimental disease should resemble the course of the disease in human beings. The fatal issue must be secondary to leaflet vegetations of bacterial nature. This disease must be produced in animals sufficiently large to permit maneuvers of visualization, excision and/or sterilization. The condition must be technically easy to produce and have a low production mortality
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In a recent report McGowan et al. [1] presented data on the occurrence of and mortality from bacteremic infections at Boston City Hospital during 12 selected years between 1935 and 1972. The mortality in patients with hospital-acquired (HA) bacteremia (46.7%) was considerably higher than that in patients with community- acquired (CA) bacteremia (32.9%, P < 0.001). Moreover, the infection was HA in 41.8% of the patients who died of the infection as compared with 28.7% in those who survived (P < 0.0001). We also reported [2] that the average number of days of hospitalization for survivors of HA bac- teremia (32.3 days) after the blood was obtained for the first positive blood culture was consider- ably longer than the total hospital stay of pa- tients with CA bacteremia (21.7 days). Survival of patients who died was also somewhat longer in those with HA bacteremia (12.3 days) than in corresponding CA cases (10.5 days). In a number of the patients included in those two studies, additional blood cultures taken later in the same admission yielded organisms other than those identified in the first positive blood culture. These bacteremic superinfections (SI) were not considered in the previous analysis. In this paper we present data on the occurrence and bacteriology of bacteremic SI, as well as the mortality and length of hospital stay resulting from these infections, in patients in whom the primary bacteremia was either CA or HA
In the previous report on the occurrence of bacteremic infections at Boston City Hospital during 12 selected years between 1935 and 1972, it was shown that the numbers of patients with such infections and the percentage of deaths among them increased progressively over most of the years of the study. These increases occurred despite a steady and considerable reduction in the total number of patients admitted to the hospital and in the number of deaths (and mortality rate) in all cases, It was also shown that case rates (numbers of patients per 1,000 admissions) of CA bacteremias declined over the last decade of the study, but those of HA bacteremic infections continued to increase. Those changes occurred despite the successive introduction of a large number and variety of effective antibacterial agents. In addition, the mortality was significantly higher in the patients with HA bacteremia than in those in whom the bacteremia was demonstrated on admission and was considered to be CA. In a separate report [2] it was also shown that the duration of hospitalization after the bacteremia was verified in the HA cases was longer than the total stay of those
with CA infections.
Similar changes in case rates [3], mortality [3], and duration of hospital stay [4] were also demonstrated in patients with acute pleural empyema at the same hospital during the same 12 selected years. Similarly, the mortality in patients with acute bacterial meningitis was higher in those in whom the meningitis developed in the hospital than in those in whom bacterial infection was
demonstrated in cerebrospinal fluid at the time of admission to the hospital [5], and the duration of hospitalization after the first positive spinal fluid culture in the HA cases was longer than the total hospital stay of the CA cases [6]. Bacteremic SI with organisms not identified in the primary bacteremic infection were demonstrated in 6.0% of all bacteremic cases over the years of this study, but they were much more frequent in bacteremia that was originally HA than in SI of primary CA bacteremia. Similarly, among all of the patients with acute bacterial meningitis, SI of the cerebrospinal fluid with organisms not present in the first diagnostic cere-
835 brospinal fluid was demonstrated in 6.1 % of the cases, but the proportion was appreciably higher among HA than among CA cases. On the other hand, additional bacteria (SI) were identified after collection of the first positive pleural fluid in about 15% of all cases of acute bacterial empyema, and this proportion was the same in the CA and in the HA cases. The mortality was also the same in both groups of cases of empyema. However, the excess hospital stay of survivors was considerably longer in those with SI of HA
empyema, although the interval from the first diagnostic pleural fluid culture to the demonstration of the SI was the same in CA and HA cases.
Maxwell Finland and Mildred W. Barnes, Bacteremic Superinfections of Patients with Bacteremia: Occurrence, Bacteriology,Mortality, and Duration of Hospitalization at Boston City Hospital during 12 Selected Yearsbetween 1935 and 1972, The Journal of Infectious Diseases, Vol. 138, No. 6 (Dec., 1978), pp. 829-836, Oxford University Press
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The_Boston_Globe_2006_08_23_8
Identification of specific types. The method used at that time for the typing of pneumococci from patients with pneumonia involved ip injec- tion of properly obtained sputum into a mouse, which usually died overnight or after ,24 hr. Peritoneal exudate obtained from the dead or moribund mouse was diluted, mixed in small tubes with types I, II, and III typing sera, incubated at 37 C, and observed for type-specific agglutina- tion. A drop of the mouse's cardiac blood, ob- tained with sterile precautions and cultured on blood agar and in blood broth, usually yielded the pneumococcus in pure culture and confirmed the diagnosis. It was at about this time that Albert Sabin, then a medical student at New York Uni- versity in New York City where he spent a good deal of time working in the bacteriology labora- tory of Dr. William H. Park, developed the Sabin test. This test involved removing a few drops of peritoneal exudate with a capillary pipette from the live, infected mouse 3 or 4 hr after inoculation and mixing one drop separately with antiserum to each of the three pneumococcal types on a slide, Gram-staining, and examining smears of the stained mixtures microscopically
Under the heading "Some Unresolved Problems Involved in the Use of Antibiotics," Waksman later enumerated many such problems in the discovery of organisms that produce antibiotics, the mechanisms of their action, and the type, ef- ficacy, and range of activity and of the reactions they produce. He ended this section as follows [8]. The physician can no longer depend on a "bedside manner." He must have a well equipped laboratory at his disposal. He must be familiar not only with the antibiotic to be used in each par- ticular patient, but also its concentration [dose], frequency of administration, and the reactions of the patient. The doctor must become more than ever before, a scientist, who studies the interaction between the host and the invading organism, learning how to control the latter, without injuring the former [shades of Ehrlich!]. Only then can man derive full benefit from the miracle drugs,- miracles contributed by the harmless microbes for the control of the injurious ones. Another Nobel Laureate, Sir Ernst B. Chain, at a symposium held in London on the occasion of the 25th anniversary of the first clinical use of penicillin, ventured to suggest that the long, time- consuming, and laborious efforts to roam around the world to seek out compost piles and soil samples for the isolation of microorganisms that might produce useful antibiotics have now become unnecessary and wasteful of time, energy, and ex- pense. Now that the chemical structure of the nucleus of penicillin (and of cephalosporin) has been defined, he suggested that it is necessary only to put the chemist to work to synthesize new derivatives and to call on the pharmacologists and clinicians to evaluate their effectiveness and usefulness in the treatment of infections. The large number of new semisynthetic penicillins and cephalosporins that has been developed in recent years and is still coming forth has certainly ex- tended their range of effectiveness and provided some justification of Dr. Chain's prediction for filling some of the gaps in therapy for infectious diseases. MAXWELL FINLAND George Richards Minot Professor of Medicine, Emeritus Harvard University and Boston City Hospital and Distinguished Physician U.S. Veterans Administration Boston, Massachusetts
Maxwell Finland, Gaps in Therapy for Infectious Diseases: A Historical Perspective, The Journal of Infectious Diseases , Mar., 1982, Vol. 145, No. 3 (Mar., 1982), pp. 401-407
Under the heading "Some Unresolved Problems Involved in the Use of Antibiotics," Waksman later enumerated many such problems in the discovery of organisms that produce antibiotics, the mechanisms of their action, and the type, ef- ficacy, and range of activity and of the reactions they produce. He ended this section as follows [8]. The physician can no longer depend on a "bedside manner." He must have a well equipped laboratory at his disposal. He must be familiar not only with the antibiotic to be used in each par- ticular patient, but also its concentration [dose], frequency of administration, and the reactions of the patient. The doctor must become more than ever before, a scientist, who studies the interaction between the host and the invading organism, learning how to control the latter, without injuring the former [shades of Ehrlich!]. Only then can man derive full benefit from the miracle drugs,- miracles contributed by the harmless microbes for the control of the injurious ones. Another Nobel Laureate, Sir Ernst B. Chain, at a symposium held in London on the occasion of the 25th anniversary of the first clinical use of penicillin, ventured to suggest that the long, time- consuming, and laborious efforts to roam around the world to seek out compost piles and soil samples for the isolation of microorganisms that might produce useful antibiotics have now become unnecessary and wasteful of time, energy, and ex- pense. Now that the chemical structure of the nucleus of penicillin (and of cephalosporin) has been defined, he suggested that it is necessary only to put the chemist to work to synthesize new derivatives and to call on the pharmacologists and clinicians to evaluate their effectiveness and usefulness in the treatment of infections. The large number of new semisynthetic penicillins and cephalosporins that has been developed in recent years and is still coming forth has certainly ex- tended their range of effectiveness and provided some justification of Dr. Chain's prediction for filling some of the gaps in therapy for infectious diseases. MAXWELL FINLAND George Richards Minot Professor of Medicine, Emeritus Harvard University and Boston City Hospital and Distinguished Physician U.S. Veterans Administration Boston, Massachusetts
Maxwell Finland, Gaps in Therapy for Infectious Diseases: A Historical Perspective, The Journal of Infectious Diseases , Mar., 1982, Vol. 145, No. 3 (Mar., 1982), pp. 401-407
Maxwell Finland, Carol Garner, Clare Wilcox and Leon D. Sabath, Susceptibility of "Enterobacteria" to Aminoglycoside Antibiotics: Comparisons with Tetracyclines, Polymyxins, Chloramphenicol, and Spectinomycin, The Journal of Infectious Diseases , Aug., 1976, Vol. 134, Supplement. Tobramycin (Aug., 1976), pp. S57-S74.
The data presented in this paper were, therefore, gathered in response to this need for reliable information on the changing pattern of serious staphylococcic and other specific bacterial infections in relation to the use of the antimicrobial agents. They were collected at the Boston City Hospital where there has been a continuous interest in infectious disease antedating the introduction of the sulfonamides, and where there is available a large amount of bacteriological material carried out by the same competent and conscientious bacteriologists throughout the same period.
widely and extensively used. In order to make valid comparisons and also to minimize errors in interpretation, as well as to
limit the study still further, only the following entities were included: ( 1) autopsies in which satisfactory cultures were made and which yielded bacterial pathogens; (2) bacteremias ( organisms grown from blood cultures) ; ( 3) meningitides (bacteria grown from cerebrospinal fluid) ; and ( 4) empyemas (bacteria grown from pleural fluid).
The background data from which this material was selected are given in figures 1 and 2. During the period of this study, the total number of admissions to the hospital rose above 43,000 in 1941 and then fell off to 33,600 in 1957, a drop of over 20%. During the same interval, the number of cultures processed in the bacteriological laboratory increased almost fivefold, from about 10,000 in 1935 to nearly 50,000 in 1957. Hereafter, the data will refer to the numbers of patients and not to the numbers of positive cultures.
The total number of deaths each year from all causes is shown in the table. This number fluctuated somewhat but had a general downward trend, almost paralleling that of the total number of admissions, with about 1 7 % fewer deaths in 19 57 than in 1935. The number of deaths from all causes per 100 admissions to the hospital fluctuated somewhat throughout this period but generally was about seven. The number of autopsies performed at the hospital (fig. 1) increased from about 700 to over 1,100, and those in which bacteriological cultures were made increased more than proportionally. The autopsy percentage for the entire hospital, that is, the proportion of fatal cases in which autopsies were performed, increased during the interval of this study from about 25 % to nearly 50% (see table)
Occurrence of Bacteremia. The most significant trends were revealed by the cases of bacteremia. The numbers of patients with
blood cultures positive for the most common gram-positive coccal organisms ( other than Staph. albus, which will be considered separately later in this paper) are indicated in figure 3, and those whose blood cultures yielded the most common of the various important gram-negative bacteria are shown in figure 4. Pneumococcus was the most frequent invader of the blood stream in 1935;
since then the number of patients with pneumococcic bacteremia has fluctuated slightly and showed a significant drop only in 1955 and 1957. Cases of hemolytic streptococcic (Streptococcus pyogenes) bacteremia were about half as frequent as those with pneumococcus in 1935, but their number declined sharply in the sulfonamide era. Very few such cases have been encountered since then and until 1957, when a moderate number again occurred. The numbers of patients with bacteremia due to streptococci of the viridans group fluctuated slightly and irregularly. On the other hand, enterococcic bacteremias were almost unknown or unrecognized before the antibiotic era, but there have been 23 to 36 cases each year since then. The greatest and most significant increase occurred in the number of patients with bacteremia due to Staph, aureus. There was a sharp increase in 1941, a temporary decline after the early use of penicillin, and a steady increase thereafter. In 1957 there were nearly four times as many cases as in 1935 and more than twice as many as in 1947
The occurrence of invasion of the blood stream. with various gram-negative bacilli showed an even more striking trend. These bacteremias were infrequently observed prior to the sulfonamide era, cases of Esch. coli bacteremia accounting for the great majority of those seen in 1935. Patients with Esch. coli bacteremia increased in number markedly after the introduction of the antibacterial
drugs. Large numbers of cases have continued to occur since then, except for a temporary and partial remission after 1947, that is, after the broadspectrum antibiotics came into use. Klebsiella pneumoniae (Friedlander's bacillus) bacteremia occurred in a small number of patients each year, with a moderately increased number in 1953. Aerobacter aerogenes had not been identified in
blood cultures at all until after 1941; however, in 1947, bacteremia with this organism occurred in 46 patients, and there have been about that number of cases each year since then. Pseudomonas bacteremia was rare in 1935, but there has been a moderate and steadily increasing number of cases each year since then (up to 20 in 1957). There were six and seven patients with Proteus
bacteremia in 1935 and 1941, respectively, and the number rose sharply during the antibiotic era until there were 65 cases in 1955 and somewhat fewer in 1957. Proteus organisms thus vie with Esch. coli for top place among the gram-negative bacteremias. Not shown in the figure are the cases of bacteremia due to Hemophilus influenzae and various species of Salmonella, including S. typhosa. These accounted for a small and fluctuating number of cases each year
Maxwell Finland, Wilfred F. Jones Jr. and Mildred W. Barnes, Occurrence of Serious Bacterial Infections since Introduction of Antibacterial Agents, The Journal of Infectious Diseases, Vol. 125, Supplement. The Art of ClinicalInvestigation (Mar., 1972), pp. S89-S100
The data presented in this paper were, therefore, gathered in response to this need for reliable information on the changing pattern of serious staphylococcic and other specific bacterial infections in relation to the use of the antimicrobial agents. They were collected at the Boston City Hospital where there has been a continuous interest in infectious disease antedating the introduction of the sulfonamides, and where there is available a large amount of bacteriological material carried out by the same competent and conscientious bacteriologists throughout the same period.
widely and extensively used. In order to make valid comparisons and also to minimize errors in interpretation, as well as to
limit the study still further, only the following entities were included: ( 1) autopsies in which satisfactory cultures were made and which yielded bacterial pathogens; (2) bacteremias ( organisms grown from blood cultures) ; ( 3) meningitides (bacteria grown from cerebrospinal fluid) ; and ( 4) empyemas (bacteria grown from pleural fluid).
The background data from which this material was selected are given in figures 1 and 2. During the period of this study, the total number of admissions to the hospital rose above 43,000 in 1941 and then fell off to 33,600 in 1957, a drop of over 20%. During the same interval, the number of cultures processed in the bacteriological laboratory increased almost fivefold, from about 10,000 in 1935 to nearly 50,000 in 1957. Hereafter, the data will refer to the numbers of patients and not to the numbers of positive cultures.
The total number of deaths each year from all causes is shown in the table. This number fluctuated somewhat but had a general downward trend, almost paralleling that of the total number of admissions, with about 1 7 % fewer deaths in 19 57 than in 1935. The number of deaths from all causes per 100 admissions to the hospital fluctuated somewhat throughout this period but generally was about seven. The number of autopsies performed at the hospital (fig. 1) increased from about 700 to over 1,100, and those in which bacteriological cultures were made increased more than proportionally. The autopsy percentage for the entire hospital, that is, the proportion of fatal cases in which autopsies were performed, increased during the interval of this study from about 25 % to nearly 50% (see table)
Occurrence of Bacteremia. The most significant trends were revealed by the cases of bacteremia. The numbers of patients with
blood cultures positive for the most common gram-positive coccal organisms ( other than Staph. albus, which will be considered separately later in this paper) are indicated in figure 3, and those whose blood cultures yielded the most common of the various important gram-negative bacteria are shown in figure 4. Pneumococcus was the most frequent invader of the blood stream in 1935;
since then the number of patients with pneumococcic bacteremia has fluctuated slightly and showed a significant drop only in 1955 and 1957. Cases of hemolytic streptococcic (Streptococcus pyogenes) bacteremia were about half as frequent as those with pneumococcus in 1935, but their number declined sharply in the sulfonamide era. Very few such cases have been encountered since then and until 1957, when a moderate number again occurred. The numbers of patients with bacteremia due to streptococci of the viridans group fluctuated slightly and irregularly. On the other hand, enterococcic bacteremias were almost unknown or unrecognized before the antibiotic era, but there have been 23 to 36 cases each year since then. The greatest and most significant increase occurred in the number of patients with bacteremia due to Staph, aureus. There was a sharp increase in 1941, a temporary decline after the early use of penicillin, and a steady increase thereafter. In 1957 there were nearly four times as many cases as in 1935 and more than twice as many as in 1947
The occurrence of invasion of the blood stream. with various gram-negative bacilli showed an even more striking trend. These bacteremias were infrequently observed prior to the sulfonamide era, cases of Esch. coli bacteremia accounting for the great majority of those seen in 1935. Patients with Esch. coli bacteremia increased in number markedly after the introduction of the antibacterial
drugs. Large numbers of cases have continued to occur since then, except for a temporary and partial remission after 1947, that is, after the broadspectrum antibiotics came into use. Klebsiella pneumoniae (Friedlander's bacillus) bacteremia occurred in a small number of patients each year, with a moderately increased number in 1953. Aerobacter aerogenes had not been identified in
blood cultures at all until after 1941; however, in 1947, bacteremia with this organism occurred in 46 patients, and there have been about that number of cases each year since then. Pseudomonas bacteremia was rare in 1935, but there has been a moderate and steadily increasing number of cases each year since then (up to 20 in 1957). There were six and seven patients with Proteus
bacteremia in 1935 and 1941, respectively, and the number rose sharply during the antibiotic era until there were 65 cases in 1955 and somewhat fewer in 1957. Proteus organisms thus vie with Esch. coli for top place among the gram-negative bacteremias. Not shown in the figure are the cases of bacteremia due to Hemophilus influenzae and various species of Salmonella, including S. typhosa. These accounted for a small and fluctuating number of cases each year
Maxwell Finland, Wilfred F. Jones Jr. and Mildred W. Barnes, Occurrence of Serious Bacterial Infections since Introduction of Antibacterial Agents, The Journal of Infectious Diseases, Vol. 125, Supplement. The Art of ClinicalInvestigation (Mar., 1972), pp. S89-S100
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Relative frequency of etiologic agents. The distribution of pathogens in all cases of bac- teremic infection2 and the fatal cases for each of the 12 selected years are shown in tables 11 and 12, respectively. The pneumococcus was the most frequent organism causing bacteremia at Boston City Hospital in 1935, accounting for nearly one-third of all cases and for > 40% of all deaths from bacteremic infection that year. After 1941 these proportions dropped to a low of 12.5% of cases and 9% of deaths in 1955 and sub- sequently remained within that range, except for an increase in the proportion of cases with a lower percentage of deaths in the last year of the study. /-Hemolytic streptococci other than en- terococci accounted for more than one-sixth of all bacteremic cases and one-fifth of all deaths among these cases in 1935. This proportion dropped precipitously after the introduction of sulfonamides and then more gradually until 1955, when 1% of all bacteremic cases and no deaths were due to p-hemolytic streptococci. Since that year the proportion of such cases has been rising until, in 1972, they accounted for about 6% of all cases and deaths. The proportion of cases caused by viridans streptococci dropped from nearly 14% in 1935 to a low of about 6% of all cases in 1953. Deaths due to these organisms accounted for nearly 11% of all bacteremic deaths in 1935 and 1941; this proportion dropped to a low of 3% in 1951. After this time the proportion of both cases and deaths associated with Streptococcus viridans bac- teremia stabilized at or about these low levels. There were no bacteremic enterococcal infec- tions in 1935, but a small proportion of cases was due to these organisms in 1941; the proportion increased to a peak of nearly 7% of cases and 5.4% of deaths in 1951 and fluctuated at or below this level in subsequent years. Bacteremia due to S. aureus showed the most striking changes. Beginning with more than one-fifth of all bacteremic cases and one-sixth of all the deaths due to bacteremic staphylococcal infections in 1935, the proportions increased to nearly 36% of all cases and deaths in 1957 and then dropped steadily to a low of about one- eighth of all cases and deaths in 1972. The high proportion of cases and of deaths in 1941 was associated with a high incidence of staphylococ- cal infections complicating influenza A, which occurred in epidemic form in that year [8]. E. coli was responsible for about 9% of all bacteremic cases and about 5% of all deaths in 1935. The proportion of cases increased some- what, ranging from about 10% to 14% during the other years of the study. E. coli accounted for 10.2%-15.4% of all the deaths in each of the 11 subsequent years. Klebsiella-Enterobacter were not encountered or were not recognized as pathogens in 1935 and 1941 (except for the occasional cases of Friedliinder's pneumonia with bacteremia, as al- ready noted), but for about 8% of all cases until 1969; in that year the proportion increased to 14.3%, and it was 13.3% in 1972. Fatal cases due to these or- ganisms accounted for 9%-14% of all fatal bac- teremic infections each year but increased to 17% and 17.5% in 1969 and 1972, respectively.
Proteus (all species) accounted for a small percentage of all cases and deaths in 1935 and 1941, but this proportion increased to between 9% and 12% of cases between 1947 and 1955, dropping irregularly to about 4% in most of the ensuing years. Proteus accounted for 10%-13% of deaths between 1947 and 1957 and for a smaller proportion in most of the subsequent years. P. aeruginosa bacteremia was rare in 1935 but increased in incidence to about 3% of all bac- teremic cases in 1951; the proportion remained at or around that level until 1961 and was somewhat higher in most of the years after that. The pro- portion of fatal cases attributed to Pseudomonas followed the same pattern except at a somewhat higher level, associated with the high fatality rate of these infections (table 10). Candidemia either was not occurring or was ignored prior to 1953; it constituted only a small proportion of blood- invasive infections until 1969 and 1972, when about 4% of all cases and about 5% and 8% of all deaths were associated with candidemia. The "other pathogens" included the less common aerobic infections such as Salmonella, Haemophilus influenzae, Neisseria, Providencia, atypical pseudomonads, Mimeae, Serratia, Listeria, and others. The occurrence of systemic salmonellosis during the same 12 selected years at this hospital was documented recently [9], as were some aspects of infections with H. influen- zae [10], Serratia [11], and Mimeae [12]. The proportion of all "other" bacteremic infections fluctuated over a wide range and was associated in some years with the endemic appearance of certain uncommon pathogens. Table 13 shows the occurrence of bacteremia due to three species of gram-negative bacilli during each of the last five years of the study.
At Boston City Hospital a number of special factors reduced these hazards and rendered the data somewhat more comparable. During the period 1964-1973, which is considered in this paper, there has been a fairly steady decrease in the number of patients admitted to the hospital each year; but this is reflected in the number of patients included in each of the four surveys that were compared. Despite this, there has been little change in the structure of the services or the admission policies of the hospital throughout the period. A standardized protocol, with the same definitions and procedures, was used each time, and each of the surveys was conducted at about the same time of the year. During the period un- der consideration, basic techniques and proce- dures utilized in the processing of clinical bac- teriologic specimens have remained relatively constant. Thus, the bacteriologic data in each of the surveys done at this hospital are fairly com- parable. On the other hand, it may be difficult to compare distribution of organisms associated with infection at this hospital with similar data from other centers, where new and different techniques, such as those for recovery of anaerobic organ- isms, have been applied. The value of prevalence surveys in any one hospital may be enhanced if done at regular inter- vals (e.g., every one to three months) and each time infections with new organisms or in unusual numbers occur at that hospital. The present survey suggests that there have not been any great changes either in the prevalence of community-acquired infections or in the bac- terial pathogens associated with them since 1967. Likewise, the overall prevalence of hospital- acquired infection in the major categories has shown no grossly discernible trends. However, the data do suggest that gram-negative bacilli have been playing an increasingly prominent role in nosocomial infections of the lower respiratory tract and that group D streptococci continue to be isolated frequently from hospital-acquired in- fections of the urinary tract. E. coli was recovered less frequently from nosocomial infections, and P. aeruginosa, which had become more prevalent in the hospital-acquired infections in 1970, was recovered less frequently in the 1973 survey
McGowan, Barnes & Finland, Bacteremia at Boston City Hospital: Occurrence and Mortality during 12 Selected Years (1935-1972), with Special Reference to Hospital-Acquired Cases, The Journal of Infectious Diseases , Sep., 1975, Vol. 132, No. 3 (Sep., 1975), pp. 316-335
Infection and Antibiotic Usage at Boston City Hospital: Changes in Prevalence during the Decade 1964-1973,Author(s): John E. McGowan Jr. and Maxwell Finland, The Journal of Infectious Diseases, Vol. 129, No. 4 (Apr., 1974), pp. 421-428, Oxford University Press
Proteus (all species) accounted for a small percentage of all cases and deaths in 1935 and 1941, but this proportion increased to between 9% and 12% of cases between 1947 and 1955, dropping irregularly to about 4% in most of the ensuing years. Proteus accounted for 10%-13% of deaths between 1947 and 1957 and for a smaller proportion in most of the subsequent years. P. aeruginosa bacteremia was rare in 1935 but increased in incidence to about 3% of all bac- teremic cases in 1951; the proportion remained at or around that level until 1961 and was somewhat higher in most of the years after that. The pro- portion of fatal cases attributed to Pseudomonas followed the same pattern except at a somewhat higher level, associated with the high fatality rate of these infections (table 10). Candidemia either was not occurring or was ignored prior to 1953; it constituted only a small proportion of blood- invasive infections until 1969 and 1972, when about 4% of all cases and about 5% and 8% of all deaths were associated with candidemia. The "other pathogens" included the less common aerobic infections such as Salmonella, Haemophilus influenzae, Neisseria, Providencia, atypical pseudomonads, Mimeae, Serratia, Listeria, and others. The occurrence of systemic salmonellosis during the same 12 selected years at this hospital was documented recently [9], as were some aspects of infections with H. influen- zae [10], Serratia [11], and Mimeae [12]. The proportion of all "other" bacteremic infections fluctuated over a wide range and was associated in some years with the endemic appearance of certain uncommon pathogens. Table 13 shows the occurrence of bacteremia due to three species of gram-negative bacilli during each of the last five years of the study.
At Boston City Hospital a number of special factors reduced these hazards and rendered the data somewhat more comparable. During the period 1964-1973, which is considered in this paper, there has been a fairly steady decrease in the number of patients admitted to the hospital each year; but this is reflected in the number of patients included in each of the four surveys that were compared. Despite this, there has been little change in the structure of the services or the admission policies of the hospital throughout the period. A standardized protocol, with the same definitions and procedures, was used each time, and each of the surveys was conducted at about the same time of the year. During the period un- der consideration, basic techniques and proce- dures utilized in the processing of clinical bac- teriologic specimens have remained relatively constant. Thus, the bacteriologic data in each of the surveys done at this hospital are fairly com- parable. On the other hand, it may be difficult to compare distribution of organisms associated with infection at this hospital with similar data from other centers, where new and different techniques, such as those for recovery of anaerobic organ- isms, have been applied. The value of prevalence surveys in any one hospital may be enhanced if done at regular inter- vals (e.g., every one to three months) and each time infections with new organisms or in unusual numbers occur at that hospital. The present survey suggests that there have not been any great changes either in the prevalence of community-acquired infections or in the bac- terial pathogens associated with them since 1967. Likewise, the overall prevalence of hospital- acquired infection in the major categories has shown no grossly discernible trends. However, the data do suggest that gram-negative bacilli have been playing an increasingly prominent role in nosocomial infections of the lower respiratory tract and that group D streptococci continue to be isolated frequently from hospital-acquired in- fections of the urinary tract. E. coli was recovered less frequently from nosocomial infections, and P. aeruginosa, which had become more prevalent in the hospital-acquired infections in 1970, was recovered less frequently in the 1973 survey
McGowan, Barnes & Finland, Bacteremia at Boston City Hospital: Occurrence and Mortality during 12 Selected Years (1935-1972), with Special Reference to Hospital-Acquired Cases, The Journal of Infectious Diseases , Sep., 1975, Vol. 132, No. 3 (Sep., 1975), pp. 316-335
Infection and Antibiotic Usage at Boston City Hospital: Changes in Prevalence during the Decade 1964-1973,Author(s): John E. McGowan Jr. and Maxwell Finland, The Journal of Infectious Diseases, Vol. 129, No. 4 (Apr., 1974), pp. 421-428, Oxford University Press
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Of the 645 patients seen in the hospital at the time of this bed-to-bed survey, 142 (22.0%) were considered to have a community-acquired infection, and 97 (15.0%) were noted to have a hospital-acquired infection. The former were more frequent in medical patients, and the latter more prevalent among surgical patients (table 1). Ten patients had both a nosocomial and a com- munity-acquired infection.
Nosocomial infections. A total of 101 hospital-acquired infections were noted in 97 patients; of the 101 infections, one was considered to be nonbacterial, and bacteriologic data were unavailable for seven. Of the remaining 93 infections, pathogenic bacteria were recovered in pure culture from 54 and in mixed culture from 39. Klebsiella-Enterobacter and S. aureus predominated among organisms recovered from cultures of nosocomial lower respiratory tract infections; Klebsiella-Enterobacter, Proteus, and group D streptococci were most frequent among the nosocomial urinary tract infections, and S. aureus
Infection and Antibiotic Usage at Boston City Hospital: Changes in Prevalence during the Decade 1964-1973,Author(s): John E. McGowan Jr. and Maxwell Finland, The Journal of Infectious Diseases, Vol. 129, No. 4 (Apr., 1974), pp. 421-428, Oxford University Press
Amalie M. Kass, Infectious Diseases at the Boston City Hospital: The First 60 Years, Clinical Infectious Diseases , Aug., 1993, Vol. 17, No. 2 (Aug., 1993), pp. 276-282, Published by: Oxford University Press
Nosocomial infections. A total of 101 hospital-acquired infections were noted in 97 patients; of the 101 infections, one was considered to be nonbacterial, and bacteriologic data were unavailable for seven. Of the remaining 93 infections, pathogenic bacteria were recovered in pure culture from 54 and in mixed culture from 39. Klebsiella-Enterobacter and S. aureus predominated among organisms recovered from cultures of nosocomial lower respiratory tract infections; Klebsiella-Enterobacter, Proteus, and group D streptococci were most frequent among the nosocomial urinary tract infections, and S. aureus
Infection and Antibiotic Usage at Boston City Hospital: Changes in Prevalence during the Decade 1964-1973,Author(s): John E. McGowan Jr. and Maxwell Finland, The Journal of Infectious Diseases, Vol. 129, No. 4 (Apr., 1974), pp. 421-428, Oxford University Press
Amalie M. Kass, Infectious Diseases at the Boston City Hospital: The First 60 Years, Clinical Infectious Diseases , Aug., 1993, Vol. 17, No. 2 (Aug., 1993), pp. 276-282, Published by: Oxford University Press
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Data are presented on the occurrence of and mortality rate from acute bacterial meningitis at Boston City Hospital during 12 years between 1935 and 1972 selected in relation to the introduction of potent antibacterial agents. The most frequent causative organisms were Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae, but large proportions were caused by other gram-positive cocci and gram-negative bacilli. The greatest reduction in mortality rate after anti- biotics became widely used was in patients with meningococcal and influenzal men- ingitis who were A 19 years old. Less striking reductions occurred in cases of other etiologies in patients a 59 years old, but in those - 60 years old, the mortality rate remained high, and the proportion of cases of meningitis in that age group more than doubled. Comparisons with similar data on all bacteremic infections
The occurrence and mortality of cases of bac- teremic infections due to clinically important pathogens at Boston City Hospital (Boston, Mass.) during 12 selected years between 1935 and 1972 were reported recently [1]. Striking changes occurred in the incidence of all bacteremic infec- tions and in the relative incidence of those due to some specific bacterial pathogens over the nearly four decades of that study. During that pe- riod numerous antibacterial drugs that are high- ly active therapeutically against narrow, broad, and medium spectrums of bacterial infections were introduced and became extensively used in hospitals, and most of them also were used by phy- sicians outside of hospitals. A similar study of the occurrence, mortality, and some other important features of bacteriologically authenticated cases of acute pyogenic meningitis at the same hospital during the same 12 selected years is reported in this paper
A comparison of the changes in the occurrence, etiology, and mortality in patients with acute bac- terial meningitis, as reported here, with corres- ponding changes in all cases of bacteremic infec- tions that occurred in the same hospital during the same selected years, 1935-1972 [1], shows many similarities but also a number of differ- ences. Most striking were the differences in the number of patients and the rate per 1,000 ad- missions to the Boston City Hospital. The cases of bacteremic infections increased steadily dur- ing the first 10 selected years and declined dur- ing the last two. The number and rates for cases of meningitis increased during the first three years, stabilized at a lower level over the next sev- en years, and then declined during the last two years. Figure 1 shows the rates for bacteremia and meningitis for the 12 years. (A logarithmic scale was used for rates to exaggerate [relatively] the low rates of meningitis and dampen those of bac- teremia.) The CFR among all of the bacteremic patients decreased from 58% in 1935 to 31% in 1947, in- creased gradually to > 40% over the next four selected years, and then remained at about that level until 1972, when it dropped again to 31%. The mortality rate from bacterial meningitis dropped from 85% to 24% between 1935 and 1957, rose over the next three selected years to 59%, and declined to 39% in the last two years. For the 12 selected years the mortality rate in the 7,440 bacteremic patients was 37.6%, and it was 49.5% in the 572 cases of meningitis. S. pneumoniae was the most frequent organ- ism in bacteremic infections in 1935, accounting for nearly one-third of the cases and 42% of the deaths from bacteremic infections in that year; it
The most striking change that occurred among cases of bacteremic infection over the 12 selected years was the markedly increased occurrence of cases due to gram-negative bacilli other than E. coli. There were very few such cases during the first two years, whereas in subsequent years there were varying numbers due to Klebsiella, Entero- bacter, Proteus, and Pseudomonas, and during the last four years there were also many cases due to Mima (Acinetobacter), Herellea (Acine- tobacter), and Serratia. Gram-negative bacilli in- cluding E. coli caused one-third or more of the bacteremic cases in each of the last 10 years, and the average mortality rate was 44%. On the other hand, there were relatively few cases of meningi- tis due to gram-negative bacilli other than E. coli- a total of 65 cases in the 12 years with a mortality of 65%. It is of interest that the number and pro- portions of these cases increased steadily during the last four selected years from 17% of all cases in 1963 to 37% in 1972. A similar, although less striking, increase occurred among all cases of bacteremic infection over the same years [1]. Only rarely was there any difficulty in differen- tiating H-A from C-A infection among either the bacteremias or the cases of meningitis. Prior ther- apy in the hospital but not therapy prior to ad- mission presented a problem in diagnosis in an occasional H-A case. In 1935, 48% of the bacteremias in patients on medical wards and 57% of those in patients on surgical services were H-A. In subsequent years, this proportion among bacteremic patients on medical services was much lower, generally rang- ing between 20% and 30%, whereas this propor- tion among surgical patients with bacteremia re- mained as high or higher (between 60% and 80%) in most of the years. The CFR for all 12 years com- bined was 32.9% for C-A cases of bacteremia and 46.7% for H-A cases (P < 0.0001). Of all cases of bacterial meningitis, 23% were H-A. The proportion of cases that were H-A was somewhat larger (28%) during the first two years, smaller (12%-19%) during the 1950s, and be- tween 22% and 36% in subsequent years. Most H-A cases followed head injuries or neurosurgical and otorhinological operations, and some were in newborns. Less than 5% of the cases of meningi- tis due to S. pneumoniae, N. meningitidis, and H. influenzae were H-A; in contrast, 59% of all other cases were H-A. The CFR in H-A cases of meningitis due to S. pneumoniae, N. meningi- tidis, and H. influenzae combined was 72% as compared to 41% among the corresponding C-A cases. Among the cases of meningitis due to other organisms, the CFR was about the same in H-A and C-A cases. Superinfection of the meninges with species of bacteria not grown in the original diagnostic cul- ture of CSF was demonstrated in 35 patients. The original meningitis was C-A in 17 and
18 of these patients. Among the C-A cases, S. pneumoniae was the original infecting organism in IO,H. influenzae in two, and N. meningitidis in one, whereas among the H-A cases the original infecting organism was S. pneumoniae in two and H.
influenzae in one, and none was caused by N. meningitidis. The original infecting organism (s) in the other cases and all of the superinfecting organisms were either gram-positive cocci other than S. pneumoniae or gram-negative bacilli. The mortality rate in the 35 patients with superinfections was 80%; that in the 81 H-A cases of meningitis caused by other gram-positive cocci and
gram-negative bacilli without superinfections was 54% (x 2 = 5.8; P < 0.05). Pathogenic bacteria other than those grown
from CSF were cultured from sites other than the nervous system in a large proportion of the cases of meningitis, and many of these organisms were associated with infections of those sites and some also with bacteremia. Some of those other infections anteceded the meningitis, but most of them were superinfections, involving particularly the respiratory and urinary tracts. None of these infections have been considered here, although some of them may have been the cause or a contributing factor in the fatal outcome of those cases.
The data presented here are from a single large municipal hospital and cover essentially the entire antibacterial era. Among cases of both bacteremic infections and bacterial meningitis, the number of cases and rates per 1,000 hospital admissions each year, the distribution of etiologic agents, the proportions that are H-A and C-A, and the CFRs vary considerably in different hos-pitals and at different times and even vary in the same hospital. No attempt will be made to compare the findings at Boston City Hospital with
those in other institutions. Hodges and Perkins [12] recently presented data on acute bacterial meningitis from their hospital for the years 1948-1973 and compared them with those reported from five other widely scattered hospitals, each covering six to IO years at different times between 1948 and 1970. These data illustrated the wide variations in the distribution of different organisms
and mortality rates. Among their own cases, 42% and, in other studies cited, 9%-21 % are listed as of unknown etiology. No such cases are included in our study.
Maxwell Finland and Mildred W. Barnes, Acute Bacterial Meningitis at Boston City Hospital during 12 Selected Years, 1935-1972, The Journal of Infectious Diseases, Vol. 136, No. 3 (Sep., 1977), pp. 400-415, Oxford University Press
The occurrence and mortality of cases of bac- teremic infections due to clinically important pathogens at Boston City Hospital (Boston, Mass.) during 12 selected years between 1935 and 1972 were reported recently [1]. Striking changes occurred in the incidence of all bacteremic infec- tions and in the relative incidence of those due to some specific bacterial pathogens over the nearly four decades of that study. During that pe- riod numerous antibacterial drugs that are high- ly active therapeutically against narrow, broad, and medium spectrums of bacterial infections were introduced and became extensively used in hospitals, and most of them also were used by phy- sicians outside of hospitals. A similar study of the occurrence, mortality, and some other important features of bacteriologically authenticated cases of acute pyogenic meningitis at the same hospital during the same 12 selected years is reported in this paper
A comparison of the changes in the occurrence, etiology, and mortality in patients with acute bac- terial meningitis, as reported here, with corres- ponding changes in all cases of bacteremic infec- tions that occurred in the same hospital during the same selected years, 1935-1972 [1], shows many similarities but also a number of differ- ences. Most striking were the differences in the number of patients and the rate per 1,000 ad- missions to the Boston City Hospital. The cases of bacteremic infections increased steadily dur- ing the first 10 selected years and declined dur- ing the last two. The number and rates for cases of meningitis increased during the first three years, stabilized at a lower level over the next sev- en years, and then declined during the last two years. Figure 1 shows the rates for bacteremia and meningitis for the 12 years. (A logarithmic scale was used for rates to exaggerate [relatively] the low rates of meningitis and dampen those of bac- teremia.) The CFR among all of the bacteremic patients decreased from 58% in 1935 to 31% in 1947, in- creased gradually to > 40% over the next four selected years, and then remained at about that level until 1972, when it dropped again to 31%. The mortality rate from bacterial meningitis dropped from 85% to 24% between 1935 and 1957, rose over the next three selected years to 59%, and declined to 39% in the last two years. For the 12 selected years the mortality rate in the 7,440 bacteremic patients was 37.6%, and it was 49.5% in the 572 cases of meningitis. S. pneumoniae was the most frequent organ- ism in bacteremic infections in 1935, accounting for nearly one-third of the cases and 42% of the deaths from bacteremic infections in that year; it
The most striking change that occurred among cases of bacteremic infection over the 12 selected years was the markedly increased occurrence of cases due to gram-negative bacilli other than E. coli. There were very few such cases during the first two years, whereas in subsequent years there were varying numbers due to Klebsiella, Entero- bacter, Proteus, and Pseudomonas, and during the last four years there were also many cases due to Mima (Acinetobacter), Herellea (Acine- tobacter), and Serratia. Gram-negative bacilli in- cluding E. coli caused one-third or more of the bacteremic cases in each of the last 10 years, and the average mortality rate was 44%. On the other hand, there were relatively few cases of meningi- tis due to gram-negative bacilli other than E. coli- a total of 65 cases in the 12 years with a mortality of 65%. It is of interest that the number and pro- portions of these cases increased steadily during the last four selected years from 17% of all cases in 1963 to 37% in 1972. A similar, although less striking, increase occurred among all cases of bacteremic infection over the same years [1]. Only rarely was there any difficulty in differen- tiating H-A from C-A infection among either the bacteremias or the cases of meningitis. Prior ther- apy in the hospital but not therapy prior to ad- mission presented a problem in diagnosis in an occasional H-A case. In 1935, 48% of the bacteremias in patients on medical wards and 57% of those in patients on surgical services were H-A. In subsequent years, this proportion among bacteremic patients on medical services was much lower, generally rang- ing between 20% and 30%, whereas this propor- tion among surgical patients with bacteremia re- mained as high or higher (between 60% and 80%) in most of the years. The CFR for all 12 years com- bined was 32.9% for C-A cases of bacteremia and 46.7% for H-A cases (P < 0.0001). Of all cases of bacterial meningitis, 23% were H-A. The proportion of cases that were H-A was somewhat larger (28%) during the first two years, smaller (12%-19%) during the 1950s, and be- tween 22% and 36% in subsequent years. Most H-A cases followed head injuries or neurosurgical and otorhinological operations, and some were in newborns. Less than 5% of the cases of meningi- tis due to S. pneumoniae, N. meningitidis, and H. influenzae were H-A; in contrast, 59% of all other cases were H-A. The CFR in H-A cases of meningitis due to S. pneumoniae, N. meningi- tidis, and H. influenzae combined was 72% as compared to 41% among the corresponding C-A cases. Among the cases of meningitis due to other organisms, the CFR was about the same in H-A and C-A cases. Superinfection of the meninges with species of bacteria not grown in the original diagnostic cul- ture of CSF was demonstrated in 35 patients. The original meningitis was C-A in 17 and
18 of these patients. Among the C-A cases, S. pneumoniae was the original infecting organism in IO,H. influenzae in two, and N. meningitidis in one, whereas among the H-A cases the original infecting organism was S. pneumoniae in two and H.
influenzae in one, and none was caused by N. meningitidis. The original infecting organism (s) in the other cases and all of the superinfecting organisms were either gram-positive cocci other than S. pneumoniae or gram-negative bacilli. The mortality rate in the 35 patients with superinfections was 80%; that in the 81 H-A cases of meningitis caused by other gram-positive cocci and
gram-negative bacilli without superinfections was 54% (x 2 = 5.8; P < 0.05). Pathogenic bacteria other than those grown
from CSF were cultured from sites other than the nervous system in a large proportion of the cases of meningitis, and many of these organisms were associated with infections of those sites and some also with bacteremia. Some of those other infections anteceded the meningitis, but most of them were superinfections, involving particularly the respiratory and urinary tracts. None of these infections have been considered here, although some of them may have been the cause or a contributing factor in the fatal outcome of those cases.
The data presented here are from a single large municipal hospital and cover essentially the entire antibacterial era. Among cases of both bacteremic infections and bacterial meningitis, the number of cases and rates per 1,000 hospital admissions each year, the distribution of etiologic agents, the proportions that are H-A and C-A, and the CFRs vary considerably in different hos-pitals and at different times and even vary in the same hospital. No attempt will be made to compare the findings at Boston City Hospital with
those in other institutions. Hodges and Perkins [12] recently presented data on acute bacterial meningitis from their hospital for the years 1948-1973 and compared them with those reported from five other widely scattered hospitals, each covering six to IO years at different times between 1948 and 1970. These data illustrated the wide variations in the distribution of different organisms
and mortality rates. Among their own cases, 42% and, in other studies cited, 9%-21 % are listed as of unknown etiology. No such cases are included in our study.
Maxwell Finland and Mildred W. Barnes, Acute Bacterial Meningitis at Boston City Hospital during 12 Selected Years, 1935-1972, The Journal of Infectious Diseases, Vol. 136, No. 3 (Sep., 1977), pp. 400-415, Oxford University Press
| finland-acutebacterialmeningitis-1977.pdf |
Resistance of gonococci to sulfonamides developed and spread after those agents became widely used [64, 65]. At Boston City Hospital, evidence of reversal to predominant sensitivity to sulfadiazine was obtained from strains of gonococci isolated in 1953-1954, after penicillin had gained universal use for therapy of gonorrhea [66], and all but a small proportion of strains isolated and
tested there in 1973 were found to be susceptible to sulfamethoxazole [67] After the late 1950s, however, increases in the
range and mode of MICs of penicillin for clinical strains of N. gonorrhoeae isolated Subsequent observations at the Center for Disease Control (Atlanta, Ga.) documented shifts in the prevalence of serotypes to a predominance of sulfadiazine-resistant group C strains and the appearance of substantial numbers of group Y strains, many of which were also sulfonamide-resistant. From 1972 to 1974 the proportion of sulfonamide- resistant strains of all types declined considerably; the proportion of resistant serogroup C strains declined from 82% to 69% [72]. There is still reluctance to recommend use of sulfonamide for prophylaxis for close contacts of patients with serious meningococcal infections [73]. More recently, a sulfonamide was successfully used for community-wide prophylaxis during an outbreak of serogroup B meningococcal disease [74].
Among the most significant and striking events associated with the availability and extensive use of the succession of highly active antibacterial agents were the changes in the relative frequency of occurrence of some of the common pathogenic bacteria as causes of serious disease. In the study of bacteremic infections carried out at Boston City Hospital during 12 selected years between 1935 and 1972 [53], the following changes were noted. (1) The proportion of all bacteremic infections that were due to pneumococci dropped from 32.5% in 1935 to 12.5% in 1955 and subsequently ranged between 13% and 15%, (2) Hemolytic streptococcal bacteremia other than that due to group D organisms accounted for I 7 ,2% of all cases of bacteremia in 1935; the proportion dropped sharply after the sulfonamides came into use and then further when penicillin became available-to 0,7% by 1955. However, the proportion of these infections rose in later years to between 4% and 7%, (3) S. aureus accounted for 21 % of bacteremic infections in I 935. This proportion increased to 36% by 1957 and then declined steadily to a low of 12% in I 972. (4) Most striking were the emergence and increasing occurrence of cases of bacteremia due to "enterobacteria," including enterococci, which increased from zero to 4%-7% after 1947, andof those due to gram-negative rods, the four most common groups of which (E. coli, Proteus species, Klebsiella-Enterobacter, and Pseudomonas aeruginosa) increased progressively from 12% (mostly E. coli) in 1935 to about 40% in 1969. Cases of bacteremia due to Klebsiella-Enterobacter and Pseudomonas were much more frequent among cases of hospital-acquired bacteremia than among those that were community• acquired. (5) Other "opportunistic pathogens" occurred in considerable numbers in the 1960s. For example, there were 58 cases of bacteremia due to Herellea vaginicola with 15 deaths in
1965, 27 cases due to M ima polymorpha with six deaths in the same year, 20 cases (five of them fatal) due to Serratia marcescens in 1972, and 30 cases of candidemia with 17 deaths, also in 1972. (6) Most of the changes in proportions of the common pathogens noted in all cases of bacteremic infections were found to be similar qualitatively but not always quantitatively to those in cases of acute bacterial meningitis [83] and acute purulent empyema [84] at Boston City Hospital during the same 12 selected years.
Similar changes in prevalence of various pathogens were reported for sepsis of the newborn at Yale-New Haven Hospital (New Haven, Conn.) over about the same years [85]. These changes in occurrence of the various pathogens were also associated with emergence and increased occurrence of multiple antibioticresistant strains of the newly emerging organisms
Like E. coli, the strains of Klebsiella pneumoniae and Enterobacter (Aerobacter) collected before 1950 showed broad ranges of MICs of penicillin, streptomycin, chlortetracycline, and chloramphenicol, and all were resistant to bacitracin; the strains of Enterobacter were uniformly sensitive to the polymyxins. The MICs of some Klebsiella varied over a wide range [4]. Also, as with E. coli, streptomycin resistance was shown to develop rapidly in Klebsiella and Enterobacter by exposures to the antibiotic in vitro or during
treatment of both pulmonary [91] and urinary tract [86] infections. Resistance of these organisms was prevented by alkalinization of urine during therapy [87] Larger proportions of strains of Klebsiella from hospital-acquired than from community-acquired infections were resistant to almost all antibiotics tested [90].
Strains isolated at Boston City Hospital 111 197 l-1972 were tested with 65 antibiotics [35, 36]. From 40% to 80% of these strains were highly resistant to IO aminoglycosides, including gentamicin, tobramycin, and sisomicin, but all were susceptible to amikacin. All were moderately or totally resistant to each of the seven tetracycline analogues, to polymyxin and colistin, as well as to chloramphenicol, spectinomycin, and sulfamethoxazole. However, all of the strains were highly susceptible to trimethoprim alone or combined in a I: 16 ratio with sulfamethoxazole [67]. Cefamandole and cefoxitin inhibited nearly all strains in concentrations of ""'= 25 μ,g/ ml, but these strains were all moderately or highly resistant to nine other cephalosporins and to 11 penicillins other than penicillinase-resistant ones, which were not used in these tests. Rifampin inhibited nearly all strains with 25-50 μ,g/ ml, and erythromycin was about one-fourth as
Geographic Differences in Resistance The marked differences in the prevalence of methicillin-resistant S. aureus in different countries were already mentioned. Recently, O'Brien and several collaborators [108] compared the prevalence of resistance to the most commonly used antibiotics of the most frequently encountered pathogenic species of bacteria among clinical isolates from a general hospital in Paris and one in Boston. The average percentage of isolates resistant to individual antibiotics was three times greater and the percentage of isolates resistant to six or more antibiotics was 14 times greater among isolates in the Parisian hospital than among those in the Boston hospital. The differences were nearly as great among strains isolated from patients during the first three days in the two hospitals, a finding that suggests differences in the bacterial flora in the communities. The authors noted that the percentage resistant to any of the antibiotics was reported to be remarkably similar among other hospitals in the United States. Different patterns of antibiotic usage in the two areas may underlie these differences in resistance. Thus, the dominant feature in the emergence and spread of resistant enterobacteria, as was shown for S. aureus, appears to be the widespread use of antibiotics, particularly in the individuals from whom the antibiotic-resistant bacteria are isolated.
Maxwell Finland, Antibiotic Resistance in Hospitals, 1935-1975 [with Discussion], Reviews of Infectious Diseases , Jan. - Feb., 1979, Vol. 1, No. 1, Cefoxitin: Biochemical, Pharmacologic, Microbiologic and Clinical Properties (Jan. - Feb., 1979), pp. 4-22
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The discipline of pathology in Boston has a rich history, extending from the early 19th century through the present day.1 Up to ~ 1950, the story can be divided roughly into three eras. The first begins with the founding in 1811 of the first full hospital in Boston, Massachusetts General Hospital (MGH), and features physicians and surgeons who practiced elements of pathology part-time; these included members of the Warren family as well as notables such as John Barnard Swett Jackson, the first professor of pathology in the United States, and Reginald Heber Fitz, the first person to have the title of ‘pathologist’ in Boston.2 The second era starts in 1892, when William T Councilman was recruited to Harvard Medical School (HMS) from Johns Hopkins University; Councilman in turn recommended the appointments of Frank Burr Mallory at the Boston City Hospital (BCH) and James Homer Wright at the MGH—two pioneering full-time pathologists who, along with Councilman, set the stage for the further development of pathology in the city. The last part begins in the earlier decades of the 20th century and tells the story of Councilman and Mallory’s trainees, including S Burt Wolbach, who went on both to found and inspire the pathology departments of the many hospitals that had grown in Boston over the first half of the twentieth century Mallory held the position of Chief of Pathology at Boston City from 1908 to his retirement in 1932, and he continued on the staff as a Consultant until his death in 1941. He was promoted to Associate Professor at HMS in 1901. He resigned his Harvard appointment in 1919 as a result of a dispute with the University but they were later reconciled and Mallory was then appointed Professor in 1928 and Professor Emeritus on reaching retirement age in 1932. Wright published numerous studies of infectious disorders related to bacteria, spirochetes, fungi, and parasites. Notable among these was a study of Actinomycosis,41 which led to an invitation to contribute on the subject in the first edition of Osler’s Modern Medicine published in 1907
The turn of the last century witnessed the emergence of many hospitals in Boston, as in other cities around the United States and the world. Some of these were specialized from the start (eg, Children’s Hospital, Massachusetts Eye and Ear Infirmary, Boston Psychopathic Hospital), whereas others grew as general hospitals to serve particular groups (Boston/ New England Baptist Hospital, Beth Israel Hospital). As the importance of diagnostic laboratory testing grew, so did the need for each hospital to have a dedicated pathologist. The story of pathology in Boston in the first half of the twentieth century is thus one of a dispersion of budding young pathologists trained at places like BCH, Peter Bent Brigham Hospital and MGH who moved to these newer hospitals and established illustrious new departments... At the BCH, itself, Frederic ‘Ted’ Parker, Jr (1890–1969) (Figure 14), who had trained with FB Mallory, followed Mallory as the chief of Pathology, serving in that role from 1932 until 1951. He was a superb diagnostician (with Mallory claiming that Parker was a better diagnostic pathologist than he Despite having a good sense of humor, he reportedly had an unusual personality, often not leaving his office. It was said that, ‘He was extremely clever in spite of his neurosis and phobia of most people. He wouldn’t let them in his office, while he sitting at his microscope... full of self-doubts, he’d go away for a few weeks and come back and lock himself up and test himself on slides to make sure he was all right.’45 Nonetheless, he had a powerful influence on patient care and on training. Following Parker as head of Pathology at the BCH (from 1951 to 1966) was the younger of FB Mallory’s two sons who became pathologists, G Kenneth Mallory (1900–1986) (Figure 8b), who is perhaps best remembered as the ‘Mallory’ of Mallory–Weiss tears in the esophagus.46 Both Boston University and Tufts medical schools established clinical and academic affiliations with BCH and the Mallory Institute in 1932. GK Mallory was appointed Professor of Pathology on the Boston University service and in 1946 succeeded Parker (who was a Professor at HMS) as Director of the Mallory Institute. All subsequent directors of the Institute had Boston University academic appointments and served as chairs of Pathology at Boston University School of Medicine. (In 1973, the Harvard and Tufts affiliations with BCH came to an end). A number of individuals who trained at the BCH went on to illustrious careers at the MGH. One was Tracy Burr Mallory (1896–1951) (Figure 8a), who trained with his father (FB Mallory) and the famous microbiologist at Harvard, Hans Zinsser. Tracy Mallory was the chief of Pathology at the MGH from 1926 to 1951. In this role, he started the MGH pathology residency training program and became the editor of the Clinico-Pathological Conferences ofthe MGH published in the New England Journal of Medicine, serving in that role from 1935 to 1951. During World War II, Mallory was the Chief Pathologist for Mediterranean theater and he published a number of important papers on the pathology of war injuries and their sequelae.
The flowering of pathology as a medical discipline in Boston, 1892-c.1950: W.T. Councilman, FB Mallory, JH Wright, SB Wolbach and their descendants, Modern Pathology (2016) 29, 944–961
Department of Pathology, 1893; Concise Encyclopedia of Tufts History (2000).
Beginning in 1893 pathology was taught at the medical school through lectures and laboratories. Henry W. Dudley was named the first professor and chair of the department and served in that capacity until 1900. That year Dr. Timothy Leary was appointed chairman; he went on to serve for twenty-nine years. During this period he brought prestige to the department through the quality of his teaching and his development of a testing laboratory; this reputation in turn helped attract increased numbers of applicants and much-needed income. After Dr. Leary retired, interim leadership was provided by Drs. Tracy B. Mallory (1929-1930); Harold MacMahon (1930-1931); and Sidney C. Dalrymple (1931-1933). In 1933 Dr. MacMahon was appointed the first full-time chair and professor of pathology. He subsequently became responsible for teaching both pathology and bacteriology to medical and dental students and for organizing the development of the department. In order to raise funds for this purpose, he made arrangements to provide pathology services to many of the community hospitals in the greater Boston area in exchange for a fee. These funds were then deposited with the college for use by the department. Dr. MacMahon later became successful in recruiting additional faculty, which allowed him to focus on the teaching of pathology. He remained a devoted and highly respected teacher throughout his thirty-eight-year tenure.
https://dl.tufts.edu/teiviewer/parent/f1881x54h/chapter/D00029
During his years at Hopkins, Councilman worked closely with the leaders of this new institution, already perceived to be a model for American scientific medicine. The faculty included physician William Osler, surgeon William Halsted and a cadre of outstanding physicians and scientists, who were led by William H. Welch, Professor of Pathology and the Dean of the new medical school. When approached by Harvard President, Charles Eliot, Welch recommended Councilman for the Shattuck chair. Councilman had been active in research during his years in Baltimore. He identified the malaria parasite in red blood cells, confirming the earlier, but at the time disputed, work of Leveran. His name is eponymously associated with the characteristic apoptotic bodies that he described in the livers of patients with yellow fever (Councilman bodies). Another important contribution (with H.A. Lafleur) was an original and definitive description of amebic dysentery. Among his notable publications during his Boston career was a detailed study of cerebrospinal meningitis (with F.B. Mallory and J.H. Wright), a study of diphtheria (with F.B. Mallory) and an extensive treatise with G.B. Magrath and others on the pathology of smallpox. Councilman’s initial clinical appointment in Boston was Chief of Pathology at Boston City Hospital. He placed F.B. Mallory, who was already at HMS, as an assistant at the hospital. Over time Mallory played the larger role at the hospital and was appointed Chief in 1908. When the Peter Bent Brigham Hospital was opened in 1913 Councilman became its first Chief of Pathology. Shortly after coming to Boston he married Isabella Coolidge, a member of a prominent Boston family. He and his wife and family of three daughters lived at 78 Baystate Road in Boston.
1896 also marked the birth of his first son and the opening of the new Pathology laboratory at Boston City Hospital. This impressive building, 180 ft long by 42 ft wide, had two stories over the basement and an attached mortuary and chapel. The postmortem room, 32 ft by 20ft was placed within an auditorium extending through two floors and had seating for 70 observers, reflecting the centrality of performance of autopsies to the laboratory’s mission at the time. There was ample accommodation for bacteriological work and laboratory space designated for research, as well as space assigned for a clinical laboratory for use “by the medical and surgical interns.” That the trustees saw fit to make an investment on this scale reflected the new status of Pathology in Boston medicine. In a 1905 report on the department, Mallory notes that the (clinical) work of the laboratory consists of “the making of autopsies” (1,934 between 1897 and 1904), examination of surgical specimens (~900 per year), and bacteriological study of material from various sources including autopsies (e.g., up to 150 throat swabs for diphtheria each day).
A detailed insight into the work of a pathological department in this era can be gained from examination of the multiple editions of Pathological Technique, A Practical Manual for Workers in Pathological Histology and Bacteriology, written by F.B. Mallory and his friend at MGH, James Homer Wright. This manual has been characterized as the “bible” of laboratory methods of the period; it was first published in 1895 and revised in seven subsequent editions. The manual, with detailed descriptions of methodology and technology, encompassed the scope of the clinical mission of pathology departments of the time. It was organized into 3 main sections, I, Postmortem examinations, II, Bacteriological methods and III, Histological methods. Its first edition had 400 pages and 105 illustrations. Mallory held the position of Chief of Pathology at Boston City from 1908 to his retirement in 1932, and he continued on the staff as a Consultant until his death in 1941. He was promoted to Associate Professor at Harvard Medical School in 1901. He resigned his Harvard appointment in 1919 as a result of a dispute with the University but he was later reconciled and appointed Professor in 1928 and Professor Emeritus on reaching retirement age in 1932.
James Homer Wright was born on April 8, 1869 in Pittsburgh, Pennsylvania. He attended John Hopkins University, and graduated with honors in 1890. He subsequently attended the medical school of the University of Maryland and graduated in 1891, receiving the gold medal and the first prize in surgery. Following graduation he came to work at the pathologic laboratory of the Johns Hopkins Hospital and became known to its director, William H. Welch, and his associate William T. Councilman. The following year he took an appointment as a Thomas A. Scott fellow at the University of Pennsylvania, and under the direction of Dr. John Shaw Billings, where he conducted an investigation of the bacteriology of the water supply of Philadelphia that was published in 1893 in the Proceeding of the National Academy of Sciences. The potential of this young man was not lost on Councilman who recruited him as an assistant in Pathology at the Sears laboratory at Boston City Hospital in 1893.
Wright published numerous studies of infectious disorders related to bacteria, spirochetes, fungi, and parasites. Notable among these was a study of Actinomycosis, which led to an invitation to contribute on the subject in the first edition of Osler’s Modern Medicine published in 1907. Another important contribution was an early report on the demonstration of spirochetes with a Levaditi stain in a series of cases of aortitis, which was also hailed by Osler in a congratulatory letter to Wright as a definitive proof of the nature of syphilitic aortitis. As observed in an obituary written by Councilman, James Homer Wright “was not a social man, rarely going to medical meetings, but he formed many enduring friendships.” He received multiple awards: two major prizes for his research, the Gross Prize for his study of actinomycosis and the Boylston Prize of Harvard University for his platelet studies; as well honorary doctorates of science from University of Missouri, Harvard University and University of Maryland; and in 1915 he was elected to the American Academy of Arts and Sciences.
History of Pathology Society 2014-2015 Officers, January 2015, https://hps.wisc.edu/wp-content/uploads/sites/366/2018/01/Newsletter_HPS_2015_March.pdf
The turn of the last century witnessed the emergence of many hospitals in Boston, as in other cities around the United States and the world. Some of these were specialized from the start (eg, Children’s Hospital, Massachusetts Eye and Ear Infirmary, Boston Psychopathic Hospital), whereas others grew as general hospitals to serve particular groups (Boston/ New England Baptist Hospital, Beth Israel Hospital). As the importance of diagnostic laboratory testing grew, so did the need for each hospital to have a dedicated pathologist. The story of pathology in Boston in the first half of the twentieth century is thus one of a dispersion of budding young pathologists trained at places like BCH, Peter Bent Brigham Hospital and MGH who moved to these newer hospitals and established illustrious new departments... At the BCH, itself, Frederic ‘Ted’ Parker, Jr (1890–1969) (Figure 14), who had trained with FB Mallory, followed Mallory as the chief of Pathology, serving in that role from 1932 until 1951. He was a superb diagnostician (with Mallory claiming that Parker was a better diagnostic pathologist than he Despite having a good sense of humor, he reportedly had an unusual personality, often not leaving his office. It was said that, ‘He was extremely clever in spite of his neurosis and phobia of most people. He wouldn’t let them in his office, while he sitting at his microscope... full of self-doubts, he’d go away for a few weeks and come back and lock himself up and test himself on slides to make sure he was all right.’45 Nonetheless, he had a powerful influence on patient care and on training. Following Parker as head of Pathology at the BCH (from 1951 to 1966) was the younger of FB Mallory’s two sons who became pathologists, G Kenneth Mallory (1900–1986) (Figure 8b), who is perhaps best remembered as the ‘Mallory’ of Mallory–Weiss tears in the esophagus.46 Both Boston University and Tufts medical schools established clinical and academic affiliations with BCH and the Mallory Institute in 1932. GK Mallory was appointed Professor of Pathology on the Boston University service and in 1946 succeeded Parker (who was a Professor at HMS) as Director of the Mallory Institute. All subsequent directors of the Institute had Boston University academic appointments and served as chairs of Pathology at Boston University School of Medicine. (In 1973, the Harvard and Tufts affiliations with BCH came to an end). A number of individuals who trained at the BCH went on to illustrious careers at the MGH. One was Tracy Burr Mallory (1896–1951) (Figure 8a), who trained with his father (FB Mallory) and the famous microbiologist at Harvard, Hans Zinsser. Tracy Mallory was the chief of Pathology at the MGH from 1926 to 1951. In this role, he started the MGH pathology residency training program and became the editor of the Clinico-Pathological Conferences ofthe MGH published in the New England Journal of Medicine, serving in that role from 1935 to 1951. During World War II, Mallory was the Chief Pathologist for Mediterranean theater and he published a number of important papers on the pathology of war injuries and their sequelae.
The flowering of pathology as a medical discipline in Boston, 1892-c.1950: W.T. Councilman, FB Mallory, JH Wright, SB Wolbach and their descendants, Modern Pathology (2016) 29, 944–961
Department of Pathology, 1893; Concise Encyclopedia of Tufts History (2000).
Beginning in 1893 pathology was taught at the medical school through lectures and laboratories. Henry W. Dudley was named the first professor and chair of the department and served in that capacity until 1900. That year Dr. Timothy Leary was appointed chairman; he went on to serve for twenty-nine years. During this period he brought prestige to the department through the quality of his teaching and his development of a testing laboratory; this reputation in turn helped attract increased numbers of applicants and much-needed income. After Dr. Leary retired, interim leadership was provided by Drs. Tracy B. Mallory (1929-1930); Harold MacMahon (1930-1931); and Sidney C. Dalrymple (1931-1933). In 1933 Dr. MacMahon was appointed the first full-time chair and professor of pathology. He subsequently became responsible for teaching both pathology and bacteriology to medical and dental students and for organizing the development of the department. In order to raise funds for this purpose, he made arrangements to provide pathology services to many of the community hospitals in the greater Boston area in exchange for a fee. These funds were then deposited with the college for use by the department. Dr. MacMahon later became successful in recruiting additional faculty, which allowed him to focus on the teaching of pathology. He remained a devoted and highly respected teacher throughout his thirty-eight-year tenure.
https://dl.tufts.edu/teiviewer/parent/f1881x54h/chapter/D00029
During his years at Hopkins, Councilman worked closely with the leaders of this new institution, already perceived to be a model for American scientific medicine. The faculty included physician William Osler, surgeon William Halsted and a cadre of outstanding physicians and scientists, who were led by William H. Welch, Professor of Pathology and the Dean of the new medical school. When approached by Harvard President, Charles Eliot, Welch recommended Councilman for the Shattuck chair. Councilman had been active in research during his years in Baltimore. He identified the malaria parasite in red blood cells, confirming the earlier, but at the time disputed, work of Leveran. His name is eponymously associated with the characteristic apoptotic bodies that he described in the livers of patients with yellow fever (Councilman bodies). Another important contribution (with H.A. Lafleur) was an original and definitive description of amebic dysentery. Among his notable publications during his Boston career was a detailed study of cerebrospinal meningitis (with F.B. Mallory and J.H. Wright), a study of diphtheria (with F.B. Mallory) and an extensive treatise with G.B. Magrath and others on the pathology of smallpox. Councilman’s initial clinical appointment in Boston was Chief of Pathology at Boston City Hospital. He placed F.B. Mallory, who was already at HMS, as an assistant at the hospital. Over time Mallory played the larger role at the hospital and was appointed Chief in 1908. When the Peter Bent Brigham Hospital was opened in 1913 Councilman became its first Chief of Pathology. Shortly after coming to Boston he married Isabella Coolidge, a member of a prominent Boston family. He and his wife and family of three daughters lived at 78 Baystate Road in Boston.
1896 also marked the birth of his first son and the opening of the new Pathology laboratory at Boston City Hospital. This impressive building, 180 ft long by 42 ft wide, had two stories over the basement and an attached mortuary and chapel. The postmortem room, 32 ft by 20ft was placed within an auditorium extending through two floors and had seating for 70 observers, reflecting the centrality of performance of autopsies to the laboratory’s mission at the time. There was ample accommodation for bacteriological work and laboratory space designated for research, as well as space assigned for a clinical laboratory for use “by the medical and surgical interns.” That the trustees saw fit to make an investment on this scale reflected the new status of Pathology in Boston medicine. In a 1905 report on the department, Mallory notes that the (clinical) work of the laboratory consists of “the making of autopsies” (1,934 between 1897 and 1904), examination of surgical specimens (~900 per year), and bacteriological study of material from various sources including autopsies (e.g., up to 150 throat swabs for diphtheria each day).
A detailed insight into the work of a pathological department in this era can be gained from examination of the multiple editions of Pathological Technique, A Practical Manual for Workers in Pathological Histology and Bacteriology, written by F.B. Mallory and his friend at MGH, James Homer Wright. This manual has been characterized as the “bible” of laboratory methods of the period; it was first published in 1895 and revised in seven subsequent editions. The manual, with detailed descriptions of methodology and technology, encompassed the scope of the clinical mission of pathology departments of the time. It was organized into 3 main sections, I, Postmortem examinations, II, Bacteriological methods and III, Histological methods. Its first edition had 400 pages and 105 illustrations. Mallory held the position of Chief of Pathology at Boston City from 1908 to his retirement in 1932, and he continued on the staff as a Consultant until his death in 1941. He was promoted to Associate Professor at Harvard Medical School in 1901. He resigned his Harvard appointment in 1919 as a result of a dispute with the University but he was later reconciled and appointed Professor in 1928 and Professor Emeritus on reaching retirement age in 1932.
James Homer Wright was born on April 8, 1869 in Pittsburgh, Pennsylvania. He attended John Hopkins University, and graduated with honors in 1890. He subsequently attended the medical school of the University of Maryland and graduated in 1891, receiving the gold medal and the first prize in surgery. Following graduation he came to work at the pathologic laboratory of the Johns Hopkins Hospital and became known to its director, William H. Welch, and his associate William T. Councilman. The following year he took an appointment as a Thomas A. Scott fellow at the University of Pennsylvania, and under the direction of Dr. John Shaw Billings, where he conducted an investigation of the bacteriology of the water supply of Philadelphia that was published in 1893 in the Proceeding of the National Academy of Sciences. The potential of this young man was not lost on Councilman who recruited him as an assistant in Pathology at the Sears laboratory at Boston City Hospital in 1893.
Wright published numerous studies of infectious disorders related to bacteria, spirochetes, fungi, and parasites. Notable among these was a study of Actinomycosis, which led to an invitation to contribute on the subject in the first edition of Osler’s Modern Medicine published in 1907. Another important contribution was an early report on the demonstration of spirochetes with a Levaditi stain in a series of cases of aortitis, which was also hailed by Osler in a congratulatory letter to Wright as a definitive proof of the nature of syphilitic aortitis. As observed in an obituary written by Councilman, James Homer Wright “was not a social man, rarely going to medical meetings, but he formed many enduring friendships.” He received multiple awards: two major prizes for his research, the Gross Prize for his study of actinomycosis and the Boylston Prize of Harvard University for his platelet studies; as well honorary doctorates of science from University of Missouri, Harvard University and University of Maryland; and in 1915 he was elected to the American Academy of Arts and Sciences.
History of Pathology Society 2014-2015 Officers, January 2015, https://hps.wisc.edu/wp-content/uploads/sites/366/2018/01/Newsletter_HPS_2015_March.pdf
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April 14, 2005 (CIDRAP News) – Despite 4 months of investigation, the source of bacteria that caused tularemia in three laboratory workers at Boston University remains a mystery, the Boston Public Health Commission (BPHC) has reported.The investigation into the three cases has led to some new safety precautions for microbiology researchers in the Boston area, however, according to the report by M. Anita Barry, MD, MPH, director of communicable disease control for the BPHC.In the coming months, the BPHC will take a number of steps to bolster monitoring and reporting of infectious diseases acquired on the job, noted John Auerbach, BPHC executive director, in the forward to the report. Steps include mandatory training, close monitoring of Boston University's improvement efforts, and training for research laboratory personnel. Most of the changes affect microbiology lab researchers throughout the Boston area, not just at Boston University.The following account of the event and conclusions of investigators are taken from the 15-page report: While studying a relatively benign strain of Francisella tularensis last year, three lab workers at the university fell ill. Two got sick in May, the third in September. Their symptoms were consistent with tularemia, which can cause fever, chills, malaise, low back pain, and chest pain. F tularensis is also considered one of a handful of pathogens with potential to be used as a biological weapon.The illnesses weren't reported until Nov 10. Authorities immediately launched an investigation that included the BPHC, the state health department, the Centers for Disease Control and Prevention (CDC), and the FBI.The investigation yielded some information on how the workers came to be infected through working with an attenuated laboratory strain not previously linked with human infection: they may have also been exposed to a wild strain of F tularensis found in some samples of their laboratory strain obtained from the University of Nebraska.But how the virulent bacteria found its way into the attenuated samples remains a mystery. The report said, "Testing at CDC continues in the effort to determine the time and place of contamination of the original vial. CDC is currently focusing its investigation on potential sources of the Type A tularemia outside Boston."There is no evidence to suggest an intentional infection or contamination, Barry reported. However, she repeatedly noted concerns over a "routine failure to comply with safety protocols."The report's conclusions also include the following:The outbreak was limited to three people and never posed a risk to the publicFailure to spot and quickly report work-related illness in lab staff is a major concern for health officials Laboratory infection control practices must be clearly documented and enforcedIn addition, the health commission is requiring that Boston University take several steps before it resumes tularemia research, including retraining workers on safety and modifying and strengthening standard operating procedures.
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INFECTION occurring during hospitalization is a major clinical and epidemiologic problem. Previous studies have
focused primarily on hospital-acquired staphylococcal infections. Because of an impression that the frequency of such
infections may have decreased and those caused by gram-negative bacilli correspondingly increased since the
introduction of the penicillinase-resistant penicillins, a simple spot survey of clinically apparent infection acquired after
admission to the Boston City Hospital was undertaken.
Method
All patients on the wards of the Boston City Hospital were seen by one or another of us during the week of January 21–27,
1964. Patients were considered to have hospital-acquired infection if . . .
Hospital-Acquired Infections and Antibiotic Usage in the Boston City Hospital — January, 1964, Authors: Jay Ward Kislak, M.D., Theodore C. Eickhoff, M.D., and Maxwell Finland, M.D., D.Sc. (HON.) N Engl J Med 1964;271:834-835
focused primarily on hospital-acquired staphylococcal infections. Because of an impression that the frequency of such
infections may have decreased and those caused by gram-negative bacilli correspondingly increased since the
introduction of the penicillinase-resistant penicillins, a simple spot survey of clinically apparent infection acquired after
admission to the Boston City Hospital was undertaken.
Method
All patients on the wards of the Boston City Hospital were seen by one or another of us during the week of January 21–27,
1964. Patients were considered to have hospital-acquired infection if . . .
Hospital-Acquired Infections and Antibiotic Usage in the Boston City Hospital — January, 1964, Authors: Jay Ward Kislak, M.D., Theodore C. Eickhoff, M.D., and Maxwell Finland, M.D., D.Sc. (HON.) N Engl J Med 1964;271:834-835
The Boston City Hospital From its founding in 1864, this hospital had paid special attention to patients with infectious diseases because there were so many of them [24]. Further- more, the Thorndike Memorial Laboratory had been established there in 1923, a separate building in the midst of the hospital complex - with beds, labora- tories, and a staff expressly for clinical research [25]. Thus, conditions were highly favorable for evaluat- ing sera from patients with pneumonia because there were research laboratories in the Thorndike build- ing, an abundance of patients in the Boston City Hospital, and collaboration with Harvard Univer- sity and the Massachusetts Antitoxin and Vaccine Laboratory, where superior antisera to pneumococci were being developed. The Thorndike Memorial Laboratory created a Pneumonia Service, which brought together the facilities of all these groups for the purposes of patient care and research. In 1928, Maxwell Finland became the Pneumonia Resident and immediately plunged into a life-long career of clinical research work-packed, broad-ranging, and universally recognized [26]. He found that the an- tiserums of the 1920s diminished the mortality and complications from pneumococcal pneumonia, but only slightly, and only if large amounts were given during the first three days of the illness [27]. Such doses precipitated many allergic reactions, some of them serious. At that point, successful serum ther- apy for pneumonia was by no means assured. Supe- rior clinical and basic research combined were neces- sary to prove that it would work. Fortunately, among the bacteriologists working to develop a better serum, Lloyd H. Felton of the Har- vard Medical School had devised a method of con- centrating antibodies to pneumococci, and the state laboratory had started to produce antisera to pneu- mococci by using his method [28]. Finland studied their use in hundreds of patients and demonstrated that administration of concentrated sera shortened the course of the illness, saved lives, and caused few adverse reactions. He, with other pioneers in the field, convinced American doctors that these sera deserved to be used routinely in the treatment of pneumococcal pneumonia. Then and subsequently, as he was evaluating a therapeutic agent in an infection - whether it was serum, antibiotic, or chemotherapeutic agent - he also studied the disease, its causes, and its pathophysiology. Furthermore, he learned how to diagnose, treat, and in every way care for the patients he was managing. His interests wid- ened to include all the infectious diseases; everything became grist for his mill. His computer brain seemed to store every fact he encountered, and he used this store to teach generations of students, residents, and fellow professionals. On his service the clinical in- vestigator strove for the welfare of patients, profes- sionals, students, science, and society. As Finland had incorporated some of the methods used by Park in the New York Health Department and Cole at the Rockefeller Institute, so many clini- cal investigators in the United States and elsewhere developed successful laboratory-hospital collabora- tions in emulation of Finland's. In most of them, as at the Boston City Hospital, the teaching of stu- dents, the training of house officers and fellows, and the pursuit of research pressed forward together, al- though few of these centers could claim, as could Finland, that >13% of the members of the Ameri- can Society for Clinical Investigation had been trainees or staff members of the Harvard Medical Unit of the Boston City Hospital [29]. Groups per- forming clinical research in infectious diseases could be found especially in university hospitals and re- search institutes, also in municipal, Veterans Ad- ministration, and other government hospitals, and in a few private, not-for-profit hospitals. Increased federal funds accelerated the movement to establish and staff them properly, as did funds from phar- maceutical companies, which were donated for evaluation of the swarms of new antimicrobial drugs.
Field, Ward, and Laboratory: Where the Infectious Disease Physician Worked, Harry F. Dowling, The Journal of Infectious Diseases, Vol. 153, No. 3 (Mar., 1986), pp. 390-396
The third assistant to Councilman in this review was Frank Burr Mallory He was born in Cleveland, Ohio on 12 November 1862 and died on 27 September 1941.[17] Mallory, too, was a graduate of Harvard Medical School, in 1890, and became anassistant in pathology under Councilman. He undertook additional training in Europe afterwhich he became a member of the Harvard pathology department, assumed Councilman'sposition when he resigned in 1908, and gained the rank of professor in 1928. Mallory wasa pioneer in the development of histological techniques and became well-known for hisbooks on the microscopic anatomy of pathological materials and the preparation of thosefor diagnosis and study.[18] Papers on protozoa and smallpox with Mallory as an authorhave not been located. However, in a footnote, he called attention to the work on thatsubject by his associates at Harvard: This study of the skin in scarlet fever with the resultant discovery of the peculiarbodies in it is the outcome of the interest taken at the present time by thepathological department of the Harvard Medical School in the subject of pathogenicprotozoa in consequence of the investigation of small-pox by Dr. W.T. Councilman andthe men associated with him in that work.[19] Then, regarding scarlet fever, he wrote: "These bodies can be interpreted in various ways,as artifacts, degenerations, or protozoa".[19, pp. 487-88] He argued against the first twopossibilities and thought the forms were sporozoan parasites: "If they are protozoa, theymay be normal or occasional inhabitants of the skin or have a causal relation to scarletfever".[19, p. 488] Mallory proceeded to name the organism, cyclaster scarlatinalis [19, p. 488] but, because of nomenclature priority, changed the name to
Cyclasterionscarlatinae. [20]
The Disproved Concept of the Protozoan Etiology of Smallpox Frank F. Katz, Ph.D.
From the Mallory Institute of Pathology, Boston City Hospital, Boston, Massachusetts. 'l'his study was aided by a grant from the American Cancer Society, Inc., New England Branch. We are indebted to Dr. Patrick J. Fitzgerald for carrying out the preliminary experiments referred to in this study, to Mrs. Marjorie Magrath for her valuable technical assistance, to Miss Lillian M. Leavitt for
our histological preparations, and to Mr. Leo Goodman for our photographs. Local anesthesia was obtained with one to two drops of 10 per cent cocaine in saline. In the absence of general anesthesia it was found expedient to use a simple animal board, securing the ankles by ties. The forty-nine tumors were implanted in 383 guinea pigs, generally using six to ten animals for each tumor. As for the actual technique of transplantation, we followed as closely as possible that outlined by Greene,lo the only known modification being the substitution of a bayonet type of Bard-Parker scalpel blade for the double-edged corneal knife. Briefly, the technique consisted of making a small incision in the superior border of the cornea adjacent to the corneoscleral junction, expressing a small amount of the aqueous humor, and inserting the tumor fragment with a no. 16 gauge lumbar-puncture needle. A short beveled needle with tight-fitting stylet was used, thus facilitating aspiration of tissue into the tip of the needle, the stylet then being used to discharge the fragment into the anterior chamber. The size of the tumor fragment was generally somewhat less than 1 mm. in diameter. Once within the anterior chamber, the tumor fragment was gently manipulated into the inferior angle between the cornea and iris. The bulk of our work was carried out during the reportedly more favorable winter monthss and, in the latter part of this work, by a trained technician. Received for publication, December 18, 1950. The animals were observed two to three times weekly for a period ranging from three to twelve months, usually at least for six months. A hand lens and on occasion a dissecting microscope were used in examining suspected growths. When growth appeared definite, as judged by vascularization and progressive incrcase in size, the animals were sacrificed. Portions of the an terior-chamber tumor were fixed in Zenker’s fixative, fifteen to twenty serial sections being prepared and stained with phloxine-methylene-blue. The remainder of the tissue was reimplanted in a4 many animals as possible, in general obtaining four to six second-generation transplants. In all instances o€ definite growth, complete autopsies were performed with special reference to eye and orbital fossa. When growth was doubtful, the animals we1 e sacrificed, and histological preparations made, but only occasional attempts at second-generation transplants. Animals with infected eyes were killed relatively early and histological examinations made. Those animals showing no evidence of growth after the observation period were returned to the general breeding stock. In four instance,, grossly questionable growths were found histologically to consist of densc, inflammatory exudates containing microscopic residual fragments of apparcntly degenerating tumor. Tumor from the liver was implanted in six male guinea pigs eighteen hours after the patient’s death. Growth appeared in one animal after ten days and by the sixteenth day had filled the anterior chamber. At this time the animal was sacrificed but, because of the extremely rapid filling of the anterior chamber arid the grossly amelanotic nature of the mass, the latter was misinterpreted as inflammatory and serial transplantation was not attempted. Microscopically, however, the transplant tumor did contain melanin and closely simulated the original tumor. The remaining animals showed no growth up to six months. Tumor from the liver was implanted in six male guinea pigs eighteen hours after the patient’s death. Growth appeared in one animal after ten days and by the sixteenth day had filled the anterior chamber. At this time the animal was sacrificed but, because of the extremely rapid filling of the anterior chamber arid the grossly amelanotic nature of the mass, the latter was misinterpreted as inflammatory and serial transplantation was not attempted. Microscopically, however, the transplant tumor did contain melanin and closely simulated the original tumor. The remaining animals showed no growth up to six months
Field, Ward, and Laboratory: Where the Infectious Disease Physician Worked, Harry F. Dowling, The Journal of Infectious Diseases, Vol. 153, No. 3 (Mar., 1986), pp. 390-396
The third assistant to Councilman in this review was Frank Burr Mallory He was born in Cleveland, Ohio on 12 November 1862 and died on 27 September 1941.[17] Mallory, too, was a graduate of Harvard Medical School, in 1890, and became anassistant in pathology under Councilman. He undertook additional training in Europe afterwhich he became a member of the Harvard pathology department, assumed Councilman'sposition when he resigned in 1908, and gained the rank of professor in 1928. Mallory wasa pioneer in the development of histological techniques and became well-known for hisbooks on the microscopic anatomy of pathological materials and the preparation of thosefor diagnosis and study.[18] Papers on protozoa and smallpox with Mallory as an authorhave not been located. However, in a footnote, he called attention to the work on thatsubject by his associates at Harvard: This study of the skin in scarlet fever with the resultant discovery of the peculiarbodies in it is the outcome of the interest taken at the present time by thepathological department of the Harvard Medical School in the subject of pathogenicprotozoa in consequence of the investigation of small-pox by Dr. W.T. Councilman andthe men associated with him in that work.[19] Then, regarding scarlet fever, he wrote: "These bodies can be interpreted in various ways,as artifacts, degenerations, or protozoa".[19, pp. 487-88] He argued against the first twopossibilities and thought the forms were sporozoan parasites: "If they are protozoa, theymay be normal or occasional inhabitants of the skin or have a causal relation to scarletfever".[19, p. 488] Mallory proceeded to name the organism, cyclaster scarlatinalis [19, p. 488] but, because of nomenclature priority, changed the name to
Cyclasterionscarlatinae. [20]
The Disproved Concept of the Protozoan Etiology of Smallpox Frank F. Katz, Ph.D.
From the Mallory Institute of Pathology, Boston City Hospital, Boston, Massachusetts. 'l'his study was aided by a grant from the American Cancer Society, Inc., New England Branch. We are indebted to Dr. Patrick J. Fitzgerald for carrying out the preliminary experiments referred to in this study, to Mrs. Marjorie Magrath for her valuable technical assistance, to Miss Lillian M. Leavitt for
our histological preparations, and to Mr. Leo Goodman for our photographs. Local anesthesia was obtained with one to two drops of 10 per cent cocaine in saline. In the absence of general anesthesia it was found expedient to use a simple animal board, securing the ankles by ties. The forty-nine tumors were implanted in 383 guinea pigs, generally using six to ten animals for each tumor. As for the actual technique of transplantation, we followed as closely as possible that outlined by Greene,lo the only known modification being the substitution of a bayonet type of Bard-Parker scalpel blade for the double-edged corneal knife. Briefly, the technique consisted of making a small incision in the superior border of the cornea adjacent to the corneoscleral junction, expressing a small amount of the aqueous humor, and inserting the tumor fragment with a no. 16 gauge lumbar-puncture needle. A short beveled needle with tight-fitting stylet was used, thus facilitating aspiration of tissue into the tip of the needle, the stylet then being used to discharge the fragment into the anterior chamber. The size of the tumor fragment was generally somewhat less than 1 mm. in diameter. Once within the anterior chamber, the tumor fragment was gently manipulated into the inferior angle between the cornea and iris. The bulk of our work was carried out during the reportedly more favorable winter monthss and, in the latter part of this work, by a trained technician. Received for publication, December 18, 1950. The animals were observed two to three times weekly for a period ranging from three to twelve months, usually at least for six months. A hand lens and on occasion a dissecting microscope were used in examining suspected growths. When growth appeared definite, as judged by vascularization and progressive incrcase in size, the animals were sacrificed. Portions of the an terior-chamber tumor were fixed in Zenker’s fixative, fifteen to twenty serial sections being prepared and stained with phloxine-methylene-blue. The remainder of the tissue was reimplanted in a4 many animals as possible, in general obtaining four to six second-generation transplants. In all instances o€ definite growth, complete autopsies were performed with special reference to eye and orbital fossa. When growth was doubtful, the animals we1 e sacrificed, and histological preparations made, but only occasional attempts at second-generation transplants. Animals with infected eyes were killed relatively early and histological examinations made. Those animals showing no evidence of growth after the observation period were returned to the general breeding stock. In four instance,, grossly questionable growths were found histologically to consist of densc, inflammatory exudates containing microscopic residual fragments of apparcntly degenerating tumor. Tumor from the liver was implanted in six male guinea pigs eighteen hours after the patient’s death. Growth appeared in one animal after ten days and by the sixteenth day had filled the anterior chamber. At this time the animal was sacrificed but, because of the extremely rapid filling of the anterior chamber arid the grossly amelanotic nature of the mass, the latter was misinterpreted as inflammatory and serial transplantation was not attempted. Microscopically, however, the transplant tumor did contain melanin and closely simulated the original tumor. The remaining animals showed no growth up to six months. Tumor from the liver was implanted in six male guinea pigs eighteen hours after the patient’s death. Growth appeared in one animal after ten days and by the sixteenth day had filled the anterior chamber. At this time the animal was sacrificed but, because of the extremely rapid filling of the anterior chamber arid the grossly amelanotic nature of the mass, the latter was misinterpreted as inflammatory and serial transplantation was not attempted. Microscopically, however, the transplant tumor did contain melanin and closely simulated the original tumor. The remaining animals showed no growth up to six months
The_Boston_Globe_1970_11_29_99
Boston Doctors May Have Cure ForHemophilia February 9, 1968
With the help of a beagle named Ellie, Harvard doctors have completedresearch that could lead to a final cure for hemophilia.
Dr. John C. Norman '50, associate in Surgery, is the head of a project at BostonCity Hospital that for the first time has succeeded in curing a dog of hemophilia. Norman and his associates--among whom is Dr. Victor C. Covelli, ResearchFellow in Surgery--earlier discovered the crucial role of the spleen in producingFactor VIII, a substance whose presence in the body prevents hemophilia.
Norman's research has so far been limited to beagles which have been specially bred to produce a strain composed largely of hemophiliac dogs. (The canine disease does not differ significantly from the human form of it.) The spleen transplant of the dog Ellie is the first totally successful one done by Norman's project. In the past, problems have arisen because the hemophiliac
dog rejected the new spleen. Rejection occurs when an animal refuses to accept living tissue from another body. In Ellie's case, doctors avoided the threat of rejection with a combination of immunosuppressors: cortisone, actinomycin C, imuran, and antilymphocyte serum. The experimental success with Ellie is a prelude to a trial with a human hemophiliac. In most cases the plan is for a normal mother to donate her spleen--which is not usually a vital organ--to her hemophiliac son. The close genetic relationship between mother and son would minimize the difficulty of the transplant. The risk of the spleen transplant operation is minimal--the same risk that there is in a regular spleen removal, from zero to one per cent. The hemophilia research has been carried out in the Sears Surgical Research Laboratories in the Cardiovascular Division, of which Norman is director. The project is financed mainly by a grant from the National Institutes of Health.
Drug resistance of bacteria is a major medical problem because it severely limits the usefulness of virtually all known antimicrobial agents and often necessitates the administration of highly toxic drugs when the more acceptable ones are found to be ineffective. Occasionally, cultures from patients with bacterial infections yield organisms resistant to all the drugs used in sensitivity tests. At Boston City Hospital multiple drug resistance is now common among strains of Staphylococcus aureus (Table 1) and in most species of gramnegative bacilli (Table 2) when tested by a singledisk method in conjunction with routine management of infections caused by these agents. Not shown are the results with Pseudomonas aeruginosa, which was rather consistently susceptible to polymyxin B and gentamicin; relatively few other agents could be expected to be effective 95 percent or more of the time against any of the organisms listed. These patterns of drug resistance may show rather abrupt changes, particularly when new anti- biotics are introduced or when there are changes in the customary usage of antimicrobial agents within a hospital or community. Understandably, considerable hospital-to-hospital variation in such patterns of resistance may exist, and it seems advisable for each institution to monitor its own drug-resistance problem so that such information may be used in the selection of antibiotics, particularly for fulminating infections. Although the appearance of heritable drug resistance in a previously susceptible strain was originally thought to be due to a spontaneous gene mutation, occurring about once in every 105 to 1010 cells, it is now known that determinants for the resistance trait may also be acquired by staphylococci by two other mechanisms: transformation and transduction. Many gram-negative bacilli may acquire the determinants by any of these three mechani sms or by a fourth one: conjugation. The last three mechanisms transmit "infectious drug resistance" although the term is mainly applied to that transmitted by conjugation. Transformation is the process by which a cell incorporates from its environment one or more genes formed by another cell. In transduction, genes formed by another cell are also incorporated into a recipient cell, but they are introduced by a temperate bacterial virus (one that does not lyse and kill its new host) along with its own genes. In conjugation, the genes to be transferred are cytoplasmic in location, and replicate independently and more rapidly than the bacterial donor cell and its other genes on the bacterial chromosome; conjugation, a form of bacterial sexual mating, may occur between cells of different species, and the genes determining drug resistance (R factors) are introduced (presumably via a "sexual pilus") into appropriate recipients by donor cells that possess the resistance-transfer factor (RTF). Transformation is a rare event, occurring perhaps once for every 108 cells; transduction may occur once for every 103 to 106 exposed cells, whereas in conjugation from less than 1 in 102 to virtually all properly exposed cells may acquire the new genes within a few minutes to an hour
MEDICAL ARTICLES DRUG RESISTANCE OF BACTERIA* Leon D. Sabath, MD. Brit Med J 280(2):91-94, Jan 9, 1969. Navy Medical Newsletter 1969-06.
MEDICAL ARTICLES DRUG RESISTANCE OF BACTERIA* Leon D. Sabath, MD. Brit Med J 280(2):91-94, Jan 9, 1969. Navy Medical Newsletter 1969-06.
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The humoral antibody response to the capsular polysaccharide of Bacteroides fragilis was quantitated in an animal model of intraabdominal abscess formation using a sensitive quantitative radioactive antigen-binding assay. Antibody detected by this technique correlated highly with antibody measured by quantitative precipitin analysis (r = 0.943). Animals infected with encapsulated B. fragilis develop high levels of circulating serum antibody to the capsular polysaccharide. This antibody can be induced by implantation of live organisms, heat-killed organisms, heterologous strains of B. fragilis, and various outer membrane components that contain the cap- sular antigen. The immunogenicity of the capsular polysaccharide could be enhanced when administered as part of the outer membrane or when not separated from outer membrane proteins. Evidence of an antibody response to this capsular polysaccharide offers support for the demonstrated pathogenic potential of encapsulated B.
Materials and Methods Microorganisms. Strains of B. fragilis (ATCC 23745 [American Type Culture Collection, Rock- ville, Md.]; BCH 26783 [Boston City Hospital, Boston, Mass..... Streptococ- cus pneumoniae type III was obtained through Ms. A. K. Daly at the Bacteriology Laboratory of Boston City Hospital and was maintained on blood agar plates
Group: Bacteroides UC + heat-killed B. fragilis C (BCH 26783) - Percentage with abscess: 90% (2nd highest)
It was found that implantation of encapsulated B. fragilis alone resulted in absces- ses in most recipients, whereas the unencapsulat- ed species seldom produced this effect unless im- planted in combination with another organism. Implants of heat-killed encapsulated B. fragilis also resulted in abscess formation. These experi- ments suggested that the abscess potentiating ability of B. fragilis was related to the capsular polysaccharide. Implantation of 200 /tg of puri- fied capsular material alone or in conjunction with unencapsulated strains caused abscesses in a majority of animals. Comparable results were not obtained using the capsular polysaccharide from E. coli or S. pneumoniae. These results sug- gest that the capsular polysaccharide of B. fragi- lis potentiates abscess formation and may repre- sent a virulence factor
Quantitative Determination of the Antibody Response to the Capsular Polysaccharide of Bacteroides Fragilis in an Animal Model of Intraabdominal Abscess Formation, Dennis L. Kasper, Andrew B. Onderdonk and John G. Bartlett, The Journal of Infectious Diseases, Vol. 136, No. 6 (Dec., 1977), pp. 789-795
Materials and Methods Microorganisms. Strains of B. fragilis (ATCC 23745 [American Type Culture Collection, Rock- ville, Md.]; BCH 26783 [Boston City Hospital, Boston, Mass..... Streptococ- cus pneumoniae type III was obtained through Ms. A. K. Daly at the Bacteriology Laboratory of Boston City Hospital and was maintained on blood agar plates
Group: Bacteroides UC + heat-killed B. fragilis C (BCH 26783) - Percentage with abscess: 90% (2nd highest)
It was found that implantation of encapsulated B. fragilis alone resulted in absces- ses in most recipients, whereas the unencapsulat- ed species seldom produced this effect unless im- planted in combination with another organism. Implants of heat-killed encapsulated B. fragilis also resulted in abscess formation. These experi- ments suggested that the abscess potentiating ability of B. fragilis was related to the capsular polysaccharide. Implantation of 200 /tg of puri- fied capsular material alone or in conjunction with unencapsulated strains caused abscesses in a majority of animals. Comparable results were not obtained using the capsular polysaccharide from E. coli or S. pneumoniae. These results sug- gest that the capsular polysaccharide of B. fragi- lis potentiates abscess formation and may repre- sent a virulence factor
Quantitative Determination of the Antibody Response to the Capsular Polysaccharide of Bacteroides Fragilis in an Animal Model of Intraabdominal Abscess Formation, Dennis L. Kasper, Andrew B. Onderdonk and John G. Bartlett, The Journal of Infectious Diseases, Vol. 136, No. 6 (Dec., 1977), pp. 789-795
When the Boston City Hospital received its first patients in the summer of 1864, Lister had not yet initiated antiseptic surgery, Pasteur was just beginning to shift his research from fermentation of wine and beer and the diseases of silkworms to the infectious agents of human disease, and Koch was 2 years away from receiving his medical degree. The Glasgow Fever Hospital (Glasgow, Scotland), the first municipal hos- pital in the world exclusively dedicated to contagious dis- eases, was not yet in service. Establishment of a municipal hospital in Boston was long overdue. The almshouses in New York and Philadelphia had been transformed into publicly owned hospitals for the sick poor, but Boston continued to rely on the Massachusetts General Hospital, founded in 1821 and privately managed, to meet the needs of its indigent population [1]. By the mid- dle of the century, its facilities were too limited for a rapidly expanding population. Most of the newcomers were immigrants, primarily from Ireland, who arrived without the finan- cial resources and family support to cope with illness. Plans for a new hospital were stimulated by the success of a tempo- rary public hospital during the cholera epidemic in 1849, a bequest of $26,000 specifically designated for a city hospital, and authorization from the state legislature to establish and maintain "a hospital for the reception of persons who by misfortune or poverty may require relief during temporary sickness" [1, 2]. More than 200,000 people lived in Boston and surroundings- The leading causes of death were en- demic diseases: tuberculosis, cholera infantum, and pneumo- nia. Excess mortality among the poor closely correlated with the overcrowding, poor sanitation, and squalid conditions in those parts of the city where foreign-born individuals and migrants from other parts of New England were clustered. People in all social classes were exposed to the major epi- demic diseases-typhoid, diphtheria, scarlet fever, and measles. Most feared hospitals as breeding grounds for dis- ease, and anyone who could be cared for at home chose to remain there. The poor usually did not have that option [3, 4]. The new hospital was built on low-lying land in the South End, close to the sewage-laden Roxbury canal [5]. This insalubrious site was already owned by the city, and its financial appeal outweighed all others. The architect's plans called for the pavilion system so that each ward would be isolated from the others and sunlight and air could freely circulate. Initially there were 208 beds divided between the surgical and the medical buildings [1, 2, 5]. No special provisions were made for contagious patients. Physicians continued to debate contagionist and anticontagionist theories, and the new hospital reflected the unresolved quandary regarding prevention and control of infectious diseases [6]. Medical care at the Boston City Hospital in 1864 and for several decades following was quasi-custodial. Diagnosis was by signs and symptoms. Microscopes were of little use, the stethoscope and ophthalmoscope were neglected, and the clinical thermometer was still too awkward for practical use. Nurses were untrained and badly supervised. Therapy was limited to bed rest, diet, ventilation, and cleanliness. A few specific remedies were available: opiates for pain, quinine for malaria, and digitalis for heart failure [1]. Cupping and leeching were still performed by the house staff. Depletion by venesection and cathartics had not entirely disappeared from the physician's armamentarium [7].
The two new contagious wards quickly proved inadequate. Persistent city-wide epidemics, especially diphtheria and scarlet fever, meant increased numbers of infectious patients and increased danger to the rest of the hospital. The crisis forced a bold decision, based on the experience of the British fever hospitals. This decision was the construction of the South Department, which was completely separated from the rest of the hospital. It was expected that the total isolation of people with contagious diseases in a separate hospital and the subsequent disinfection of their homes and possessions by the Board of Health would do much to control major epidemics [27]. The middle class was assumed reliable enough to quarantine and disinfect themselves. The South Department was built on a large tract that once housed the city greenhouses and was separated by a wide boulevard from the main hospital. Opened in I 895, it had its own administration building, laundry, and mortuary. The two medical buildings, one for diphtheria and the other for scarlet fever, were constructed with maximum attention to cross ventilation, continuous disinfection, and isolation of patients with complications. The initial capacity was 260 beds. The unit was surrounded by a high wall to prevent germs from escaping into the neighborhood. To prevent the spread of disease back into the main hospital, the South Department had its own nursing and medical staff. The nursing service was arranged to prevent those caring for patients with diphtheria and those caring for patients with scarlet fever from ever coming into contact with each other, on the wards, on the grounds, or in their living quarters. The South Department also had its own separate ambulance service that the public was urged to use rather than risk contamination of public vehicles. The medical director, Dr. John McCollom, had been the City Physician and was well acquainted with epidemics. The preponderance of patients were children, and an average hospital stay was 30 days. The South Department was the first contagious diseases hospital in the United States and quickly set an example for other cities [I, 5, 28
Amalie M. Kass, Infectious Diseases at the Boston City Hospital: The First 60 Years, Clinical Infectious Diseases , Aug., 1993, Vol. 17, No. 2 (Aug., 1993), pp. 276-282
The two new contagious wards quickly proved inadequate. Persistent city-wide epidemics, especially diphtheria and scarlet fever, meant increased numbers of infectious patients and increased danger to the rest of the hospital. The crisis forced a bold decision, based on the experience of the British fever hospitals. This decision was the construction of the South Department, which was completely separated from the rest of the hospital. It was expected that the total isolation of people with contagious diseases in a separate hospital and the subsequent disinfection of their homes and possessions by the Board of Health would do much to control major epidemics [27]. The middle class was assumed reliable enough to quarantine and disinfect themselves. The South Department was built on a large tract that once housed the city greenhouses and was separated by a wide boulevard from the main hospital. Opened in I 895, it had its own administration building, laundry, and mortuary. The two medical buildings, one for diphtheria and the other for scarlet fever, were constructed with maximum attention to cross ventilation, continuous disinfection, and isolation of patients with complications. The initial capacity was 260 beds. The unit was surrounded by a high wall to prevent germs from escaping into the neighborhood. To prevent the spread of disease back into the main hospital, the South Department had its own nursing and medical staff. The nursing service was arranged to prevent those caring for patients with diphtheria and those caring for patients with scarlet fever from ever coming into contact with each other, on the wards, on the grounds, or in their living quarters. The South Department also had its own separate ambulance service that the public was urged to use rather than risk contamination of public vehicles. The medical director, Dr. John McCollom, had been the City Physician and was well acquainted with epidemics. The preponderance of patients were children, and an average hospital stay was 30 days. The South Department was the first contagious diseases hospital in the United States and quickly set an example for other cities [I, 5, 28
Amalie M. Kass, Infectious Diseases at the Boston City Hospital: The First 60 Years, Clinical Infectious Diseases , Aug., 1993, Vol. 17, No. 2 (Aug., 1993), pp. 276-282
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In an analysis of the occurrence of and mortality due to bacteremic infections at Boston City Hos- pital during 12 selected years between 1935 and 1972 [1], it was shown that, in spite of steadily declining numbers of patients admitted to the hospital over this period and the declining case- fatality ratio among those patients, the number of bacteremic infections, the rate of those infec- tions per 1,000 hospital admissions, and the num- ber of deaths per 100 deaths from all causes among all of the hospitalized patients increased steadily over the first 10 selected years of this study (through 1965) and then declined appre- ciably in the last two years. These paradoxical changes were noted in spite of the successive in- troduction and intensive use of many highly po- tent antimicrobial agents. In the present study we present a limited analysis of the length of hospital stay among the bacteremic patients at Boston City Hospital during the same 12 selected years.
Maxwell Finland and Mildred W. Barnes, Duration of Hospitalization for Bacteremic Infections at Boston City Hospital during 12 Selected Years between 1935 and 1972, The Journal of Infectious Diseases, Vol. 138, No. 6 (Dec., 1978), pp. 837-848, Oxford University Press
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The occurrence, etiology, and demography of acute bacterial empyema are present- ed to reflect the widespread use of sulfonamides, penicillin, and other active anti- biotics. In community-acquired (C-A) cases Streptococcus pneumoniae, hemolytic streptococci, and Staphylococcus aureus were the most frequent single organisms identified in initial positive cultures of pleural fluid during 1935. S. pneumoniae declined steadily until 1953 but continued to occur frequently in C-A cases. Hemolytic streptococci became infrequent. S. aureus increased and became the most frequent organism in 1955 and declined to original levels after 1965 while gram-negative rods increased. S. aureus, aerobic gram-negative rods, and enterococci were most frequent in originally mixed infections, hospital-acquired cases, and superinfections. Anaerobes wit Cases with single organisms. In cases with single organisms in the initial positive culture, the most frequent pathogens were S. pneumoniae (37.7%), Staphylococcus aureus (29.2%), and hemolytic streptococci (nearly all group A) (7.8%). Haemophilus influenzae accounted for 3.0%, viridans streptococci for 3.4%, and entero- cocci for 1.5% of the cases. Among the gram-neg- ative rods, Klebsiella-Enterobacter, Escherichia coli, and Pseudomonas aeruginosa were the most frequent; they accounted for 5.1%, 4.0%, and 2.1% of the cases, respectively. Single anaerobes were identified infrequently; an anaerobic (or microaerophilic) Streptococcus was identified as the only organism in 1.7% of the cases
Among the cases 9with single organisms, only 2% of the cases in which S. pneumoniae was the only pathogen found in the initial positive fluid culture were H-A. Likewise, H-A cases constitut- ed relatively small proportions of cases in which hemolytic streptococci (12%), anaerobic strep- tococci (13%), H. influenzae (21%), and viri- dans streptococci (25%) were found singly. On the other hand, 48% of the cases with S. aureus alone, and --50% of the cases in which enterococci, various gram-negative rods, and other organisms were identified were H-A.
Cases of mixed infections. In cases with more than one organism in the initial positive pleural fluid culture, the order of occurrence of the vari- ous pathogens was different than in those with a single organism. The most frequent were lytic strepococci (17.4%), anearobic streptocci (10.6%), S aureus (10.2%) and fusiform bacilli (9.%). Other organisms, in order of de- scending frequency of occurrence were entero- cocci, E. coli, Klebsiella-Enterobacter, Proteus, P. aeruginosa, and Bacteroides species; each account- ed for 8.8%-4.6% of the organisms isolated initially from fluids with mixed infections. H. influenzae accounted for 3.1% and Clostridium for 2.9%.A majority (>60%) of the strains of S. pneu- moniae, hemolytic streptococci, and viridans streptococci among the aerobes, and of anaero- bic streptococci, Bacteroides, and fusiform bacilli among the anaerobes in cases with initially mixed infections, were from C-A cases. On the other hand, the great majority of strains of enterococci, various aerobic gram-negative rods, and S. aureus identified in the original mixed cultures were from H-A cases. Of the 218 strains from originally mixed infections in C-A cases, 96 (44.0%) were from fatal cases. By comparison, 214 (70.6%) of the 303 strains from the initial mixed cultures of H-A cases were from fatal cases
Maxwell Finland and Mildred W. Barnes, Changing Ecology of Acute Bacterial Empyema: Occurrence and Mortality at Boston City Hospital during 12 Selected Years from 1935 to 1972, The Journal of Infectious Diseases , Mar., 1978, Vol. 137, No. 3 (Mar., 1978), pp. 274-291
The source and significance of the new organ- isms, here designated as superinfections, are diffi- cult to evaluate. Some may represent coloniza- tion with organisms from chest tubes, dressings, or other environmental sources, but many, par- ticularly in H-A cases that followed trauma or operations, probably originated in the lungs. They were more frequent in H-A cases than in C-A cases with mixed growth in the initial posi- tive fluid. In some cases, superinfection was asso- ciated with rapid deterioration and death within one or two days, and the same organisms were predominant in cultures of the lungs and pleural fluid and in some instances were grown from cardiac blood at autopsy. The overall mortality was not significantly different in patients within some categories with and without superinfection. However, the mean duration of hospitalization in those who lived and the mean survival time in fatal cases after the first positive fluid culture were two weeks longer in C-A cases with super- infection and about six weeks longer in H-A ca- ses with superinfection than in the correspond- ing cases with no superinfection.
Maxwell Finland and Mildred W. Barnes, Changing Ecology of Acute Bacterial Empyema: Occurrence and Mortality at Boston City Hospital during 12 Selected Years from 1935 to 1972, The Journal of Infectious Diseases , Mar., 1978, Vol. 137, No. 3 (Mar., 1978), pp. 274-291
Not many reports on acute empyema similar to this one and covering the same interval are available...The selection of cases for inclusion in this study was based on the report of a significant bacterial pathogen demonstrated in pleaural fluid obtained operation, or at autopsy. Very few of the cases are in the last category, which includes mostly patients who died within the first day or two after ad- mission to the hospital.
The early sharp decline in numbers of cases and rates of empyema was limited to the C-A cases, that is, those in which the "infection" was acquired before admission to the hospital, where- as the H-A cases showed no such decline but fluc- tuated independently. The early decline in C-A cases may be a reflection of the extensive use of the antibiotics, particularly the oral forms, out- side the hospital
l. At Boston City Hospital the overall mortality in the 671 cases (45.8%) was considerably higher than that reported by Weese et al. [7] and by most other authors [14, 15, 17-21]. However, in the series of Snider and Saleh [16], there were 49 deaths in 105 cases (47%); most of those deaths were in patients with serious underlying diseases, and only five were attributed directly to the em- pyema. In other reports that dealt mostly or en- tirely with adults [7, 14, 15, 18-21], the mortality rate ranged from 4% [21] to 30% [15], and in most of these reports, the deaths occurred chiefly in patients with serious complicating diseases, and few of them were attributed to the pleural infection (table 10
Maxwell Finland and Mildred W. Barnes, Changing Ecology of Acute Bacterial Empyema: Occurrence and Mortality at Boston
City Hospital during 12 Selected Years from 1935 to 1972, The Journal of Infectious Diseases , Mar., 1978, Vol. 137, No. 3 (Mar., 1978), pp. 274-291
Among the cases 9with single organisms, only 2% of the cases in which S. pneumoniae was the only pathogen found in the initial positive fluid culture were H-A. Likewise, H-A cases constitut- ed relatively small proportions of cases in which hemolytic streptococci (12%), anaerobic strep- tococci (13%), H. influenzae (21%), and viri- dans streptococci (25%) were found singly. On the other hand, 48% of the cases with S. aureus alone, and --50% of the cases in which enterococci, various gram-negative rods, and other organisms were identified were H-A.
Cases of mixed infections. In cases with more than one organism in the initial positive pleural fluid culture, the order of occurrence of the vari- ous pathogens was different than in those with a single organism. The most frequent were lytic strepococci (17.4%), anearobic streptocci (10.6%), S aureus (10.2%) and fusiform bacilli (9.%). Other organisms, in order of de- scending frequency of occurrence were entero- cocci, E. coli, Klebsiella-Enterobacter, Proteus, P. aeruginosa, and Bacteroides species; each account- ed for 8.8%-4.6% of the organisms isolated initially from fluids with mixed infections. H. influenzae accounted for 3.1% and Clostridium for 2.9%.A majority (>60%) of the strains of S. pneu- moniae, hemolytic streptococci, and viridans streptococci among the aerobes, and of anaero- bic streptococci, Bacteroides, and fusiform bacilli among the anaerobes in cases with initially mixed infections, were from C-A cases. On the other hand, the great majority of strains of enterococci, various aerobic gram-negative rods, and S. aureus identified in the original mixed cultures were from H-A cases. Of the 218 strains from originally mixed infections in C-A cases, 96 (44.0%) were from fatal cases. By comparison, 214 (70.6%) of the 303 strains from the initial mixed cultures of H-A cases were from fatal cases
Maxwell Finland and Mildred W. Barnes, Changing Ecology of Acute Bacterial Empyema: Occurrence and Mortality at Boston City Hospital during 12 Selected Years from 1935 to 1972, The Journal of Infectious Diseases , Mar., 1978, Vol. 137, No. 3 (Mar., 1978), pp. 274-291
The source and significance of the new organ- isms, here designated as superinfections, are diffi- cult to evaluate. Some may represent coloniza- tion with organisms from chest tubes, dressings, or other environmental sources, but many, par- ticularly in H-A cases that followed trauma or operations, probably originated in the lungs. They were more frequent in H-A cases than in C-A cases with mixed growth in the initial posi- tive fluid. In some cases, superinfection was asso- ciated with rapid deterioration and death within one or two days, and the same organisms were predominant in cultures of the lungs and pleural fluid and in some instances were grown from cardiac blood at autopsy. The overall mortality was not significantly different in patients within some categories with and without superinfection. However, the mean duration of hospitalization in those who lived and the mean survival time in fatal cases after the first positive fluid culture were two weeks longer in C-A cases with super- infection and about six weeks longer in H-A ca- ses with superinfection than in the correspond- ing cases with no superinfection.
Maxwell Finland and Mildred W. Barnes, Changing Ecology of Acute Bacterial Empyema: Occurrence and Mortality at Boston City Hospital during 12 Selected Years from 1935 to 1972, The Journal of Infectious Diseases , Mar., 1978, Vol. 137, No. 3 (Mar., 1978), pp. 274-291
Not many reports on acute empyema similar to this one and covering the same interval are available...The selection of cases for inclusion in this study was based on the report of a significant bacterial pathogen demonstrated in pleaural fluid obtained operation, or at autopsy. Very few of the cases are in the last category, which includes mostly patients who died within the first day or two after ad- mission to the hospital.
The early sharp decline in numbers of cases and rates of empyema was limited to the C-A cases, that is, those in which the "infection" was acquired before admission to the hospital, where- as the H-A cases showed no such decline but fluc- tuated independently. The early decline in C-A cases may be a reflection of the extensive use of the antibiotics, particularly the oral forms, out- side the hospital
l. At Boston City Hospital the overall mortality in the 671 cases (45.8%) was considerably higher than that reported by Weese et al. [7] and by most other authors [14, 15, 17-21]. However, in the series of Snider and Saleh [16], there were 49 deaths in 105 cases (47%); most of those deaths were in patients with serious underlying diseases, and only five were attributed directly to the em- pyema. In other reports that dealt mostly or en- tirely with adults [7, 14, 15, 18-21], the mortality rate ranged from 4% [21] to 30% [15], and in most of these reports, the deaths occurred chiefly in patients with serious complicating diseases, and few of them were attributed to the pleural infection (table 10
Maxwell Finland and Mildred W. Barnes, Changing Ecology of Acute Bacterial Empyema: Occurrence and Mortality at Boston
City Hospital during 12 Selected Years from 1935 to 1972, The Journal of Infectious Diseases , Mar., 1978, Vol. 137, No. 3 (Mar., 1978), pp. 274-291
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In August 1949, on a day when the temperature simmered around 105°F, Edward Kass climbed the stairs of the Thorndike Memorial Laboratory. He would soon begin a fellowship there in 1/21/26, 4:48 PM At Their Service | Harvard Medicine Magazine https://magazine.hms.harvard.edu/articles/their-service 1/9 infectious diseases. Upon reaching the fourth fl oor of theHarvard Medical School-led clinical research center at BostonCity Hospital, Kass was startled to fi nd his mentor, MaxwellFinland ’26, at the bench, bare-chested and sweat-soaked. Thebrilliant scientist was going through stacks of cards thatcontained sensitivity data on various antimicrobial drugs. “I asked him why he was working on such a miserable day,” Kass recalled yearslater, “and he responded, in characteristic fashion, that the only way to keep one’smind off the weather was to immerse oneself in work.”
That sense of purpose fueled Finland’s extraordinary career as an infectious diseaseresearcher and permeated what was then known as the Harvard Medical Unit atBoston City Hospital, a world-class program of teaching, research, and patient carethat thrived from the mid-1920s through the mid-1970s. It comprised two patient-care services and the research activities of the Thorndike.
The unit was a magnet for physician–scientists eager to train with medical giantssuch as Finland, William Bosworth Castle ’21, Sidney Ingbar ’47, and James Jandl’49. Its researchers had a profound infl uence on medicine, yielding early discoverieson infections, blood disorders, diabetes, liver diseases, and other conditions thatsickened Boston City patients. “There was an excitement and a sense of unlimited potential in the atmosphere,”wrote Kass, an epidemiologist who spent nearly 30 years at Boston City and was theSchool’s William Ellery Channing Professor of Medicine until shortly before hisdeath in 1990. According to many who participated in it, the program fosteredcuriosity, imagination, precision, intellectual rigor, camaraderie, and pride. All thatwithin the confi nes of an underfunded, overcrowded hospital with broken plumbing,supply shortages, and the grinding reality of poverty. HMS had served Boston City since the hospital’s founding in the South End in 1864,but the School’s role expanded in the 1920s with the appointment of Francis WeldPeabody, Class of 1907, to lead its efforts there and to spearhead the construction ofthe Thorndike Lab, the fi rst clinical research center in a U.S. municipal hospital.Named for surgeon William Thorndike, Class of 1848, the center housed a 17-bedward for clinical research and two fl oors for laboratory investigations. For years, Boston City was affi liated with Harvard, Boston University, and TuftsMedical Schools and was widely acknowledged as a stimulating environment forclinical research, patient care, and medical education. During the pre-Medicare era,the hospital attracted “some of the sickest, poorest, saddest, and often drunkestpeople you can imagine,” notes Daniel Federman ’53, HMS Carl W. WalterDistinguished Professor of Medicine. Patients didn’t know how long they’d wait, butonce seen, “they knew they would receive some of the kindest, most loving, mostdedicated care on Earth.” The Harvard Medical Unit drew students, postgraduate trainees in internalmedicine, and fellows focused on clinical subspecialties and medical research.What is remembered as a glorious tradition, however, ended in the early 1970s whenhospital trustees, facing fi nancial pressures and a falling patient census, decided toaffi liate with BU only. Eventually the hospital was renamed Boston Medical Center. But the Harvard program’s legacy endures: Many members have assumed leadershiproles, earning positions as professors, department chairs, and deans in Boston andbeyond, training new generations of physician–scientists along the way. And the But the Harvard program’s legacy endures: Many members have assumed leadershiproles, earning positions as professors, department chairs, and deans in Boston andbeyond, training new generations of physician–scientists along the way.
George Minot (left), who followedFrancis Peabody as director of theHarvard Medical Unit, stands withEdwin Allen Locke, a Boston CityHospital physician.
Advances in medicine sprang from the work of Thorndike investigators. They werea remarkably productive group, publishing nearly 100 papers during the four yearsbefore Peabody’s death in 1927 and roughly 100 papers a year during the tenures ofsubsequent directors George Minot, Class of 1912, and Castle. Many studies werebased on clinical observations, but basic research and animal experiments also tookplace. Thorndike’s research divisions, formed in the 1950s, embraced investigators whospurred progress in hematology, cardiology, infectious diseases, endocrinology,diabetes, gastroenterology, pulmonary diseases, and nephrology—and later, asmedicine evolved, in genetics and other areas. Finland and his infectious diseases group conducted seminal work on pneumonia,antibiotics, and hospital-acquired infections. This included rigorous studies of theeffi cacy and side effects of almost every antibiotic developed between the late 1930sand the 1970s, among them sulfonamides and penicillin. Finland’s team alsodocumented the emergence of antibiotic-resistant bacterial organisms—in particular,gram-negative bacilli and
Staphylococcus aureus —and their role in causing seriousinfections in patients at Boston City.
Considered the birthplace of modern hematology, the Thorndike produced crucialinsights into the pathophysiology of anemia, the destruction of red blood cells andplatelets, the nature of hemoglobin in normal and sickle cells, therapies forhemophilia, and classifi cations of lymphomas based on cell morphology. In addition,Thorndike researchers discovered that a diet rich in vitamin B12 could successfullythwart pernicious anemia, which, at the time, was a fatal disease affecting 1 to 2percent of adults over age 50. Minot and William Murphy ’20 shared the 1934 NobelPrize in Physiology or Medicine for this work with George Whipple of the Universityof Rochester. Castle extended these fi ndings through years of study on the biologicalcauses of pernicious anemia. As a resident, he ingested and regurgitated hamburgermeat that was then fed to patients through a nasogastric tube, a clever, and, bytoday’s standards, alarming, experiment that demonstrated the existence of anintrinsic factor necessary for the body’s absorption of vitamin B12. Castle wasn’t alone in volunteering himself for research. Years later, physicianVictor Herbert set out to examine folate behavior in adults by eliminating thevitamin from his diet. Ronald Arky, a Thorndike fellow in the 1960s and early 1970swho studied diabetes and metabolism, recalls the effects of that self-study, “OnChristmas Day in 1961, I came into the Thorndike building and found Victor, so weakhe didn’t have the strength to push the elevator button.” Arky is now the Daniel D.Federman Professor of Medicine and Medical Education and master of the School’sFrancis Weld Peabody Society. The School’s research enterprise at Boston City expanded in the early 1960s with the construction of the Channing Laboratory. Led for years by Kass and now part of Brigham and Women’s Hospital, Channing is a locus for research on infectious diseases and epidemiology. The Nurses’ Health Study was begun in 1976 by longtime lab member Frank Speizer, now the HMS Edward H. Kass Distinguished Professor of Medicine, when he headed Channing’s clinical epidemiology division. Among other accomplishments of Channing investigators are studies that advanced the diagnosis and treatment of urinary tract infections. A team led by Kass in the mid-1980s found that toxic shock syndrome, a rare but debilitating, and sometimes fatal, bacterial infection, was triggered by magnesium deficiency, an imbalance that occurred when the mineral was absorbed from the body by fibers in certain tampons. Channing scientists also helped launch the East Boston Neighborhood Health Center, which was directed for more than 40 years by chronic disease epidemiologist James Taylor, and which remains one of the nation’s most successful community health centers.
What made the Harvard Medical Unit unusual? Former trainees and faculty point to the collaborative atmosphere, high expectations, and exceptional colleagues, nurses, technicians, office staff, and patients. “We all spoke to one another in those days,” says Harry Jacob ’58, an intern and fellow from 1958 to 1969, who went on to head the Division of Hematology/Oncology/Bone Marrow Transplant at the University of Minnesota for nearly four decades. “The lunchroom tables were always shared by a mixture of Thorndikers, house staff, and faculty from the three universities teaching at Boston City,” he adds. “Conversation was brisk, funny, and, uncannily, almost always engendered new ideas for laboratory research.”
.....
Supplies were scarce, and medical students often “procured” rubber gloves,tourniquets, needles, and other essentials during their rotations at better-equippedhospitals. House staffers were the ultimate do-it-yourselfers, seeing to everythingfrom collecting specimens and delivering them to the lab to transporting patientsthrough the hospital’s slippery, inclined tunnels.
Those adventures could be hair-raising, as former resident Matthew Liang ’69, nowan HMS professor of medicine at Brigham and Women’s and the chief ofrheumatology at the Boston VA Healthcare System, can attest. He describes ferryinga man with end-stage liver disease and gastrointestinal bleeding along one of thetunnels. The patient weighed at least twice as much as Liang. “I took a running startup a ramp, but I didn’t have enough oomph to clear it, and the gurney drifted to theside and hit the wall,” he says. “I was helpless to prevent the collision.”
That sense of purpose fueled Finland’s extraordinary career as an infectious diseaseresearcher and permeated what was then known as the Harvard Medical Unit atBoston City Hospital, a world-class program of teaching, research, and patient carethat thrived from the mid-1920s through the mid-1970s. It comprised two patient-care services and the research activities of the Thorndike.
The unit was a magnet for physician–scientists eager to train with medical giantssuch as Finland, William Bosworth Castle ’21, Sidney Ingbar ’47, and James Jandl’49. Its researchers had a profound infl uence on medicine, yielding early discoverieson infections, blood disorders, diabetes, liver diseases, and other conditions thatsickened Boston City patients. “There was an excitement and a sense of unlimited potential in the atmosphere,”wrote Kass, an epidemiologist who spent nearly 30 years at Boston City and was theSchool’s William Ellery Channing Professor of Medicine until shortly before hisdeath in 1990. According to many who participated in it, the program fosteredcuriosity, imagination, precision, intellectual rigor, camaraderie, and pride. All thatwithin the confi nes of an underfunded, overcrowded hospital with broken plumbing,supply shortages, and the grinding reality of poverty. HMS had served Boston City since the hospital’s founding in the South End in 1864,but the School’s role expanded in the 1920s with the appointment of Francis WeldPeabody, Class of 1907, to lead its efforts there and to spearhead the construction ofthe Thorndike Lab, the fi rst clinical research center in a U.S. municipal hospital.Named for surgeon William Thorndike, Class of 1848, the center housed a 17-bedward for clinical research and two fl oors for laboratory investigations. For years, Boston City was affi liated with Harvard, Boston University, and TuftsMedical Schools and was widely acknowledged as a stimulating environment forclinical research, patient care, and medical education. During the pre-Medicare era,the hospital attracted “some of the sickest, poorest, saddest, and often drunkestpeople you can imagine,” notes Daniel Federman ’53, HMS Carl W. WalterDistinguished Professor of Medicine. Patients didn’t know how long they’d wait, butonce seen, “they knew they would receive some of the kindest, most loving, mostdedicated care on Earth.” The Harvard Medical Unit drew students, postgraduate trainees in internalmedicine, and fellows focused on clinical subspecialties and medical research.What is remembered as a glorious tradition, however, ended in the early 1970s whenhospital trustees, facing fi nancial pressures and a falling patient census, decided toaffi liate with BU only. Eventually the hospital was renamed Boston Medical Center. But the Harvard program’s legacy endures: Many members have assumed leadershiproles, earning positions as professors, department chairs, and deans in Boston andbeyond, training new generations of physician–scientists along the way. And the But the Harvard program’s legacy endures: Many members have assumed leadershiproles, earning positions as professors, department chairs, and deans in Boston andbeyond, training new generations of physician–scientists along the way.
George Minot (left), who followedFrancis Peabody as director of theHarvard Medical Unit, stands withEdwin Allen Locke, a Boston CityHospital physician.
Advances in medicine sprang from the work of Thorndike investigators. They werea remarkably productive group, publishing nearly 100 papers during the four yearsbefore Peabody’s death in 1927 and roughly 100 papers a year during the tenures ofsubsequent directors George Minot, Class of 1912, and Castle. Many studies werebased on clinical observations, but basic research and animal experiments also tookplace. Thorndike’s research divisions, formed in the 1950s, embraced investigators whospurred progress in hematology, cardiology, infectious diseases, endocrinology,diabetes, gastroenterology, pulmonary diseases, and nephrology—and later, asmedicine evolved, in genetics and other areas. Finland and his infectious diseases group conducted seminal work on pneumonia,antibiotics, and hospital-acquired infections. This included rigorous studies of theeffi cacy and side effects of almost every antibiotic developed between the late 1930sand the 1970s, among them sulfonamides and penicillin. Finland’s team alsodocumented the emergence of antibiotic-resistant bacterial organisms—in particular,gram-negative bacilli and
Staphylococcus aureus —and their role in causing seriousinfections in patients at Boston City.
Considered the birthplace of modern hematology, the Thorndike produced crucialinsights into the pathophysiology of anemia, the destruction of red blood cells andplatelets, the nature of hemoglobin in normal and sickle cells, therapies forhemophilia, and classifi cations of lymphomas based on cell morphology. In addition,Thorndike researchers discovered that a diet rich in vitamin B12 could successfullythwart pernicious anemia, which, at the time, was a fatal disease affecting 1 to 2percent of adults over age 50. Minot and William Murphy ’20 shared the 1934 NobelPrize in Physiology or Medicine for this work with George Whipple of the Universityof Rochester. Castle extended these fi ndings through years of study on the biologicalcauses of pernicious anemia. As a resident, he ingested and regurgitated hamburgermeat that was then fed to patients through a nasogastric tube, a clever, and, bytoday’s standards, alarming, experiment that demonstrated the existence of anintrinsic factor necessary for the body’s absorption of vitamin B12. Castle wasn’t alone in volunteering himself for research. Years later, physicianVictor Herbert set out to examine folate behavior in adults by eliminating thevitamin from his diet. Ronald Arky, a Thorndike fellow in the 1960s and early 1970swho studied diabetes and metabolism, recalls the effects of that self-study, “OnChristmas Day in 1961, I came into the Thorndike building and found Victor, so weakhe didn’t have the strength to push the elevator button.” Arky is now the Daniel D.Federman Professor of Medicine and Medical Education and master of the School’sFrancis Weld Peabody Society. The School’s research enterprise at Boston City expanded in the early 1960s with the construction of the Channing Laboratory. Led for years by Kass and now part of Brigham and Women’s Hospital, Channing is a locus for research on infectious diseases and epidemiology. The Nurses’ Health Study was begun in 1976 by longtime lab member Frank Speizer, now the HMS Edward H. Kass Distinguished Professor of Medicine, when he headed Channing’s clinical epidemiology division. Among other accomplishments of Channing investigators are studies that advanced the diagnosis and treatment of urinary tract infections. A team led by Kass in the mid-1980s found that toxic shock syndrome, a rare but debilitating, and sometimes fatal, bacterial infection, was triggered by magnesium deficiency, an imbalance that occurred when the mineral was absorbed from the body by fibers in certain tampons. Channing scientists also helped launch the East Boston Neighborhood Health Center, which was directed for more than 40 years by chronic disease epidemiologist James Taylor, and which remains one of the nation’s most successful community health centers.
What made the Harvard Medical Unit unusual? Former trainees and faculty point to the collaborative atmosphere, high expectations, and exceptional colleagues, nurses, technicians, office staff, and patients. “We all spoke to one another in those days,” says Harry Jacob ’58, an intern and fellow from 1958 to 1969, who went on to head the Division of Hematology/Oncology/Bone Marrow Transplant at the University of Minnesota for nearly four decades. “The lunchroom tables were always shared by a mixture of Thorndikers, house staff, and faculty from the three universities teaching at Boston City,” he adds. “Conversation was brisk, funny, and, uncannily, almost always engendered new ideas for laboratory research.”
.....
Supplies were scarce, and medical students often “procured” rubber gloves,tourniquets, needles, and other essentials during their rotations at better-equippedhospitals. House staffers were the ultimate do-it-yourselfers, seeing to everythingfrom collecting specimens and delivering them to the lab to transporting patientsthrough the hospital’s slippery, inclined tunnels.
Those adventures could be hair-raising, as former resident Matthew Liang ’69, nowan HMS professor of medicine at Brigham and Women’s and the chief ofrheumatology at the Boston VA Healthcare System, can attest. He describes ferryinga man with end-stage liver disease and gastrointestinal bleeding along one of thetunnels. The patient weighed at least twice as much as Liang. “I took a running startup a ramp, but I didn’t have enough oomph to clear it, and the gurney drifted to theside and hit the wall,” he says. “I was helpless to prevent the collision.”
Serial surveys on the etiology of nosocomial bacteremia have been conducted over a period of years at Boston City Hospital (Boston) and Grady Memorial Hospital (Atlanta). A comparison of the information from these surveys with that from single-period surveys at 10 other hospitals in the United States illustrates changes in the etiology of nosocomial bloodstream infection over the past five decades. Prominent trends include an increased frequency of episodes of polymicrobial bacteremia, an increased frequency
of sequential episodes of bacteremia in the same patient, a resurgence of infection due to Staphylococcus aureus, the recognition of Staphylococcus epidermidis and other components of the endogenous flora as pathogens, and an increased prominence of enterococci, gram-negative aerobic bacilli, anaerobes, and fungi as agents of nosocomial bloodstream infection. Changes in the etiology of nosocomial infection that are not illustrated by the data on bacteremia include an increased appreciation of the importance of viruses, a diminished role for Mycobacterium tuberculosis, and the description of new and unusual pathogens, usually in patients with compromised host defenses. This last trend can be expected to continue
The longest study of bacteremic infection was done at Boston City Hospital during 12 selected years in the period 1935-1972 [8]. This study had the singular advantage of the guidance provided by Maxwell Finland and Mildred Barnes as principal investigator
and data collector, respectively, throughout the entire period. As a result, there was excellent continuity in methods of data collection, recording of data, and definitions used. In 1973 the size, administration, and population of patients at Boston City
Hospital changed markedly [22], and these changes profoundly affected the comparability of information collected subsequently with prior data. Some factors were not necessarily constant or controlled during the study period. These variables included methods and techniques available in the microbiology laboratory and changes in the population of the hospital. These and other factors are discussed in the original report on this study [8]. Cases included in the survey were selected on the basis of laboratory reports of positive blood cultures and the suggestion in patients' records of clinical findings consistent with infection due to the organism recovered from the blood. No case-finding was performed outside the laboratory. This study used an arbitrary definition of nosocomial cases of bacteremia as those occurring on or after the third day of hospitalization; the advantages and disadvantages of such a definition and its applicability to data from the 1972 survey are discussed in the original paper [8]. The 12 years reviewed were selected because new, effective antimicrobial agents had been introduced into general use in the periods between the study years. Certain organisms that are usually considered separately today because of their different epidemiologic implications were lumped together because they could not be distinguished micro biologically in the early years of the study. For example, Klebsiella and Enterobacter species were reported together because they were grouped as "Klebsiella-Aerobacter" or "Klebsiella-Enterobacter' in some study years. In addition, some isolates were arbitrarily excluded from the study; these included Staphylococcus epidermidis, diphtheroids, Bacillus species, and "others considered by the bacteriologist to be contaminants" Observations on the microbial etiology of nosocomial bacteremia in six of the 12 years of the original study [8] are shown in table 1. I have supplied some additional details from the original data sheets to help illustrate some of the trends that were observed. Of note were the markedly different casefatality ratios associated with the different organisms causing bacteremia. Surveillance of bacteremic infection in the NNIS is directed at the entity of primary bacteremia, which is defined as a ,case of bloodstream invasion for which no preceding or simultaneous site of infection with the same pathogen can be identified [21]. Cases involving such a preceding or simultaneous site are defined as secondary. Only in the most recent NNIS report (that for 1980-1982) is secondary bacteremia addressed [26], and the information given is incomplete. Thus, NNIS data on primary bacteremia
are shown for selected years in table 7, but these data are not comparable to those in tables 1-6.
The increase in the average number of organisms isolated from culture per infection is illustrated by the data from Boston City Hospital (table 1). In the early study years, virtually every case involved a single isolate; for example, there were 149 isolates from 147 patients in 1935. In succeeding years the average number of isolates per case gradually increased; by 1972 there were 354 isolates from 280 patients, for an average of 1.3 organisms per patient. This trend has continued to the present; the NNIS data for 1980-1982 [26] indicate the isolation of multiple pathogens in 200Jo of cases, a single pathogen in 650Jo, and no pathogen in the remaining 150Jo. The likelihood of isolation of multiple pathogens is particularly high for patients in intensive care, for diabetics, and for individuals with altered host defenses [27]. For example, one-third of the nosocomial bloodstream infections encountered in a study of patients at a cancer treatment hospital were polymicrobial [20].
Earlier studies either ignored or discounted S. epidermidis (which will be used in this review to represent all pathogenic coagulase-negative staphylococci) as a likely cause of nosocomial bacteremia. For example, the Boston City Hospital study [8] arbitrarily
excluded this organism from consideration. However, studies since 1968 have described S. epidermidis as a true pathogen in 10Jo-100Jo of cases. One of the important trends noted in the Boston City Hospital surveys was the rise in importance of Klebsiella and Enterobacter species (formerly called Aerobacter in many hospitals) as nosocomial pathogens during the years after the introduction of antimicrobial agents (table 1). By 1969 these two organisms together were the pathogens most frequently isolated from the blood of patients with nosocomial bacteremia at Boston City Hospital. In addition, the organisms were important agents at a number of
other hospitals during the 1970s (table 5) and in 1983 at Grady Memorial Hospital (table 2).
Enterobacter (formerly Aerobacter) accounted for a sizable proportion (3 O/o-110/o) of nosocomial bacteremic infections during the 1970s (tables 5 and 7). The percentage has been even a bit higher in surveys during the 1980s. The role of this organism has been
enhanced by its frequent development of resistance to multiple antimicrobial agents and by its propensity to be found in contaminated products and solutions [48]. Particularly notable are those outbreaks associated with Enterobacter-contaminated intravenous fluids [33]. John et al. [48] described strains of Enterobacter as "endemic pathogens in some but not all hospitals" and noted that "they occasionally cause community-acquired infection." These authors thought that any outbreak of infections with Enterobacter in hospitals should lead to a search for contaminated products or solutions. Until the 1960s Serratia species were virtually unknown as a source of nosocomial infection (or perhaps were identified by another name). Subsequently, Serratia has accounted for up to 50/o of nosocomial bacteremia isolates (table 5). Because strains of Serratia are notorious for persistence in
hospital reservoirs, it has been suggested that the frequency of nosocomial infection due to Serratia be used as an indicator of the efficiency of a hospital's infection control program [49]. Klebsiella, Enterobacter, and Serratia are closely related organisms [50]. Other members of the Enterobacteriaceae involved in nosocomial bacteremia and other hospital-acquired infections are Proteus, Providencia, Morganella, Citrobacter, and occasionally Salmonella. These organisms played an increasing role in hospital-acquired infections during the 1940s and early 1950s; their incidence has been relatively stable since then (table 5). The major contexts in which these organisms have been noted are (1) outbreaks associated with intestinal colonization [51] and (2) the presence of resistance to many different antibiotics [52]. Morganella morganii (formerly classified as Proteus morganii or lumped with the other "indole-positive Proteus" organisms) recently has received increased attention [53]; its epidemiologic
characteristics are still being elucidated
Pseudomonas aeruginosa has been an appreciable source of nosocomial bacteremia since the earliest study at Boston City Hospital in 1935 (table 6), yet pseudomonas bacteremia was infrequently reported before the beginning of the antimicrobial era [54]. The relative contribution of P. aeruginosa to the total number of isolates from blood has varied markedly from hospital to hospital and from time to time (tables 6 and 7). At some hospitals (e.g., Hartford Hospital in 1969-1970 and the University of Virginia Hospital in 1975), P. aeruginosa has accounted for more than 100/o of all blood isolates associated with hospital-acquired infections (table 6). High casefatality ratios have characterized infections associated with this organism; the likelihood of death changed little over the decades of the Boston City Hospital study (table 1). P. aeruginosa has been studied extensively, and excellent reviews on its epidemi-ologic characteristics and modes of transmission have recently been compiled [21, 55].
The so-called nonfermenters (gram-negative aerobic bacilli that do not ferment the sugars commonly tested in clinical laboratories) include both Pseudomonas and nonpseudomonas organisms. Among the nonpseudomonas isolates reported in studies
of nosocomial bacteremia, Acinetobacter (formerly called Here/lea) is probably the most prominent. In the Boston City Hospital series, Acinetobacter isolates first were seen in 1961 and continued to play a small role in subsequent years, as at other hospitals (table 6). Acinetobacter was particularly prominent at Grady Memorial Hospital in the 1983 survey (table 2), and its importance is indicated by its mention as a nosocomial pathogen over the past few years in a number of reports [59, 60]. Flavobacterium meningosepticum has caused a variety of nosocomial infections, including bacteremia [61]. This organism appeared sporadically at Boston City Hospital in the years studied but had to be identified in retrospect, since its name was proposed only in the late 1950s. Most hospital outbreaks of infection associated with Flavobacterium have involved environmental contamination of fluids, whether solutions, medications for respiratory therapy, or antiseptics [61].
For many years it was beyond the ability of many laboratories to isolate anaerobic bacilli from the blood [62]. This deficiency perhaps explains to some extent the lack of prominence of these organisms in bacteremia series described before the mid-1960s. In the Boston City Hospital series (table 1), such cases were not noted until 1969, but difficulties with anaerobe detection were specifically noted. Anaerobes played an important role in virtually all of the other series shown in table 6. These organisms accounted for more than 10% of isolates from the blood of patients with bacteremia in some reports and for 20% of isolates at one community hospital.
Bacteroidesfragilis and Clostridium species have been the most frequently reported anaerobic organisms. In part, this predominance may be due to a selection bias, as many laboratories identify only certain anaerobes and provide a morphologic description
of the remainder [63). Among the anaerobes infrequently related to bacteremia, Clostridium difficile appears to be a potential source of hospitalacquired cross-infection [64).
A major trend during the period under review is the rise in importance of fungemia as a nosocomial infection. Of the study years at Boston City Hospital that are listed in table 1, 1953 was the first in which Candida was noted. Other fungi (predominantly Torulopsis) appeared beginning with the 1961 survey. Fungal organisms have been found at levels of 10Jo-120Jo in more recent surveys at other hospitals (table 6). Nationally, fungi accounted for 5% of cases ("primary fungemia"?) in two of the NNIS surveys summarized in table 7. Cases due to fungi were not specifically reported in the most recent survey [26). Hospital-acquired fungemia has been associated with prior antimicrobial therapy, indwelling intravascular catheters, parenteral alimentation, and urinary catheterization [65). In addition, dialysis appears to be a risk factor for infection at sites other than the bloodstream [66). Some of the increase in the frequency of isolation of these organisms may be due to the better methods of identification now available for use in clinical and research laboratories [67). Increasing susceptibility of the average hospitalized patient may also play a part.
Among infections reported in the NNIS summary for 1980-1982, "91% were caused by aerobic bacteria, 2% by anaerobic bacteria, and 6% by fungi. Viruses, protozoa, and parasites each accounted for less than 1 OJo of infections of known etiology" [26). In 1978 viruses caused 0.20Jo of the total number of infections reported to the NNIS [70). No cases of viremia were reported in the series reviewed in tables 1-6, yet viral infections can be a significant cause of cross-infection in the hospital. The importance
of such infections was emphasized by Welliver and McLaughlin, whose surveillance in a children's hospital documented viral infections to be more common than those caused by gram-negative aerobic bacilli [18). Valenti et al., working at a hospital with excellent viral diagnostic facilities, estimated that nosocomial viral infections accounted for "-'50Jo of the cases detected in a 17-month period beginning in 1977 [70). The absence of viral agents from most nosocomial infection surveys results largely from the lack of adequate viral diagnostic facilities in most hospitals.
John E. McGowan, Jr., Changing Etiology of Nosocomial Bacteremia and Fungemia and Other Hospital-Acquired Infections, Reviews of Infectious Diseases , Jul. - Aug., 1985, Vol. 7, Supplement 3.
of sequential episodes of bacteremia in the same patient, a resurgence of infection due to Staphylococcus aureus, the recognition of Staphylococcus epidermidis and other components of the endogenous flora as pathogens, and an increased prominence of enterococci, gram-negative aerobic bacilli, anaerobes, and fungi as agents of nosocomial bloodstream infection. Changes in the etiology of nosocomial infection that are not illustrated by the data on bacteremia include an increased appreciation of the importance of viruses, a diminished role for Mycobacterium tuberculosis, and the description of new and unusual pathogens, usually in patients with compromised host defenses. This last trend can be expected to continue
The longest study of bacteremic infection was done at Boston City Hospital during 12 selected years in the period 1935-1972 [8]. This study had the singular advantage of the guidance provided by Maxwell Finland and Mildred Barnes as principal investigator
and data collector, respectively, throughout the entire period. As a result, there was excellent continuity in methods of data collection, recording of data, and definitions used. In 1973 the size, administration, and population of patients at Boston City
Hospital changed markedly [22], and these changes profoundly affected the comparability of information collected subsequently with prior data. Some factors were not necessarily constant or controlled during the study period. These variables included methods and techniques available in the microbiology laboratory and changes in the population of the hospital. These and other factors are discussed in the original report on this study [8]. Cases included in the survey were selected on the basis of laboratory reports of positive blood cultures and the suggestion in patients' records of clinical findings consistent with infection due to the organism recovered from the blood. No case-finding was performed outside the laboratory. This study used an arbitrary definition of nosocomial cases of bacteremia as those occurring on or after the third day of hospitalization; the advantages and disadvantages of such a definition and its applicability to data from the 1972 survey are discussed in the original paper [8]. The 12 years reviewed were selected because new, effective antimicrobial agents had been introduced into general use in the periods between the study years. Certain organisms that are usually considered separately today because of their different epidemiologic implications were lumped together because they could not be distinguished micro biologically in the early years of the study. For example, Klebsiella and Enterobacter species were reported together because they were grouped as "Klebsiella-Aerobacter" or "Klebsiella-Enterobacter' in some study years. In addition, some isolates were arbitrarily excluded from the study; these included Staphylococcus epidermidis, diphtheroids, Bacillus species, and "others considered by the bacteriologist to be contaminants" Observations on the microbial etiology of nosocomial bacteremia in six of the 12 years of the original study [8] are shown in table 1. I have supplied some additional details from the original data sheets to help illustrate some of the trends that were observed. Of note were the markedly different casefatality ratios associated with the different organisms causing bacteremia. Surveillance of bacteremic infection in the NNIS is directed at the entity of primary bacteremia, which is defined as a ,case of bloodstream invasion for which no preceding or simultaneous site of infection with the same pathogen can be identified [21]. Cases involving such a preceding or simultaneous site are defined as secondary. Only in the most recent NNIS report (that for 1980-1982) is secondary bacteremia addressed [26], and the information given is incomplete. Thus, NNIS data on primary bacteremia
are shown for selected years in table 7, but these data are not comparable to those in tables 1-6.
The increase in the average number of organisms isolated from culture per infection is illustrated by the data from Boston City Hospital (table 1). In the early study years, virtually every case involved a single isolate; for example, there were 149 isolates from 147 patients in 1935. In succeeding years the average number of isolates per case gradually increased; by 1972 there were 354 isolates from 280 patients, for an average of 1.3 organisms per patient. This trend has continued to the present; the NNIS data for 1980-1982 [26] indicate the isolation of multiple pathogens in 200Jo of cases, a single pathogen in 650Jo, and no pathogen in the remaining 150Jo. The likelihood of isolation of multiple pathogens is particularly high for patients in intensive care, for diabetics, and for individuals with altered host defenses [27]. For example, one-third of the nosocomial bloodstream infections encountered in a study of patients at a cancer treatment hospital were polymicrobial [20].
Earlier studies either ignored or discounted S. epidermidis (which will be used in this review to represent all pathogenic coagulase-negative staphylococci) as a likely cause of nosocomial bacteremia. For example, the Boston City Hospital study [8] arbitrarily
excluded this organism from consideration. However, studies since 1968 have described S. epidermidis as a true pathogen in 10Jo-100Jo of cases. One of the important trends noted in the Boston City Hospital surveys was the rise in importance of Klebsiella and Enterobacter species (formerly called Aerobacter in many hospitals) as nosocomial pathogens during the years after the introduction of antimicrobial agents (table 1). By 1969 these two organisms together were the pathogens most frequently isolated from the blood of patients with nosocomial bacteremia at Boston City Hospital. In addition, the organisms were important agents at a number of
other hospitals during the 1970s (table 5) and in 1983 at Grady Memorial Hospital (table 2).
Enterobacter (formerly Aerobacter) accounted for a sizable proportion (3 O/o-110/o) of nosocomial bacteremic infections during the 1970s (tables 5 and 7). The percentage has been even a bit higher in surveys during the 1980s. The role of this organism has been
enhanced by its frequent development of resistance to multiple antimicrobial agents and by its propensity to be found in contaminated products and solutions [48]. Particularly notable are those outbreaks associated with Enterobacter-contaminated intravenous fluids [33]. John et al. [48] described strains of Enterobacter as "endemic pathogens in some but not all hospitals" and noted that "they occasionally cause community-acquired infection." These authors thought that any outbreak of infections with Enterobacter in hospitals should lead to a search for contaminated products or solutions. Until the 1960s Serratia species were virtually unknown as a source of nosocomial infection (or perhaps were identified by another name). Subsequently, Serratia has accounted for up to 50/o of nosocomial bacteremia isolates (table 5). Because strains of Serratia are notorious for persistence in
hospital reservoirs, it has been suggested that the frequency of nosocomial infection due to Serratia be used as an indicator of the efficiency of a hospital's infection control program [49]. Klebsiella, Enterobacter, and Serratia are closely related organisms [50]. Other members of the Enterobacteriaceae involved in nosocomial bacteremia and other hospital-acquired infections are Proteus, Providencia, Morganella, Citrobacter, and occasionally Salmonella. These organisms played an increasing role in hospital-acquired infections during the 1940s and early 1950s; their incidence has been relatively stable since then (table 5). The major contexts in which these organisms have been noted are (1) outbreaks associated with intestinal colonization [51] and (2) the presence of resistance to many different antibiotics [52]. Morganella morganii (formerly classified as Proteus morganii or lumped with the other "indole-positive Proteus" organisms) recently has received increased attention [53]; its epidemiologic
characteristics are still being elucidated
Pseudomonas aeruginosa has been an appreciable source of nosocomial bacteremia since the earliest study at Boston City Hospital in 1935 (table 6), yet pseudomonas bacteremia was infrequently reported before the beginning of the antimicrobial era [54]. The relative contribution of P. aeruginosa to the total number of isolates from blood has varied markedly from hospital to hospital and from time to time (tables 6 and 7). At some hospitals (e.g., Hartford Hospital in 1969-1970 and the University of Virginia Hospital in 1975), P. aeruginosa has accounted for more than 100/o of all blood isolates associated with hospital-acquired infections (table 6). High casefatality ratios have characterized infections associated with this organism; the likelihood of death changed little over the decades of the Boston City Hospital study (table 1). P. aeruginosa has been studied extensively, and excellent reviews on its epidemi-ologic characteristics and modes of transmission have recently been compiled [21, 55].
The so-called nonfermenters (gram-negative aerobic bacilli that do not ferment the sugars commonly tested in clinical laboratories) include both Pseudomonas and nonpseudomonas organisms. Among the nonpseudomonas isolates reported in studies
of nosocomial bacteremia, Acinetobacter (formerly called Here/lea) is probably the most prominent. In the Boston City Hospital series, Acinetobacter isolates first were seen in 1961 and continued to play a small role in subsequent years, as at other hospitals (table 6). Acinetobacter was particularly prominent at Grady Memorial Hospital in the 1983 survey (table 2), and its importance is indicated by its mention as a nosocomial pathogen over the past few years in a number of reports [59, 60]. Flavobacterium meningosepticum has caused a variety of nosocomial infections, including bacteremia [61]. This organism appeared sporadically at Boston City Hospital in the years studied but had to be identified in retrospect, since its name was proposed only in the late 1950s. Most hospital outbreaks of infection associated with Flavobacterium have involved environmental contamination of fluids, whether solutions, medications for respiratory therapy, or antiseptics [61].
For many years it was beyond the ability of many laboratories to isolate anaerobic bacilli from the blood [62]. This deficiency perhaps explains to some extent the lack of prominence of these organisms in bacteremia series described before the mid-1960s. In the Boston City Hospital series (table 1), such cases were not noted until 1969, but difficulties with anaerobe detection were specifically noted. Anaerobes played an important role in virtually all of the other series shown in table 6. These organisms accounted for more than 10% of isolates from the blood of patients with bacteremia in some reports and for 20% of isolates at one community hospital.
Bacteroidesfragilis and Clostridium species have been the most frequently reported anaerobic organisms. In part, this predominance may be due to a selection bias, as many laboratories identify only certain anaerobes and provide a morphologic description
of the remainder [63). Among the anaerobes infrequently related to bacteremia, Clostridium difficile appears to be a potential source of hospitalacquired cross-infection [64).
A major trend during the period under review is the rise in importance of fungemia as a nosocomial infection. Of the study years at Boston City Hospital that are listed in table 1, 1953 was the first in which Candida was noted. Other fungi (predominantly Torulopsis) appeared beginning with the 1961 survey. Fungal organisms have been found at levels of 10Jo-120Jo in more recent surveys at other hospitals (table 6). Nationally, fungi accounted for 5% of cases ("primary fungemia"?) in two of the NNIS surveys summarized in table 7. Cases due to fungi were not specifically reported in the most recent survey [26). Hospital-acquired fungemia has been associated with prior antimicrobial therapy, indwelling intravascular catheters, parenteral alimentation, and urinary catheterization [65). In addition, dialysis appears to be a risk factor for infection at sites other than the bloodstream [66). Some of the increase in the frequency of isolation of these organisms may be due to the better methods of identification now available for use in clinical and research laboratories [67). Increasing susceptibility of the average hospitalized patient may also play a part.
Among infections reported in the NNIS summary for 1980-1982, "91% were caused by aerobic bacteria, 2% by anaerobic bacteria, and 6% by fungi. Viruses, protozoa, and parasites each accounted for less than 1 OJo of infections of known etiology" [26). In 1978 viruses caused 0.20Jo of the total number of infections reported to the NNIS [70). No cases of viremia were reported in the series reviewed in tables 1-6, yet viral infections can be a significant cause of cross-infection in the hospital. The importance
of such infections was emphasized by Welliver and McLaughlin, whose surveillance in a children's hospital documented viral infections to be more common than those caused by gram-negative aerobic bacilli [18). Valenti et al., working at a hospital with excellent viral diagnostic facilities, estimated that nosocomial viral infections accounted for "-'50Jo of the cases detected in a 17-month period beginning in 1977 [70). The absence of viral agents from most nosocomial infection surveys results largely from the lack of adequate viral diagnostic facilities in most hospitals.
John E. McGowan, Jr., Changing Etiology of Nosocomial Bacteremia and Fungemia and Other Hospital-Acquired Infections, Reviews of Infectious Diseases , Jul. - Aug., 1985, Vol. 7, Supplement 3.
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"Beginning in 1849, with lapses of several years at different periods, the question of establishing a hospital for the worthy poor who are citiz6ns of Boston was, at various times, agitated. The project, however, did not take definite shape until 1861. On June 13 of that year it was voted by the City Council that the Committee on City Hospital present plans for a hospital to cost not more than $100,000. This ,Joint Standing Committee of the City Council on City Hospital, consisting of Thomas C. Amory, Jr., Elisha T. Wilson, Prescott Barker, Sumner Crosby and George Sprague, made a formal report to the City Council. At this time the City received a legacy of $26,OOO from Elisha Goodnow, a former resident of South Boston, upon condition that, with other sums of money, it should be devoted to the erection of a hospital, situated in Wards 11 or 12, which at that time were the wards of South Boston and the South End. It was thought that the only suitable sites in South Boston were "too far removed from the city proper," and after much deliberation the present site was decided. According to present advanced hospital science, this was an unfortunate and unhygienic site.
The old Roxbury canal, which carried the sewage of Roxbury to tide-water, ran through one corner of the premises, and a considerable portion of the land ,vas salt water flats, largely of clock mud. The city already was in possession of this land, and, therefore, would not have to expend what was then considered a considerable sum for the purchase of a better site elsewhere. Roxbury, which had many excellent sites for a hospital, was not at that time a part of the City of Boston. The South End was the "court land" of the town, and the Back Bay was practically not in existence.
On March 27, 1858, the City of Boston was authorized to establish a City Hospital (Acts of 1858, chapter 113). By the Acts of the Commonwealth of 1880, chapter 77 4, the Hospital was incorporated under the name of "The Trustees of the City Hospital of the City of Boston.
The Hospital site had previously been used for the so called Agricultural Fair Grounds at the South End of Boston. At high tide the land was flooded. The site is what is known as "made land,'' and gravel used in bringing the ground to proper level was brought from Braintree. The average grade of the surface is 7 feet above the original level, and the ground grade of the building is fully 17 feet above mean low water. At that time this was considered sufficiently solid for a foundation for the buildings, piles being driven to the usual depth. The floors of the basement were 3.5 feet below the ground level. The buildings, as originally constructed, had about forty patients in the basements. It was found after some years, however, that because the basement floors were 3½ feet below the average grade there was a great deal of dampness, and the method of construction did not provide for the exclusion of dampness. Extensive bacteriological experiments were made of the air by cultures taken in the basement, which were found to have innumerable colonies of moulds. Again, the amount of carbonic acid gas in country pastures, or in the woods, is only a small fraction of 1 per cent.; in cities and towns, 2 to 8 per cent. The amount of carbonic acid gas, found not from borings upon the ground, but from various places throughout the basement. showed that there was 5 to 6 per cent. of carbonic acid gas. These conditions caused great deterioration in the Hospital buildings, but they would not have been recognized except for actual scientific tests."
"the old Roxbury canal, before alluded to, a villainous site for a hospital ward."
Previous to the year 1894 the principal pathological work consisted of autopsies, gross pathology, and routine bacteriological work. 1'"or some time this work was done in a mall room about 20 feet by 12 feet, in the basement of the Medical Library Building. The impetus given to pathological research, the vast amount of material in the Hospital, and the increase of bacteriological work on account of the new department for infectious diseases, to say nothing of new and original work, made the Pathological Laboratory
the greatest necessity in keeping pace with the proper development of the Hospital.
The largest and most important addition from the appropriation for "New Buildings" was the creation and election of the South Department. For some years previous to 1892-1895, Ward A for scarlet fever and Ward E for diphtheria had been over-crowded. Cases with both diseases were rejected in large numbers. Antitoxin was as yet unknown. The mortality from diphtheria was very large, in some years exceeding 50 percent of cases admitted. It therefore became the duty of the city to provide a suitable
hospital for these and other infectious diseases - smallpox excepted. The grounds of the Hospital proper were already crowded with buildings, there being a total of 520 beds.
In this period garbage destructors were installed in the main Hospital for the absolute destruction of surgical dressings, food returned uneaten by patients, newspapers, bouquet!!, fruit skim:1, etc., etc. In the l\Iain Hospital about twenty-five barrels of such refuse is destroyed daily. A second. smaller garbage destructor was installed in the Pathological Laboratory for the destruction of offensive and possibly infectious pathological material. A third destructor was installed in the boiler-house, and is a part of the permanent improvement to be relied upon in the destruction of infected bedding and larger things.
The boiler-house, dynamo-house. ambulance station and coal-pocket were located upon land owned by the city, between Albany street and the Roxbury canal. The Hospital Department was allowed to occupy it by favor, and it was not until July 19, 1901, that, by vote of the City Council, this was transferred to the Hospital Department.
The propulsion of air through conduits in some places 10 feet wide by 12 feet high, is attended by too many unexpected leaks and mishaps to attain proper results. The system was never considered a success. Unfortunately, rats soon burrowed between the sewers and the imperfectly constructed air conduits. and air vitiated with sewer gas was pushed into the wards. Members of our Medical Staff who served during the earlier years of the Hospital asserted that all patients with surgical open wounds who were assigned to beds near the air inlets invariably had erysipelaa, pyaemia. or some other septic complication, many of whom died.
At the rear of the boiler house, connected with it, and bordering on the Roxbury canal, is the coal-pocket, with a capacity of 3,000 tons. It contains the coal-handling machinery, consisting of a Procter coal tower and shovel, a Rawson and Morrison type double hoisting engine and Hunt coal conveyor apparatus. The coal is hoisted from vessels lying alongside of the wharf by the steam shovel, and carried by the conveyor from the tower to any desired point in the coal-pocket, where it is automatically dumped. hen required, the coal is drawn from the coal bunker and carried by the conveyor to the boiler-room and dumped into receiving hoppers, which
have a capacity of about 30 tons. From these storage hoppers the coal is drawn off by the firemen into weighing hoppers, where 800 lbs. is weighed at each discharge and then allowed to flow through connecting tubes to a truck car on the floor of the boiler-room. The coal is then shovelled into the furnaces.
Every hospital must have an efficient Sewerage system. In the early years much trouble resulted from the seepage of ooze and flow of tides in some parts of the building, owing to the low grades upon which the Hospital was built. Various expedients were tried, such as tide-gates and other contrivances, hut the difficulty was never wholly remedied until 1878 when the large intercepting sewer for the south side of the city was built. This construction served as a bulkhead, and since that time there has been no trouble.
In the older buildings the sewage was removed by old fashioned "barrel" sewers but the sluggish flow caused the solids to settle, forming a deposit that gradually became obstructive. In the buildings erected from 1872-1876, the rain and surface water were delivered into catch-basins and the soil-pipe sewage into the sewer proper.
1892. A temporary Pathological Laboratory was installed under the library building. No attempt was made to do bacteriological and histological work at the Hospital until early in 1893, when a small, poorly-lighted basement room beneath the present library was obtained for laboratory purposes. Previous to then all microscopic examinations had to be made in the pathological laboratory of the Harvard Medical School
It is an interesting fact that the Board of Trustees of the Boston City Hospital established the first separate hospital for the treatment o( infectious diseases in this country. This is known as the South Department of the Boston City Hospital, and was opened for the admission of patients August 31, 1893. Since the Hospital has been in operation, ten years and four months, during which time nearly 25,000 patients ill with infectious diseases have been treated there. The number of autopsies from 1897 to 1904, inclusive, was 1,934. Almost without exception every autopsy is worked up carefully, both histologically and bacteriologically Three large cabinets each containing 9,ooq slides are filled to overflowing. The result is that men interested in any lesion or almost any disease can find in these cabinets from one to a hundred or more examples of whatever they want to study. A carefully prepared cross reference catalogue renders the material easily accessible.
A History of Boston City Hospital from its Foundation until 1904, Committee of the Hospital Staff (1906).
The old Roxbury canal, which carried the sewage of Roxbury to tide-water, ran through one corner of the premises, and a considerable portion of the land ,vas salt water flats, largely of clock mud. The city already was in possession of this land, and, therefore, would not have to expend what was then considered a considerable sum for the purchase of a better site elsewhere. Roxbury, which had many excellent sites for a hospital, was not at that time a part of the City of Boston. The South End was the "court land" of the town, and the Back Bay was practically not in existence.
On March 27, 1858, the City of Boston was authorized to establish a City Hospital (Acts of 1858, chapter 113). By the Acts of the Commonwealth of 1880, chapter 77 4, the Hospital was incorporated under the name of "The Trustees of the City Hospital of the City of Boston.
The Hospital site had previously been used for the so called Agricultural Fair Grounds at the South End of Boston. At high tide the land was flooded. The site is what is known as "made land,'' and gravel used in bringing the ground to proper level was brought from Braintree. The average grade of the surface is 7 feet above the original level, and the ground grade of the building is fully 17 feet above mean low water. At that time this was considered sufficiently solid for a foundation for the buildings, piles being driven to the usual depth. The floors of the basement were 3.5 feet below the ground level. The buildings, as originally constructed, had about forty patients in the basements. It was found after some years, however, that because the basement floors were 3½ feet below the average grade there was a great deal of dampness, and the method of construction did not provide for the exclusion of dampness. Extensive bacteriological experiments were made of the air by cultures taken in the basement, which were found to have innumerable colonies of moulds. Again, the amount of carbonic acid gas in country pastures, or in the woods, is only a small fraction of 1 per cent.; in cities and towns, 2 to 8 per cent. The amount of carbonic acid gas, found not from borings upon the ground, but from various places throughout the basement. showed that there was 5 to 6 per cent. of carbonic acid gas. These conditions caused great deterioration in the Hospital buildings, but they would not have been recognized except for actual scientific tests."
"the old Roxbury canal, before alluded to, a villainous site for a hospital ward."
Previous to the year 1894 the principal pathological work consisted of autopsies, gross pathology, and routine bacteriological work. 1'"or some time this work was done in a mall room about 20 feet by 12 feet, in the basement of the Medical Library Building. The impetus given to pathological research, the vast amount of material in the Hospital, and the increase of bacteriological work on account of the new department for infectious diseases, to say nothing of new and original work, made the Pathological Laboratory
the greatest necessity in keeping pace with the proper development of the Hospital.
The largest and most important addition from the appropriation for "New Buildings" was the creation and election of the South Department. For some years previous to 1892-1895, Ward A for scarlet fever and Ward E for diphtheria had been over-crowded. Cases with both diseases were rejected in large numbers. Antitoxin was as yet unknown. The mortality from diphtheria was very large, in some years exceeding 50 percent of cases admitted. It therefore became the duty of the city to provide a suitable
hospital for these and other infectious diseases - smallpox excepted. The grounds of the Hospital proper were already crowded with buildings, there being a total of 520 beds.
In this period garbage destructors were installed in the main Hospital for the absolute destruction of surgical dressings, food returned uneaten by patients, newspapers, bouquet!!, fruit skim:1, etc., etc. In the l\Iain Hospital about twenty-five barrels of such refuse is destroyed daily. A second. smaller garbage destructor was installed in the Pathological Laboratory for the destruction of offensive and possibly infectious pathological material. A third destructor was installed in the boiler-house, and is a part of the permanent improvement to be relied upon in the destruction of infected bedding and larger things.
The boiler-house, dynamo-house. ambulance station and coal-pocket were located upon land owned by the city, between Albany street and the Roxbury canal. The Hospital Department was allowed to occupy it by favor, and it was not until July 19, 1901, that, by vote of the City Council, this was transferred to the Hospital Department.
The propulsion of air through conduits in some places 10 feet wide by 12 feet high, is attended by too many unexpected leaks and mishaps to attain proper results. The system was never considered a success. Unfortunately, rats soon burrowed between the sewers and the imperfectly constructed air conduits. and air vitiated with sewer gas was pushed into the wards. Members of our Medical Staff who served during the earlier years of the Hospital asserted that all patients with surgical open wounds who were assigned to beds near the air inlets invariably had erysipelaa, pyaemia. or some other septic complication, many of whom died.
At the rear of the boiler house, connected with it, and bordering on the Roxbury canal, is the coal-pocket, with a capacity of 3,000 tons. It contains the coal-handling machinery, consisting of a Procter coal tower and shovel, a Rawson and Morrison type double hoisting engine and Hunt coal conveyor apparatus. The coal is hoisted from vessels lying alongside of the wharf by the steam shovel, and carried by the conveyor from the tower to any desired point in the coal-pocket, where it is automatically dumped. hen required, the coal is drawn from the coal bunker and carried by the conveyor to the boiler-room and dumped into receiving hoppers, which
have a capacity of about 30 tons. From these storage hoppers the coal is drawn off by the firemen into weighing hoppers, where 800 lbs. is weighed at each discharge and then allowed to flow through connecting tubes to a truck car on the floor of the boiler-room. The coal is then shovelled into the furnaces.
Every hospital must have an efficient Sewerage system. In the early years much trouble resulted from the seepage of ooze and flow of tides in some parts of the building, owing to the low grades upon which the Hospital was built. Various expedients were tried, such as tide-gates and other contrivances, hut the difficulty was never wholly remedied until 1878 when the large intercepting sewer for the south side of the city was built. This construction served as a bulkhead, and since that time there has been no trouble.
In the older buildings the sewage was removed by old fashioned "barrel" sewers but the sluggish flow caused the solids to settle, forming a deposit that gradually became obstructive. In the buildings erected from 1872-1876, the rain and surface water were delivered into catch-basins and the soil-pipe sewage into the sewer proper.
1892. A temporary Pathological Laboratory was installed under the library building. No attempt was made to do bacteriological and histological work at the Hospital until early in 1893, when a small, poorly-lighted basement room beneath the present library was obtained for laboratory purposes. Previous to then all microscopic examinations had to be made in the pathological laboratory of the Harvard Medical School
It is an interesting fact that the Board of Trustees of the Boston City Hospital established the first separate hospital for the treatment o( infectious diseases in this country. This is known as the South Department of the Boston City Hospital, and was opened for the admission of patients August 31, 1893. Since the Hospital has been in operation, ten years and four months, during which time nearly 25,000 patients ill with infectious diseases have been treated there. The number of autopsies from 1897 to 1904, inclusive, was 1,934. Almost without exception every autopsy is worked up carefully, both histologically and bacteriologically Three large cabinets each containing 9,ooq slides are filled to overflowing. The result is that men interested in any lesion or almost any disease can find in these cabinets from one to a hundred or more examples of whatever they want to study. A carefully prepared cross reference catalogue renders the material easily accessible.
A History of Boston City Hospital from its Foundation until 1904, Committee of the Hospital Staff (1906).
A History of Boston City Hospital from its Foundation until 1904, Committee of the Hospital Staff (1906).
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October 29, 1968. Description on the back of the photograph reads: "The Board recommended that the building program already begun at Boston City Hospital proceed to completion. Demolition of the
South Department, shown above, will make way for new buildings in the first phase of the program."
During the ten years and four months that the South Department has been in operation there have been 24,932 patients admitted. The deaths during this time have been 2,953, giving a ratio of mortality of 11.84 per cent.
A History of Boston City Hospital from its Foundation until 1904, Committee of the Hospital Staff (1906).
Curry, J. J , A Report on the Bacteriological Investigations of Three Hundred and Twelve Cases of Surgical Infection. Medical and Surgical Reports of the Boston City Hospital, 1897, VIII., 111-128. Also, Boston Medical and Surgical Journal, 1897, CXXXVI., 374.
Leary, T., On an unusual Pathogenic Action of the Diphtheria Bacilli. Medical and Surgical Reports of the Boston City Hospital, 1897, VIII., 129-133.
Munro, J. C, and Councilman, W. T., A Case of Amoebic Abscesses of the Liver, with Autopsy. Medical and Surgical Reports of the Boston City Hospital, 1897, VIII., 352-338.
Strong, L. W., Two Cases of Amoebic Enteritis. Medical and Surgical Reports of the Boston City Hospital, 1898, IX., 249-259.
Walker, D. H., Actinomycosis. Medical and Surgical Reports of the Boston City Hospital, 1899, X., 130-137
Pratt, J. H., A Case of Filariasis in which the adult worms were found. Transactions of Association of American Physicians, 1900.
Pratt, Joseph H., and Fulton, F. T. Report of Cases in which Bacillus ^Erogenes Capsulatus was Found. Boston Medical and Surgical Journal, 1900, CXLII., 599.
Mallory, F. B., Scarlet Fever. Protozoon-like Bodies found in Four Cases. Journal of Medical Research, 1904, X., 483-492.
Wolbaoh, S. B., The Life Cycle of the Organism of " Dermatitis Coccidioides." Journal of Medical Research, 1904, XIII., 53.
Duval, C. W., Die Protozoen des Scharlachfiebers. Virchow's Archiv., 1905, CLXXIX., 485-498
Two discoveries by members of the pathological staff deserve mention here, because they may later prove of nmch value. The first of these is the confirmation of the work of Wasielewski and Guarniere that the peculiar bodies found in the cytoplasm of the epithelial cells in the lesions of variola and vaccinia represent different stages in the life cycle of a protozoon (cjtoryctes variolae), and the demonstration that another cycle of development of the protozoon takes place within the cell nuclei in variola, but not in vaccinia. This original observation has since led to a large amount of experimental work on monkeys, carried on for a year in the Philippines and not yet published. The second discovery was the finding of protozoon-like bodies in the skin of several scarlet fever cases. This has since been confirmed by obtaining the bodies from living patients by means of vesication of the skin, and has led to some experimental work on monkeys, which is still in progress.
In April, 1906, the patient presented himself at the Hospital to show how well he was. He had been free from pain ; his skin was in perfect condition ; he had become rather stout, and was walking oh miles a day for exercise. The use of the X-Rays as a means of treating certain new growths has a special interest for us, because cases of these diseases treated at the Hospital are among the earliest mwhich the X-Rays were so employed, and, so far as I am aware, were the earliest in which it was demonstrated, as
already mentioned, that the use of the X-Rays was followed hy healing without in any way acting as a cautery ; that is to say, that the mild use of the X-Rays, without producing any hurn, caused some superficial new growths to heal. Figs. 26 and 27, pages 346 and 347, show a case of rodent ulcer of the nose, before and after treatment by the X-Rays. This account of the X-Ray department should not be closed without a reference at least to the use of radium as a therapeutic agent, its action is so similar to that of the
X-Rays. Dr. William Rollins was the first person to appreciate that radium salts would probably be useful in tlie treatmentof
certain diseases. The earliest specimen used was weak and the results obtained were not conclusive, but in 1903 Dr. Williams obtained in Europe some pure radium bromide, and has used it since that time at the Hospital, with excellent results, in small superficial new growths and skin diseases such as eczema and psoriasis. Radium is not of service in diagnosis.
A History of Boston City Hospital from its Foundation until 1904, Committee of the Hospital Staff (1906).
During the ten years and four months that the South Department has been in operation there have been 24,932 patients admitted. The deaths during this time have been 2,953, giving a ratio of mortality of 11.84 per cent.
A History of Boston City Hospital from its Foundation until 1904, Committee of the Hospital Staff (1906).
Curry, J. J , A Report on the Bacteriological Investigations of Three Hundred and Twelve Cases of Surgical Infection. Medical and Surgical Reports of the Boston City Hospital, 1897, VIII., 111-128. Also, Boston Medical and Surgical Journal, 1897, CXXXVI., 374.
Leary, T., On an unusual Pathogenic Action of the Diphtheria Bacilli. Medical and Surgical Reports of the Boston City Hospital, 1897, VIII., 129-133.
Munro, J. C, and Councilman, W. T., A Case of Amoebic Abscesses of the Liver, with Autopsy. Medical and Surgical Reports of the Boston City Hospital, 1897, VIII., 352-338.
Strong, L. W., Two Cases of Amoebic Enteritis. Medical and Surgical Reports of the Boston City Hospital, 1898, IX., 249-259.
Walker, D. H., Actinomycosis. Medical and Surgical Reports of the Boston City Hospital, 1899, X., 130-137
Pratt, J. H., A Case of Filariasis in which the adult worms were found. Transactions of Association of American Physicians, 1900.
Pratt, Joseph H., and Fulton, F. T. Report of Cases in which Bacillus ^Erogenes Capsulatus was Found. Boston Medical and Surgical Journal, 1900, CXLII., 599.
Mallory, F. B., Scarlet Fever. Protozoon-like Bodies found in Four Cases. Journal of Medical Research, 1904, X., 483-492.
Wolbaoh, S. B., The Life Cycle of the Organism of " Dermatitis Coccidioides." Journal of Medical Research, 1904, XIII., 53.
Duval, C. W., Die Protozoen des Scharlachfiebers. Virchow's Archiv., 1905, CLXXIX., 485-498
Two discoveries by members of the pathological staff deserve mention here, because they may later prove of nmch value. The first of these is the confirmation of the work of Wasielewski and Guarniere that the peculiar bodies found in the cytoplasm of the epithelial cells in the lesions of variola and vaccinia represent different stages in the life cycle of a protozoon (cjtoryctes variolae), and the demonstration that another cycle of development of the protozoon takes place within the cell nuclei in variola, but not in vaccinia. This original observation has since led to a large amount of experimental work on monkeys, carried on for a year in the Philippines and not yet published. The second discovery was the finding of protozoon-like bodies in the skin of several scarlet fever cases. This has since been confirmed by obtaining the bodies from living patients by means of vesication of the skin, and has led to some experimental work on monkeys, which is still in progress.
In April, 1906, the patient presented himself at the Hospital to show how well he was. He had been free from pain ; his skin was in perfect condition ; he had become rather stout, and was walking oh miles a day for exercise. The use of the X-Rays as a means of treating certain new growths has a special interest for us, because cases of these diseases treated at the Hospital are among the earliest mwhich the X-Rays were so employed, and, so far as I am aware, were the earliest in which it was demonstrated, as
already mentioned, that the use of the X-Rays was followed hy healing without in any way acting as a cautery ; that is to say, that the mild use of the X-Rays, without producing any hurn, caused some superficial new growths to heal. Figs. 26 and 27, pages 346 and 347, show a case of rodent ulcer of the nose, before and after treatment by the X-Rays. This account of the X-Ray department should not be closed without a reference at least to the use of radium as a therapeutic agent, its action is so similar to that of the
X-Rays. Dr. William Rollins was the first person to appreciate that radium salts would probably be useful in tlie treatmentof
certain diseases. The earliest specimen used was weak and the results obtained were not conclusive, but in 1903 Dr. Williams obtained in Europe some pure radium bromide, and has used it since that time at the Hospital, with excellent results, in small superficial new growths and skin diseases such as eczema and psoriasis. Radium is not of service in diagnosis.
A History of Boston City Hospital from its Foundation until 1904, Committee of the Hospital Staff (1906).
In 1968, the Finland Laboratory for Infectious Diseases was established at Boston City Hospital in honor of Dr. Maxwell Finland, a leading clinical investigator in infectious diseases. When academic and clinical responsibility for Boston City Hospital passed to Boston University in 1973, these laboratories were incorporated into the research programs of the Boston University Department of Medicine faculty. Maxwell Finland's career in infectious diseases spanned more than 50 years, from his appointment as the Pneumonia Resident at Boston City Hospital in 1928
HA infections were diagnosed 11-25 days after admission; sick longer than CA; and more died and a lot died. More than ½ the HA infections died in the hospital.
Maxwell Finland and Mildred W. Barnes, Duration of Hospitalization for Bacteremic Infections at Boston City Hospital during 12 Selected Years between 1935 and 1972, The Journal of Infectious Diseases, Vol. 138, No. 6 (Dec., 1978), pp. 837-848, Oxford University Press
Tucker, Greenleaf R.. "IX. MICRO-ORGANISMS IN THE AIR OF THE BOSTON CITY HOSPITAL". Volume II State Sanitation: A Review of the Work of the Massachusetts State Board of Health, Volume II, Cambridge, MA and London, England: Harvard University Press, 1917, pp. 65-76.
Tucker, Greenleaf R, The number and distribution of micro-organisms in the air of the Boston City Hospital: with some carbonic acid determinations, Medicine in the Americas, 1610-1920, p. [161]-230, (1889).
Maxwell Finland and Mildred W. Barnes, Duration of Hospitalization for Bacteremic Infections at Boston City Hospital during 12 Selected Years between 1935 and 1972, The Journal of Infectious Diseases, Vol. 138, No. 6 (Dec., 1978), pp. 837-848, Oxford University Press
Tucker, Greenleaf R.. "IX. MICRO-ORGANISMS IN THE AIR OF THE BOSTON CITY HOSPITAL". Volume II State Sanitation: A Review of the Work of the Massachusetts State Board of Health, Volume II, Cambridge, MA and London, England: Harvard University Press, 1917, pp. 65-76.
Tucker, Greenleaf R, The number and distribution of micro-organisms in the air of the Boston City Hospital: with some carbonic acid determinations, Medicine in the Americas, 1610-1920, p. [161]-230, (1889).
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The Thorndike Memorial Laboratory. The year 1925 was the second complete year since the formal opening of the Thorndike Memorial Laboratory, and experience has demonstrated that the Board of Trustees provided wisely and adequately for this Depart¬ ment of Clinical Research. The nonresident professional staff consists at present of eight members, the resident staff of four members, and there is a technical and secre¬ tarial staff of seven. In addition there have been six volunteer assistants who have worked for periods ranging from a few months to more than a year. It has been a great pleasure to have associated with us physi¬ cians from various foreign countries, including Dr. Edouard Willocx and Dr. Robert Verhoogen from Bel¬ gium, Fellows of the Commission for Relief in Belgium Education Foundation, Dr. Alberto Hurtado from Peru, and Dr. Victor Hugh Norris of Singapore, Straits Settle¬ ments, a Fellow of the Rockefeller Foundation. There have been few changes in the personnel of the staff during the year. Dr. Millard Smith was appointed in April, 1925, and Dr. Soma Weiss, formerly resident physician on the Second (Cornell) Medical Division, Bellevue Hospital, New York, came to us in September. Dr. Charles A. Doan left in September to take a position at the Rockefeller Institute. The Staff has already learned to appreciate the extraordinary opportunities for the investigation of disease offered by a fully equipped research department which is an integral part of a large Municipal Hospital. The wards and Out-Patient Department of The Boston City Hospital offer such a wealth of clinical material that almost any stage of the diseases likely to be investi¬ gated can be procured at short notice, and as a result of the hearty co-operation of the members of the Visiting Staff, there has been no difficulty in transferring patients to the Thorndike Ward for special study. At the present time the chief clinical subjects under investiga¬ tion are pernicious anemia, chronic nephritis and hyper¬ tension, certain aspects of heart disease (including the rate of the circulation), and diabetes in children. One laboratory has been assigned to Doctor Lennox, of the Department of Neurology, who is studying epilepsy. In addition to these clinical investigations a number of researches are also being carried on which are at present of a strictly laboratory nature but all of which are aimed more or less directly at elucidating the problems of disease in man. The work of the laboratory has been greatly facilitated by the addition to the Animal House, which was finished during the current year, and which has made possible such animal experimentation as must necessarily be carried on before or simultaneously with the study of disease in the human being. The number of ward patients treated in the Thorndike Memorial Ward during the year 1925 was 108. Thirty-five of these were transfers from other wards in the hospital.
DOCUMENTS OF THE CITY OF BOSTON, FOR THE YEAR 1926. IN FOUR VOLUMES. VOLUME II. CONTAINING CITY DOCUMENTS FROM NO. 14 TO NO. 35, INCLUSIVE. CITY OF BOSTON PRINTING DEPARTMENT 1927
Special Laboratory and Animal House. To the original appropriation of $25,000.00 granted in January, 1925, for construction of a Special Laboratory and Animal House, an additional appropriation of $7,500 was added in June. The Animal House, which is to be used temporarily as a Special Laboratory, is nearing completion. It is situated on the Hospital grounds adjacent to the Path¬ ological Building and faces Albany street. It is a brick building of two stories, and has a basement for storage, piping, ventilation, etc. The exterior is trimmed with stone and backed with terra cotta. The building is supported on piles and has reinforced con¬ crete floors supported by steel columns and beams inside, and exterior walls. The floors of the corridors, media room, bacteriology room, filtration room and office are covered with linoleum. The partitions are nonsupporting and are made of terra cotta blocks. There is no interior plaster¬ ing, or wood finish outside of doors and frames and quarter-rounds at windows and at door frames. North Carolina pine is used for this interior finish Plans for this building were drawn by Edward T. P. Graham, Architect; and the contract for construction was awarded to Walsh Brothers for the sum of $23,988
During the year animal cages were erected and in¬ stalled on the roof of the Thorndike Memorial Building, this work being done by P. J. Dinn and Company.
DOCUMENTS OF THE CITY OF BOSTON, FOR THE YEAR 1926. IN FOUR VOLUMES. VOLUME II. CONTAINING CITY DOCUMENTS FROM NO. 14 TO NO. 35, INCLUSIVE. CITY OF BOSTON PRINTING DEPARTMENT 1927
Blood Laboratory. Following is the report on the Blood Laboratory for the term February 1, 1925, to December 31, 1925, inclusive:
During this time the laboratory made 2,550 examina¬ tions of the blood, of which 873 were on regular house cases, 912 on out-patients and 765 on cases seen in consultation. In addition 117 transfusion donors were supplied from our directory and 359 transfusion group¬ ings were tested. These figures do not include a con¬ siderable number of cases in which blood was taken for Wassermann tests in other laboratories —mostly on individuals who offered themselves as transfusion donors. In addition to this work the technicians have kept the laboratory records and made up many stains and reagents not otherwise procurable. About six technicians from other departments or other institutions have received instruction in the laboratory during the year. The resignation of Doctor Buckman in September was a great loss to the laboratory and has seriously disrupted its work in other lines than that of regular routine. The resignation of Miss MacNaugher, tech¬ nician, and the illness of Doctor Larrabee have kept the laboratory short-handed and have delayed the plans for reorganization. Recently a second technician has been appointed and the work will doubtless go on in a more satisfactory manner. Doctor Hornor has agreed to supervise the laboratory work of the house officers of the First Medical Service, with which the Blood Service is allied, and the relations between the two laboratories have still to be worked out.
A statistical study of our many transfusions is being prepared by Doctors Larrabee and Dameshek, and Doctor Hallisey has continued his work on the fragility of the red corpuscles in diluted sera.
DOCUMENTS OF THE CITY OF BOSTON, FOR THE YEAR 1926. IN FOUR VOLUMES. VOLUME II. CONTAINING CITY DOCUMENTS FROM NO. 14 TO NO. 35, INCLUSIVE. CITY OF BOSTON PRINTING DEPARTMENT 1927
South Department. During the thirty-one years that the department has been in operation, 74,809 patients have been received, nearly all ill with an infectious disease
DOCUMENTS OF THE CITY OF BOSTON, FOR THE YEAR 1926. IN FOUR VOLUMES. VOLUME II. CONTAINING CITY DOCUMENTS FROM NO. 14 TO NO. 35, INCLUSIVE. CITY OF BOSTON PRINTING DEPARTMENT 1927
Boston City Hospital Revenue 1919, 1927....
"Sales of bones and trimmings..."
1927: 962/yr in Hospital Proper, 257/year in South Dept, 16/year from Haymarket Sq Relief Station.
Total revenue: sales of bones, trimmings, old material; automatic telephone commission; birth fees; interest on bank account; rent for West Dept., sale of x-ray plates, sale of hospital junk.
DOCUMENTS OF THE CITY OF BOSTON, FOR THE YEAR 1926. IN FOUR VOLUMES. VOLUME II. CONTAINING CITY DOCUMENTS FROM NO. 14 TO NO. 35, INCLUSIVE. CITY OF BOSTON PRINTING DEPARTMENT 1927
Special Laboratory and Animal House. To the original appropriation of $25,000.00 granted in January, 1925, for construction of a Special Laboratory and Animal House, an additional appropriation of $7,500 was added in June. The Animal House, which is to be used temporarily as a Special Laboratory, is nearing completion. It is situated on the Hospital grounds adjacent to the Path¬ ological Building and faces Albany street. It is a brick building of two stories, and has a basement for storage, piping, ventilation, etc. The exterior is trimmed with stone and backed with terra cotta. The building is supported on piles and has reinforced con¬ crete floors supported by steel columns and beams inside, and exterior walls. The floors of the corridors, media room, bacteriology room, filtration room and office are covered with linoleum. The partitions are nonsupporting and are made of terra cotta blocks. There is no interior plaster¬ ing, or wood finish outside of doors and frames and quarter-rounds at windows and at door frames. North Carolina pine is used for this interior finish Plans for this building were drawn by Edward T. P. Graham, Architect; and the contract for construction was awarded to Walsh Brothers for the sum of $23,988
During the year animal cages were erected and in¬ stalled on the roof of the Thorndike Memorial Building, this work being done by P. J. Dinn and Company.
DOCUMENTS OF THE CITY OF BOSTON, FOR THE YEAR 1926. IN FOUR VOLUMES. VOLUME II. CONTAINING CITY DOCUMENTS FROM NO. 14 TO NO. 35, INCLUSIVE. CITY OF BOSTON PRINTING DEPARTMENT 1927
Blood Laboratory. Following is the report on the Blood Laboratory for the term February 1, 1925, to December 31, 1925, inclusive:
During this time the laboratory made 2,550 examina¬ tions of the blood, of which 873 were on regular house cases, 912 on out-patients and 765 on cases seen in consultation. In addition 117 transfusion donors were supplied from our directory and 359 transfusion group¬ ings were tested. These figures do not include a con¬ siderable number of cases in which blood was taken for Wassermann tests in other laboratories —mostly on individuals who offered themselves as transfusion donors. In addition to this work the technicians have kept the laboratory records and made up many stains and reagents not otherwise procurable. About six technicians from other departments or other institutions have received instruction in the laboratory during the year. The resignation of Doctor Buckman in September was a great loss to the laboratory and has seriously disrupted its work in other lines than that of regular routine. The resignation of Miss MacNaugher, tech¬ nician, and the illness of Doctor Larrabee have kept the laboratory short-handed and have delayed the plans for reorganization. Recently a second technician has been appointed and the work will doubtless go on in a more satisfactory manner. Doctor Hornor has agreed to supervise the laboratory work of the house officers of the First Medical Service, with which the Blood Service is allied, and the relations between the two laboratories have still to be worked out.
A statistical study of our many transfusions is being prepared by Doctors Larrabee and Dameshek, and Doctor Hallisey has continued his work on the fragility of the red corpuscles in diluted sera.
DOCUMENTS OF THE CITY OF BOSTON, FOR THE YEAR 1926. IN FOUR VOLUMES. VOLUME II. CONTAINING CITY DOCUMENTS FROM NO. 14 TO NO. 35, INCLUSIVE. CITY OF BOSTON PRINTING DEPARTMENT 1927
South Department. During the thirty-one years that the department has been in operation, 74,809 patients have been received, nearly all ill with an infectious disease
DOCUMENTS OF THE CITY OF BOSTON, FOR THE YEAR 1926. IN FOUR VOLUMES. VOLUME II. CONTAINING CITY DOCUMENTS FROM NO. 14 TO NO. 35, INCLUSIVE. CITY OF BOSTON PRINTING DEPARTMENT 1927
Boston City Hospital Revenue 1919, 1927....
"Sales of bones and trimmings..."
1927: 962/yr in Hospital Proper, 257/year in South Dept, 16/year from Haymarket Sq Relief Station.
Total revenue: sales of bones, trimmings, old material; automatic telephone commission; birth fees; interest on bank account; rent for West Dept., sale of x-ray plates, sale of hospital junk.
"Surgeon administers ether and Dr. Cheever operates on patient in Sears Building amphitheater" Boston City Hospital, circa 1880-1900
May 22, 1968. 1 photograph : film negative ; 35 mm (roll format). [fits timeline of demolition of South Dept. in Oct. 1968] https://www.digitalcommonwealth.org/search/commonwealth:t148hh402
BIOLOGICAL TESTING INVOLVING HUMAN SUBJECTS BY THE DEPARTMENT OF DEFENSE, 1977
MONDAY, MAY 23, 1977 U. S. SE-NATE. SUBCOMMITTEE ON HEALTH AND SCIENTIFIC RESEARCH OF TIHE CO3M3irEE ON HU31A\N RESOURCES,
W1ashington., D.C. The subcommittee met, pursuant to notice, at 9.40 a.m., in room 4232, Dirksen Senate Office Building, Senator Edward M. Kennedy (chairman of the subcommittee) presiding. Present: Senators Kennedy and Schweiker.
Biological testing involving human subjects by the Department of Defense, 1977 : hearings before the Subcommittee on Health and Scientific Research of the Committee on Human Resources, United States Senate, Ninety-fifth Congress, first session ... March 8 and May 23, 1977. ALWD 7th ed.
MARYLAND STATE DEPARTMENT OF HEALTH AND MENTAL HYGIENELABORATORIES ADMINISTRATIONSTATEMENT ON THE USE OF THE SIMULANT SERRATIA MARCESCENSIN AEROSOL STUDIES OF HUMAN POPULATION CENTERS
My name is J. Mehsen Joseph, Ph.D., and I am Director of the Laboratories Administration, Maryland State Department of Health and Mental Hygiene, and Assistant Professor of Microbiology, University of Maryland, Baltimore, Maryland. Because of the public concern over the conduct of experiments by the Army in which the bacterium Serratia marcescans was used as an aerosol over the city of San Francisco in the early 1950's, I wish to describe the early history of this bacterium, to discuss its potential for causing disease in man, and to comment on the health hazard associated with the study. Serratia marcescens has had a long and remarkable history with classical accounts by historians of the appearance of "miraculous blood" appearing on bread dating back to the siege of Tyre in Lebanon in 332 B.C. This remarkable manifestation struck fear in the hearts of the superstitious and credulous people of the Middle Ages. However, early in the 19th Century the phenomenon was examined in a scientific matter and the causative agent identified and characterized. Doctor Bartolomeo Bizio, a young pharmacist, was the first to observe reddened polenta (corn meal mush), and by a series of lengthy and ingenious experiments, he concluded that the red mucilaginous substance was the result of activity of masses of very small bodies.290-2-Numerous studies of red pigmentation of foods, particularly bread and starchy foods, were recorded in the history of this bacterium beginning in 332 B.C. and continuing through the 19th Century. However, during that period, reports of clinical illness among those who consumed these foods were extremely rare occurrences. Thus, the bacterium was considered to have little or no pathogenic potential for man.Since its discovery in 1823 by Bizio, Serratia marcescenshas been recognized as a biological entity and during its early history was considered to be a saprophyte which was relatively avirulent. The organism is widely distributed in nature and is found naturally in water, soil and as a contaminant of food.As standard bacteriological techniques were developed to distinguish among the microorganisms closely related to Serratia marcescens, investigators began to recognize non-pigmented strains of the latter.In 1959 the Center for Disease Control, USPHS, in Atlanta reported on a study in which 75 per cent of over 200 strains examined failed to produce pigment. Failure to recognize this fact probably accounted for the infrequent reports of recovery of this organism from infections in man. As a result of this finding, recognition of non-pigmented varieties of S. marcescens, combined with the extensive use of broad spectrum antibiotics among hospitalized patients, probably accounts for the increased frequency with which hospitalacquired infections by this organism are now being recognized.291-3-In 1967 at the Boston City Hospital an increased incidence of isolations of Serratia marcescens was noted. In 1970 a study of the occurrence of Serratia infections at the same hospital revealed that non-pigmented strains of this bacterium were more common than the pigmented variety, and that many clinicalbacteriology laboratories were unable to correctly identify these non-pigmented forms.Since 1913 when the first case of Serratia infection inman was described, isolated reports have stressed the potential pathogenicity of this organism for man. In 1962 the Communicable Disease Center pointed out the nosocomial nature of most Serratia marcescens infections. Several hospital outbreaks involving urinary tract infections and respiratory tract infections and two epidemics in nurseries for newborn infants have been described.Infections also have been noted to occur at the site of indwelling urinary and intravenous catheters and after lumbar punctures or peritoneal dialysis. Previous antibiotic therapy and underlying chronic debilitating disease may also predispose to serious Serratia infection. Urinary tract infection has been the most frequent site of Serratia infections but the epidemiology of such hospital outbreaks is still unclear and any attempts to determine the source of the organism has been unrevealing. However, most patients had indwelling catheterization and urinary tract abnormality. Also, Serratia marcescens is isolated frequently from the respiratory tract but these isolations are infrequently of clinical significance.2924-Hospital outbreaks of respiratory infection are usually associated with Serratia contaminatibn of respiratory equipment. Associated clinical illness was either pneumonia, empyema, or lung abscess.Prior to 1960 Serratia marcescens was considered a commongarden variety microorganism which was so benign that it was not capable of producing clinical illness in man in its own right.Because of its apparent nonpathogenic potential and its characteristic red pigmentation and ease of isolation, Serratia marcescens was commonly used as a tracer bacterium in numerous studies.It was intentionally spread in hospitals to study bacterial drifting and settling as an aid to understanding the spread of hospital cross-infections. Classical experiments in epidemiology were routinely conducted to demonstrate to students the basic principle of establishing the index case of infection by a microorganism.Aerosolization of the test organism was used in courses in Microbiology to demonstrate bacteriological air sampling techniques.The organism was intentionally painted on the gums of patients to demonstrate its passage from the oral cavity to the blood stream following dental manipulatinn and/or extraction. This organism has been used also by high school students in science fair projects without regard to its potential pathogenicity.Of particular significance is the occurrence in 1958 ofa condition referred to as "Red Diaper Syndrome" in a child born at the University of Wisconsin Hospital. The child was cultured 2935-and found to have an overwhelming growth of the red pigmented Serratia marcescens in the intestinal tract. Exhaustive studies of the child's family failed to reveal carriers of the organism.Epidemiological sleuthing uncovered the fact that the organism was being used at that time in a study of aerosol techniques in a biochemistry laboratory within the hospital and in an adjoining building where genetic studies were being conducted. Aerosol spread from these sources could have accounted for the colonization of the intestinal tract of the infant soon after birth. Apparently the organism established itself in the child's intestine and replaced the normal flora, but the child continued in excellent health and required almost one year of treatment to eliminate this bacterium.An experiment conducted in 1960 in a London hospital alsoaroused a great deal of concern over the use of S. marcescens as a tracer microorganism. In attempting to prove an hypothesis that Staphylococcus aureus (a bacterium associated with hospital-acquired infection) was spread from floor-to-floor up the elevator shaft by movement of elevator, the tracer organism Serratia marcescens was aerosolized near the elevator door on the lower floor of the hospital and air sampling was done on the upper floors. In time, S. marcescens was detected in the area around the elevator shaft on each floor. What was not expected was the occurrence of several 294-6cases of S. marcescens necrotizing pneumonia among hospitalized patients presumably by aerosol transmission. Soon thereafter the use of S. marcescens as an indicator organism ceased in many countires, including the United States.Even though Serratia marcescens is often regarded as anonpathogen, or of low virulence for healthy individuals, it is found occasionally in conditions where host resistance is diminished (postoperative patients, burn cases, diabetics, cancer patients, steroid therapy), or in conditions predisposing to bacterial infection (frequent catheterization, malformation or obstruction of the urinary tract). Prolonged antibiotic therapy seems to favor the emergence of highly antibiotic resistant strains of S. marcescens. Generally the bacterium is considered an "opportunist".It is difficult to assess how much bacterial invasionhas contributed to the underlying disease in many cases. Its presence in clinical materials is more frequent than generally suspected because of our failure to properly identify thebacterium due to the false belief that it is an obligate pigment former. Pigmentation is demonstrable in only about 20-30 per cent of the strains isolated from patients.It should be reemphasized that infections with S. marcescens occur mainly in hospitalized individuals with some underlying disease.The mode of transmission has not been sufficiently elucidated 295-7but contaminated hands and instruments, as well as dropletaerosols, have been incriminated. It probably spreads likeother hospital-acquired bacteria. Infection may or may notcause clinical disease, and a fatal outcome is very rare.At the time the simulated testing was done in SanFrancisco by the Army, Serratia marcescens was considered an innocuous saprophytic water organism which was nonpathogenic to man or animals, but was occasionally recovered from comprimised hospitalized patients. Since 1960, however, infectionsdue to this organism have been reported with increasing frequency in association with urinary tract infections, pneumonia, empyema, lung abscess, wound infection, meningitis, septicemia andendocarditis. The ability of S. marcescens to cause infection was once-thought to be limited to patients with chronic debilitating disorders, but it is now clear that there are many predisposing factors such as broad spectrum antibiotic therapy, diabetes, indwelling catheters, mechanical ventilation therapy and corticosteroid therapy.This knowledge reemphasizes the hazard in using S. marcescens as a tracer organism in experimental studies of aerosols and related experiments involving humans.No longer can we consider the disease potential of an organism simply a property in its own right, nor as an interaction of a parasite with a healthy host, but as a consequence of interaction with a comprdnised individual. Secondary invasion must also be viewed with 296-8-the same concern as regards primary infections because the consequences are equally hazardous and the former often resultin prolonged hospitalization. Since it was known that a clear danger of S. marcescens infection existed for hospitalized and debilitated individuals, it is inconceivable and unconscionable that the organism would have been spread as an aerosol over unsuspecting masses of people, some of whom would have beenat high risk. Whether or not the illnesses in which S. marcescens was isolated from hospitalized patients in the San Francisco area immediately following the testing in the early 1950's is impossible to establish with certainty because of the natural occurrence of this agent in the hospital environment and its wide distribution in nature. Simulated environmental conditions, as well as simulated microorganisms, could have been employed and would have provided adequate information as to the airborne spread, drift, survival and consequent infection Mass environmental exposure on the scale conducted by the Army was apparently unnecessary on its scientific merit and constituted an unjustifiable health hazard for a particular segment of the population. To ratinnalize the validity for the study would be sheer folly. Respectfully submitted, J Mehsen Josseph, Ph.D.May 20, 1977 Senator KENNEDY. The committee will come to order. On March 8 the Department of Defense presented to the subcommittee a report of the history of biological research and testing by the U.S. Army. Representatives of the Department testified that during the 1950's and 1960's the Army had conducted a number of simulated biological warfare tests in the public domain and without the knowledge or consent of the people exposed to these tests. They also acknowledged that, while the simulants used in the tests were believed to be safe at that time, it is known that at least some of them are not safe and were not safe then. While we understand that these simulated tests were initiated and carried out in the atmosphere of the cold war when the threat of biological attack was considered a potential threat to our security, I think we can all agree and the Defense Department spokesman did agree in the earlier hearing, that such open air testing with the unwitting exposure of civilian and military populations should not and cannot be tolerated. Senator Schweiker, the ranking minority member of the subcommittee has been extremely concerned, as I have, with the protection of human subjects in all areas of scientific research. He shares my concern that past deficiencies in the protection of the human subjects must be remedied and that people must not be put at risk without their full knowledge and consent and adequate review procedure. Human experimentation legislation to expand the jurisdiction of the National Commission for the Protection of Human Subjects in these areas will be introduced soon. Limited open air testing of biological simulants is continuing at one military installation. Is it safe? Are we sure? Do scientists agree? To assist us in a better understanding of these problems and how we might profit from our past experiences we have asked four eminent scientists to share with us today the benefit of their knowledge and views.... STLIE1111T OF 519- plm WEITZimiAy' laxD., PA0E O MICROBIOLOGY, SCH OL OF BASIC HEALTH SCIENCES, HEALTH 00=0 CE MI~ER, STATE UXVXERSITY OF YZEW YORX, STOZ~Y BRCOIX; J. M~. JOSE 2E PH.T D., DIRECTOR LABORATORIES ADMIXISTRATIOXq, MARYLA D STATE DEPARTMENT OF HEALTH AZD MENTAL HYGIENE; GEORGE H. CONNELL, PH. D., ASSISTANT TO THE DIRECTOR, CENTER FOR DISEASE CONTROL, ATLANTA, GA.; MATTHEW MESELSOIN, PH. D., CHAIRMAN, DEPARTMENT OF BIOCHEMISTRY AND MOLECULAR BIOLOGY, HARVARD UNIVERSITY.... The techniques used to isolate this organism in the early period depended upon its red pigmentation, but that fact was one of the reasons it was not recognized earlier as an important agent for the production of disease in certain segments of the population. It since has been shown that the majority of strains actually do not produce pigment. In a study done in the 1950's at the Center for Disease Control it was shown that about 75 percent of those strains isolated from human disease did not have this red pigmentation, and therefore they would not have been recognized by many laboratories around the country, or hospitals would not have identified the organism. So, the failure to recognize that the organism existed without the red pigment accounted for the infrequent discovery of disease in man. But, of course, as soon as this fact was recognized and, of course, as a result of extensive use of antibiotics and the new medical manipulation of patients--the managing of patients--the incidence of infection by this organism appeared to increase. In 1957, at the Boston City Hospital, an increase of incidence of isolations of the Serratia organism was noted. In fact, the study indicated again that the nonpigment strain was more common in clinical disease than the typical red variety, and many laboratories around the country were unable to correctly identify this form. But since 1913, when the first cases of infection were described in man, there have been isolated reports that stress the potential pathegenicity of this organism for man. Again, in the early 1960's hospitals identified in primary urinary tract infections, respiratory tract infections this organism in man. But before these outbreaks there were instances of infection that occurred prior to the time the testing was held by the Army. So, there was an indication of potential pathogenicity for a certain segment of our population. Infections, of course, have been noted in debilitated individuals, ,is was pointed out, individuals whose defenses have been compromised. That was not clearly evident in the early 1950's, but there was enough indication that it was potentially dangerous for man. The outbreaks occurring, of course. again indicated primarily that water might be a possible means of spread, -nd that airborne spread was less evident at that time. Prior to 1960, then, Serratia was considered a common garden variety micro-organism which was so benign that it was not capable of producing clinical illness in man in its own right. But, because of its apparent nonpathogenic potential and its characteristic red pigmentation and ease of isolation, Serratia was commonly used as a tracer bacterium in numerous studies. It was intentionally spread in some hospitals to study bacterial drifting and settling as an aid in trying to understand the spread of hospital cross-infections. So, classical experiments were routinely conducted to demonstrate to students the basic principle of establishing the index case of infection by a micro-organism. Aerosolization of the test organism was used in courses in microbiology to demonstrate bacteriological air sampling techniques. The organism was intentionally painted on the gums of patients following dental extractions to demonstrate its passage from the oral cavity to the bloodstream. So, there was widespread use of it as somethin g that was not ablo to cause disease in man. Since the 1960's, however, infections due to the organism have been reported with increasing frequency in a variety of illnesses. The ability of this organism to cause disease was established on sufficient basis to question the use of the organism for the simulant testing that was done. We no longer, of course, consider this organism as a harmless saprophyte, and I think at that time it should not have been considered as harmless, either. Whether or not the illnesses in which the organism was isolated from hospitalized patients in the San Francisco area immediately following the study, and the relationship of that organism, was due to those tests, cannot be established with certainty from the data accumulated at that time. However, I believe that the environmental studies that were conducted, the environmental conditions, could have been simulated as well as using simulated organisms. I do not believe it was necessary to conduct these open-air studies on the masses, that we could have gotten adequate information from the use of a simulated environmental condition to determine airborne spread, drift, survival, and consequent infection. Mass environmental exposure on the scale conducted by the Army was apparently unnecessary on its scientific merit and constituted an unjustifiable health hazard for a particular segment of the population. It was inconceivable and unconscionable, and the study should never have been conducted on the unsuspecting population. No way can we rationalize the validity of that study. Thank you. Senator SCHWEIKER. Thank you very much, Doctor We will now hear from Dr. Connell. Mr. CO.N.NELL. I do not have a prepared statement. I have been ill for several days, trying to recover from a fractured skull. I would like to talk a little bit about this group of orga'nisms. I worked with these things over a period of many years when I was at Fort Detrick and Pine Bluff back in the early 1950's, we worked with Serratia marcescemn. IVe used that organism in such unbelievable numbers that you would have to see the kinds of experiments that were done, and none of us thought there was any problem; nobody got sick. as a matter of fact. At the present time, at the Center for Disease Control where I am employed, we are finding infections, hospital infections, in surprising numbers: and again, these are people who are largely debilitated, or whose defense mechanisms are compromised for some reason or other. We found something else, that some of these so-called strains that do not produce pigment do produce pigment if you grow them at different temperatures from normal body temperatures. We have done that on a number of them. The idea that the organism has a red pigment and is therefore a good marker does not always work because there are a lot of strains that will grow without color whatsoever if you grow them at other than body temperature. In my own opinion there is no such thing as a microorganism that cannot cause trouble. 'When you look at a microorganism to use as tracer, or soiething of that sort. I think you have to keep that in mind. If you get the right concentration at the right place, at the right time, and in the right person, something is going to happen. Now, Serratia marcescens, as has been mentioned before, has been used for a long time. It has been recognized, as was mentioned earlier, from prebiblical times. And again, the reason was because of the color of most of the strains that were detected. If I had my choice, I would never use this organism or expose anyone to it at any time. That is my own opinion. I consider there is some risk here. Certainly, for the future this has to be considered, whether for defensive work, or anything else because there is some chance that somebody can get hurt. Many of the strains that have been found in people that are ill, are not treatable, they simply do not respond to antibiotics. You can also find this organism, by the way, in sewage as well as in water. You can find it in the normal gut contents of some people who are not ill; we find it frequently in the urinary tract where it causes serious difficulty in some people. Generally speaking, the infections that are detected are in people who have been catheterized in hospitals. There is a fair percentage of association between catheterization and infection with that particular organism. That is all I have. Senator SCHWEIKER. Thank you very much, Dr. Connell.
MONDAY, MAY 23, 1977 U. S. SE-NATE. SUBCOMMITTEE ON HEALTH AND SCIENTIFIC RESEARCH OF TIHE CO3M3irEE ON HU31A\N RESOURCES,
W1ashington., D.C. The subcommittee met, pursuant to notice, at 9.40 a.m., in room 4232, Dirksen Senate Office Building, Senator Edward M. Kennedy (chairman of the subcommittee) presiding. Present: Senators Kennedy and Schweiker.
Biological testing involving human subjects by the Department of Defense, 1977 : hearings before the Subcommittee on Health and Scientific Research of the Committee on Human Resources, United States Senate, Ninety-fifth Congress, first session ... March 8 and May 23, 1977. ALWD 7th ed.
MARYLAND STATE DEPARTMENT OF HEALTH AND MENTAL HYGIENELABORATORIES ADMINISTRATIONSTATEMENT ON THE USE OF THE SIMULANT SERRATIA MARCESCENSIN AEROSOL STUDIES OF HUMAN POPULATION CENTERS
My name is J. Mehsen Joseph, Ph.D., and I am Director of the Laboratories Administration, Maryland State Department of Health and Mental Hygiene, and Assistant Professor of Microbiology, University of Maryland, Baltimore, Maryland. Because of the public concern over the conduct of experiments by the Army in which the bacterium Serratia marcescans was used as an aerosol over the city of San Francisco in the early 1950's, I wish to describe the early history of this bacterium, to discuss its potential for causing disease in man, and to comment on the health hazard associated with the study. Serratia marcescens has had a long and remarkable history with classical accounts by historians of the appearance of "miraculous blood" appearing on bread dating back to the siege of Tyre in Lebanon in 332 B.C. This remarkable manifestation struck fear in the hearts of the superstitious and credulous people of the Middle Ages. However, early in the 19th Century the phenomenon was examined in a scientific matter and the causative agent identified and characterized. Doctor Bartolomeo Bizio, a young pharmacist, was the first to observe reddened polenta (corn meal mush), and by a series of lengthy and ingenious experiments, he concluded that the red mucilaginous substance was the result of activity of masses of very small bodies.290-2-Numerous studies of red pigmentation of foods, particularly bread and starchy foods, were recorded in the history of this bacterium beginning in 332 B.C. and continuing through the 19th Century. However, during that period, reports of clinical illness among those who consumed these foods were extremely rare occurrences. Thus, the bacterium was considered to have little or no pathogenic potential for man.Since its discovery in 1823 by Bizio, Serratia marcescenshas been recognized as a biological entity and during its early history was considered to be a saprophyte which was relatively avirulent. The organism is widely distributed in nature and is found naturally in water, soil and as a contaminant of food.As standard bacteriological techniques were developed to distinguish among the microorganisms closely related to Serratia marcescens, investigators began to recognize non-pigmented strains of the latter.In 1959 the Center for Disease Control, USPHS, in Atlanta reported on a study in which 75 per cent of over 200 strains examined failed to produce pigment. Failure to recognize this fact probably accounted for the infrequent reports of recovery of this organism from infections in man. As a result of this finding, recognition of non-pigmented varieties of S. marcescens, combined with the extensive use of broad spectrum antibiotics among hospitalized patients, probably accounts for the increased frequency with which hospitalacquired infections by this organism are now being recognized.291-3-In 1967 at the Boston City Hospital an increased incidence of isolations of Serratia marcescens was noted. In 1970 a study of the occurrence of Serratia infections at the same hospital revealed that non-pigmented strains of this bacterium were more common than the pigmented variety, and that many clinicalbacteriology laboratories were unable to correctly identify these non-pigmented forms.Since 1913 when the first case of Serratia infection inman was described, isolated reports have stressed the potential pathogenicity of this organism for man. In 1962 the Communicable Disease Center pointed out the nosocomial nature of most Serratia marcescens infections. Several hospital outbreaks involving urinary tract infections and respiratory tract infections and two epidemics in nurseries for newborn infants have been described.Infections also have been noted to occur at the site of indwelling urinary and intravenous catheters and after lumbar punctures or peritoneal dialysis. Previous antibiotic therapy and underlying chronic debilitating disease may also predispose to serious Serratia infection. Urinary tract infection has been the most frequent site of Serratia infections but the epidemiology of such hospital outbreaks is still unclear and any attempts to determine the source of the organism has been unrevealing. However, most patients had indwelling catheterization and urinary tract abnormality. Also, Serratia marcescens is isolated frequently from the respiratory tract but these isolations are infrequently of clinical significance.2924-Hospital outbreaks of respiratory infection are usually associated with Serratia contaminatibn of respiratory equipment. Associated clinical illness was either pneumonia, empyema, or lung abscess.Prior to 1960 Serratia marcescens was considered a commongarden variety microorganism which was so benign that it was not capable of producing clinical illness in man in its own right.Because of its apparent nonpathogenic potential and its characteristic red pigmentation and ease of isolation, Serratia marcescens was commonly used as a tracer bacterium in numerous studies.It was intentionally spread in hospitals to study bacterial drifting and settling as an aid to understanding the spread of hospital cross-infections. Classical experiments in epidemiology were routinely conducted to demonstrate to students the basic principle of establishing the index case of infection by a microorganism.Aerosolization of the test organism was used in courses in Microbiology to demonstrate bacteriological air sampling techniques.The organism was intentionally painted on the gums of patients to demonstrate its passage from the oral cavity to the blood stream following dental manipulatinn and/or extraction. This organism has been used also by high school students in science fair projects without regard to its potential pathogenicity.Of particular significance is the occurrence in 1958 ofa condition referred to as "Red Diaper Syndrome" in a child born at the University of Wisconsin Hospital. The child was cultured 2935-and found to have an overwhelming growth of the red pigmented Serratia marcescens in the intestinal tract. Exhaustive studies of the child's family failed to reveal carriers of the organism.Epidemiological sleuthing uncovered the fact that the organism was being used at that time in a study of aerosol techniques in a biochemistry laboratory within the hospital and in an adjoining building where genetic studies were being conducted. Aerosol spread from these sources could have accounted for the colonization of the intestinal tract of the infant soon after birth. Apparently the organism established itself in the child's intestine and replaced the normal flora, but the child continued in excellent health and required almost one year of treatment to eliminate this bacterium.An experiment conducted in 1960 in a London hospital alsoaroused a great deal of concern over the use of S. marcescens as a tracer microorganism. In attempting to prove an hypothesis that Staphylococcus aureus (a bacterium associated with hospital-acquired infection) was spread from floor-to-floor up the elevator shaft by movement of elevator, the tracer organism Serratia marcescens was aerosolized near the elevator door on the lower floor of the hospital and air sampling was done on the upper floors. In time, S. marcescens was detected in the area around the elevator shaft on each floor. What was not expected was the occurrence of several 294-6cases of S. marcescens necrotizing pneumonia among hospitalized patients presumably by aerosol transmission. Soon thereafter the use of S. marcescens as an indicator organism ceased in many countires, including the United States.Even though Serratia marcescens is often regarded as anonpathogen, or of low virulence for healthy individuals, it is found occasionally in conditions where host resistance is diminished (postoperative patients, burn cases, diabetics, cancer patients, steroid therapy), or in conditions predisposing to bacterial infection (frequent catheterization, malformation or obstruction of the urinary tract). Prolonged antibiotic therapy seems to favor the emergence of highly antibiotic resistant strains of S. marcescens. Generally the bacterium is considered an "opportunist".It is difficult to assess how much bacterial invasionhas contributed to the underlying disease in many cases. Its presence in clinical materials is more frequent than generally suspected because of our failure to properly identify thebacterium due to the false belief that it is an obligate pigment former. Pigmentation is demonstrable in only about 20-30 per cent of the strains isolated from patients.It should be reemphasized that infections with S. marcescens occur mainly in hospitalized individuals with some underlying disease.The mode of transmission has not been sufficiently elucidated 295-7but contaminated hands and instruments, as well as dropletaerosols, have been incriminated. It probably spreads likeother hospital-acquired bacteria. Infection may or may notcause clinical disease, and a fatal outcome is very rare.At the time the simulated testing was done in SanFrancisco by the Army, Serratia marcescens was considered an innocuous saprophytic water organism which was nonpathogenic to man or animals, but was occasionally recovered from comprimised hospitalized patients. Since 1960, however, infectionsdue to this organism have been reported with increasing frequency in association with urinary tract infections, pneumonia, empyema, lung abscess, wound infection, meningitis, septicemia andendocarditis. The ability of S. marcescens to cause infection was once-thought to be limited to patients with chronic debilitating disorders, but it is now clear that there are many predisposing factors such as broad spectrum antibiotic therapy, diabetes, indwelling catheters, mechanical ventilation therapy and corticosteroid therapy.This knowledge reemphasizes the hazard in using S. marcescens as a tracer organism in experimental studies of aerosols and related experiments involving humans.No longer can we consider the disease potential of an organism simply a property in its own right, nor as an interaction of a parasite with a healthy host, but as a consequence of interaction with a comprdnised individual. Secondary invasion must also be viewed with 296-8-the same concern as regards primary infections because the consequences are equally hazardous and the former often resultin prolonged hospitalization. Since it was known that a clear danger of S. marcescens infection existed for hospitalized and debilitated individuals, it is inconceivable and unconscionable that the organism would have been spread as an aerosol over unsuspecting masses of people, some of whom would have beenat high risk. Whether or not the illnesses in which S. marcescens was isolated from hospitalized patients in the San Francisco area immediately following the testing in the early 1950's is impossible to establish with certainty because of the natural occurrence of this agent in the hospital environment and its wide distribution in nature. Simulated environmental conditions, as well as simulated microorganisms, could have been employed and would have provided adequate information as to the airborne spread, drift, survival and consequent infection Mass environmental exposure on the scale conducted by the Army was apparently unnecessary on its scientific merit and constituted an unjustifiable health hazard for a particular segment of the population. To ratinnalize the validity for the study would be sheer folly. Respectfully submitted, J Mehsen Josseph, Ph.D.May 20, 1977 Senator KENNEDY. The committee will come to order. On March 8 the Department of Defense presented to the subcommittee a report of the history of biological research and testing by the U.S. Army. Representatives of the Department testified that during the 1950's and 1960's the Army had conducted a number of simulated biological warfare tests in the public domain and without the knowledge or consent of the people exposed to these tests. They also acknowledged that, while the simulants used in the tests were believed to be safe at that time, it is known that at least some of them are not safe and were not safe then. While we understand that these simulated tests were initiated and carried out in the atmosphere of the cold war when the threat of biological attack was considered a potential threat to our security, I think we can all agree and the Defense Department spokesman did agree in the earlier hearing, that such open air testing with the unwitting exposure of civilian and military populations should not and cannot be tolerated. Senator Schweiker, the ranking minority member of the subcommittee has been extremely concerned, as I have, with the protection of human subjects in all areas of scientific research. He shares my concern that past deficiencies in the protection of the human subjects must be remedied and that people must not be put at risk without their full knowledge and consent and adequate review procedure. Human experimentation legislation to expand the jurisdiction of the National Commission for the Protection of Human Subjects in these areas will be introduced soon. Limited open air testing of biological simulants is continuing at one military installation. Is it safe? Are we sure? Do scientists agree? To assist us in a better understanding of these problems and how we might profit from our past experiences we have asked four eminent scientists to share with us today the benefit of their knowledge and views.... STLIE1111T OF 519- plm WEITZimiAy' laxD., PA0E O MICROBIOLOGY, SCH OL OF BASIC HEALTH SCIENCES, HEALTH 00=0 CE MI~ER, STATE UXVXERSITY OF YZEW YORX, STOZ~Y BRCOIX; J. M~. JOSE 2E PH.T D., DIRECTOR LABORATORIES ADMIXISTRATIOXq, MARYLA D STATE DEPARTMENT OF HEALTH AZD MENTAL HYGIENE; GEORGE H. CONNELL, PH. D., ASSISTANT TO THE DIRECTOR, CENTER FOR DISEASE CONTROL, ATLANTA, GA.; MATTHEW MESELSOIN, PH. D., CHAIRMAN, DEPARTMENT OF BIOCHEMISTRY AND MOLECULAR BIOLOGY, HARVARD UNIVERSITY.... The techniques used to isolate this organism in the early period depended upon its red pigmentation, but that fact was one of the reasons it was not recognized earlier as an important agent for the production of disease in certain segments of the population. It since has been shown that the majority of strains actually do not produce pigment. In a study done in the 1950's at the Center for Disease Control it was shown that about 75 percent of those strains isolated from human disease did not have this red pigmentation, and therefore they would not have been recognized by many laboratories around the country, or hospitals would not have identified the organism. So, the failure to recognize that the organism existed without the red pigment accounted for the infrequent discovery of disease in man. But, of course, as soon as this fact was recognized and, of course, as a result of extensive use of antibiotics and the new medical manipulation of patients--the managing of patients--the incidence of infection by this organism appeared to increase. In 1957, at the Boston City Hospital, an increase of incidence of isolations of the Serratia organism was noted. In fact, the study indicated again that the nonpigment strain was more common in clinical disease than the typical red variety, and many laboratories around the country were unable to correctly identify this form. But since 1913, when the first cases of infection were described in man, there have been isolated reports that stress the potential pathegenicity of this organism for man. Again, in the early 1960's hospitals identified in primary urinary tract infections, respiratory tract infections this organism in man. But before these outbreaks there were instances of infection that occurred prior to the time the testing was held by the Army. So, there was an indication of potential pathogenicity for a certain segment of our population. Infections, of course, have been noted in debilitated individuals, ,is was pointed out, individuals whose defenses have been compromised. That was not clearly evident in the early 1950's, but there was enough indication that it was potentially dangerous for man. The outbreaks occurring, of course. again indicated primarily that water might be a possible means of spread, -nd that airborne spread was less evident at that time. Prior to 1960, then, Serratia was considered a common garden variety micro-organism which was so benign that it was not capable of producing clinical illness in man in its own right. But, because of its apparent nonpathogenic potential and its characteristic red pigmentation and ease of isolation, Serratia was commonly used as a tracer bacterium in numerous studies. It was intentionally spread in some hospitals to study bacterial drifting and settling as an aid in trying to understand the spread of hospital cross-infections. So, classical experiments were routinely conducted to demonstrate to students the basic principle of establishing the index case of infection by a micro-organism. Aerosolization of the test organism was used in courses in microbiology to demonstrate bacteriological air sampling techniques. The organism was intentionally painted on the gums of patients following dental extractions to demonstrate its passage from the oral cavity to the bloodstream. So, there was widespread use of it as somethin g that was not ablo to cause disease in man. Since the 1960's, however, infections due to the organism have been reported with increasing frequency in a variety of illnesses. The ability of this organism to cause disease was established on sufficient basis to question the use of the organism for the simulant testing that was done. We no longer, of course, consider this organism as a harmless saprophyte, and I think at that time it should not have been considered as harmless, either. Whether or not the illnesses in which the organism was isolated from hospitalized patients in the San Francisco area immediately following the study, and the relationship of that organism, was due to those tests, cannot be established with certainty from the data accumulated at that time. However, I believe that the environmental studies that were conducted, the environmental conditions, could have been simulated as well as using simulated organisms. I do not believe it was necessary to conduct these open-air studies on the masses, that we could have gotten adequate information from the use of a simulated environmental condition to determine airborne spread, drift, survival, and consequent infection. Mass environmental exposure on the scale conducted by the Army was apparently unnecessary on its scientific merit and constituted an unjustifiable health hazard for a particular segment of the population. It was inconceivable and unconscionable, and the study should never have been conducted on the unsuspecting population. No way can we rationalize the validity of that study. Thank you. Senator SCHWEIKER. Thank you very much, Doctor We will now hear from Dr. Connell. Mr. CO.N.NELL. I do not have a prepared statement. I have been ill for several days, trying to recover from a fractured skull. I would like to talk a little bit about this group of orga'nisms. I worked with these things over a period of many years when I was at Fort Detrick and Pine Bluff back in the early 1950's, we worked with Serratia marcescemn. IVe used that organism in such unbelievable numbers that you would have to see the kinds of experiments that were done, and none of us thought there was any problem; nobody got sick. as a matter of fact. At the present time, at the Center for Disease Control where I am employed, we are finding infections, hospital infections, in surprising numbers: and again, these are people who are largely debilitated, or whose defense mechanisms are compromised for some reason or other. We found something else, that some of these so-called strains that do not produce pigment do produce pigment if you grow them at different temperatures from normal body temperatures. We have done that on a number of them. The idea that the organism has a red pigment and is therefore a good marker does not always work because there are a lot of strains that will grow without color whatsoever if you grow them at other than body temperature. In my own opinion there is no such thing as a microorganism that cannot cause trouble. 'When you look at a microorganism to use as tracer, or soiething of that sort. I think you have to keep that in mind. If you get the right concentration at the right place, at the right time, and in the right person, something is going to happen. Now, Serratia marcescens, as has been mentioned before, has been used for a long time. It has been recognized, as was mentioned earlier, from prebiblical times. And again, the reason was because of the color of most of the strains that were detected. If I had my choice, I would never use this organism or expose anyone to it at any time. That is my own opinion. I consider there is some risk here. Certainly, for the future this has to be considered, whether for defensive work, or anything else because there is some chance that somebody can get hurt. Many of the strains that have been found in people that are ill, are not treatable, they simply do not respond to antibiotics. You can also find this organism, by the way, in sewage as well as in water. You can find it in the normal gut contents of some people who are not ill; we find it frequently in the urinary tract where it causes serious difficulty in some people. Generally speaking, the infections that are detected are in people who have been catheterized in hospitals. There is a fair percentage of association between catheterization and infection with that particular organism. That is all I have. Senator SCHWEIKER. Thank you very much, Dr. Connell.
A Brief Review of Specific Studies of Antibiotic Usage in Hospital and Community Studies Antibiotic Prescribing In Community Practice.-Several studies of prescribing in defined areas have shown that antibiotics are the most commonly prescribed class of drugs, accounting for 15% to 20% of all new and refill prescriptions. Thus, approximately one of five prescriptions issued are for an antibiotic.I Investigations designed to link the prescription to the reason prescribed are few, but they suggest that the following practices-occur at a high frequency: (1) Prescribing an antibiotic without having taken a culture. (2) Prescribing an antibiotic (by telephone) without examining the patient. (3) Prescribing an antibiotic for a viral illness. (4) Prescribing chlorampheniml for a viral illness or a bacterial infection that could be treated by an alternate agent. (5) Prescribing an antibiotic prophylactically in a situation where the efficacy of.' such prophylaxis is unproven. A marketing research company was able to assess the extent of antibiotic prescribing for the "common cold" in 1972 (Table 5). Studies of Hospital Prescrihing of Antibiotics.-A number of well-designed studies of antibiotic prescribing in the hospital setting have been reported. These studies are fairly consistent in finding that about one quarter to one third of all patients on a general medical or surgical ward receive an antibiotic during their hospital stay; antibiotic utilization appears to be highest on pediatric and surgical wards. Furthermore, chart reviews reveal that many of the treated patients(ranging from 30' to GOl), especially on the surgical wards, had no clear-cut evidence of infec- Lion. Presumably, much of the antibiotic use is intended for "prophylactic" purpose.' Other surveys have shown 1024 JAMA. March 4. 1974 * Vol 227. No 9 that antibiotics are commonly used in a routine "propiylactic" manner for hernia repair, tonsillectomy and adenoidectomy, vasectomies, and hysterectomies.' These same studies show a considerable variation in the type and frequency of antibiotic use among hospitals. (Table 6.) A more recent study suggests that most antibiotic prescribing is done without a prior bacterial culture. Furthermore, when cltures and sensitivity tests were obtained. an inappropriate antibiotic was often chosen and therapy was continued by the attending physician., A recent national survey of hospital records showed that of 50.5% of hospital discharges in 1972 where antibiotics were given, no record of a bacterial culture was recorded on the chart, as noted by V. Slee (written communication, September 1973). It is clear that antibiotic prescribing is more common in hospitals than community practice and that much of it in both settings is done with a "prophylactic" intent This is being done despite the fact that initially, all experts in the field have condemned such use because of the hazards entailed and the absence of evidence of efficacy for most such uses. In 1962, an estimated $94 million worth of antibiotics were purchased by hospitals; in 1971, the corresponding figure was $218 million (uncorrected for inflation). It is estimated that about 27% of the 33 million patients discharged from general hospitals in 1972 received one or more antibiotics during their hospital stays.' Although many hospitals have drug formularies and a few have antibiotic utilization review committees, the fixed-ratio combination antibiotics have enjoyed a remarkable popularity in the hospital setting, as well as in ambulatory practice. An interesting survey in a Canadian hospital suggests that physicians have difficulty in identifying the ingredients in some commonly used drug combinations.
Infections caused by Gram-negative bacilli are becoming increasingly prevalent and currently constitute the most frequent type of nosecomial infection. Several major centers have reported an annual frequency of Gram-negative bacteremia approximately 0 per 100 hospital patients, with fatality rates of 30 to 50 percent If similar incidence and fatality rates hold for the 30,000,00a0c ute hospital admissions annually in the United States, as man0 as 300,000e pisodes and more than 100.00f0a talities from Gram-negative bscterenia may occur each year. In fact, it is not known if similar incidence and fatality rates due to Gram-negative bacteremia prevail in other hospitals in the United States, but there are good grounds to suggest these rates are somewhat lower in community and nonteaching hospitals that often refer their complex cases and severely ill patients to teaching centers. Nevertheless, an important problem due to Gram-negative infeetions does exist even though the precise dimensions of this problem are as yet undetermined. There is little disagreement as to the cause of this emerging health hazard: the use of antimicrobial agents primarilv active against Gram-positive organisms has resulted in a shift of the bacterial ecologic equilibrium to selectively favor the Gram-negative organisms. An editorial review of the Journal of Infectious Diseases has perhaps best summarized the situation: A crude but conservative projection of the published data suggests that the frequency of Gram-negative rod bacteremia in American hospitals in 1968 was in the range of 6/1.000 admissions, and all bacteremias, about 10/1,000. If this was the case, then at least a quarter of a million bacterenias occurred in American hospitals last year and contributed to a minimum of some 50,000 deaths. We are dealing, therefore, not with a scatteringof local institutional problems, but with a full-blown national epidemic." The emergence of antibiotic-resistant strains of certain Gram-positive organisms (meningococcus, gonococcus, and Staphylococcus, for example) has been noted by many investigators but appears to pose less of a problem than that of the increasing incidence of Gram-negative infections. Finland,, in analyzing his experience at Boston City Hospital, found that there has been a steady increase in the number of bacteremic patients (especially those with Gram-negative organisms), with an 80o increase from 1957 to 1965 (the last year of the study). In addition, he found that the case-fatality rate among all bacteremic pa. tients showed a dramatic decline following the introduction. and use of the sulfonamides and another, but less striking, drop by 1947, after penicillin and streptomycin had achieved widespread use. However, in the ensuing years, in spite of the successive introduction of the many broad-spectrum and antistaphylococcal antibiotics, the mortality has increased slowly but steadily so that by 1965, the mortality (35%) was still nearly the same as that observed in 1941 before petticillin first became available. Finland presumes that the major factor responsible for the changing ecology of the serious bacterial infections and for the marked increase in their occurrence, at least at Boston City Hospital. is the selective pressure of the antibiotics so widely and intensively used in therapy and especially for prophylaxis. Other Serious Adverse Elfects of Antibiotic Use.-Wellknown, serious, adverse effects due to antibiotic therapy include anaphylaxis with penicillin and aplastic anemia with chloramphenicvl. The problem of aplastic ancmia has been well documented; this fatal reaction occurs about once in approximately 60,000 to 80,000 doses. Though fortunately a rare occurrence, it is disheartening that the American Medical Association Blood Dsycrasia Registry reported that a large majority of these usually fatal reactions occurred in patients who received chloramphenicol for either trivial infections, undocumented infections, or infections for which a safer and as effective alternate antibiotic could have been selected." A study of prescribing in a geographically defined community showed that chloramphenicol was the 64th most frequently prescribed drug and the 15th most popular antibiotic. However, when the prescribing profiles of individual physicians were inspected, it was clear that this antibiotic was used as the drug of choice for most common infections by only a few of the practitioners." Using strict criteria, Weinstein et alP and Weinstein and Musher" reported a superinfection rate of 2.2% in more than 3,000 patients treated with antibiotics. Quite striking in this study was the predominance of Gram-negative bacteria involved in the majority of superinfections that were viuch more difficult to manage than the primary disorder was. The author emphasized the need for avoiding antibiotics in untreatable infections (prophylactic use and viral infections), lest a benign and self-limited disease be converted into a serious or even fatal one.
(1973) Examination of the pharmaceutical industry, 1973-74 : hearings before the Subcommittee on Health of the Committee on Labor and Public Welfare, United States Senate, Ninety-third Congress, first and second sessions, on S. 3441 and S. 966 .... Part 2
Medical Progress-Simmons & Stoney, JAMA. March 4, 1974 ' Vol 227. No 9
Infections caused by Gram-negative bacilli are becoming increasingly prevalent and currently constitute the most frequent type of nosecomial infection. Several major centers have reported an annual frequency of Gram-negative bacteremia approximately 0 per 100 hospital patients, with fatality rates of 30 to 50 percent If similar incidence and fatality rates hold for the 30,000,00a0c ute hospital admissions annually in the United States, as man0 as 300,000e pisodes and more than 100.00f0a talities from Gram-negative bscterenia may occur each year. In fact, it is not known if similar incidence and fatality rates due to Gram-negative bacteremia prevail in other hospitals in the United States, but there are good grounds to suggest these rates are somewhat lower in community and nonteaching hospitals that often refer their complex cases and severely ill patients to teaching centers. Nevertheless, an important problem due to Gram-negative infeetions does exist even though the precise dimensions of this problem are as yet undetermined. There is little disagreement as to the cause of this emerging health hazard: the use of antimicrobial agents primarilv active against Gram-positive organisms has resulted in a shift of the bacterial ecologic equilibrium to selectively favor the Gram-negative organisms. An editorial review of the Journal of Infectious Diseases has perhaps best summarized the situation: A crude but conservative projection of the published data suggests that the frequency of Gram-negative rod bacteremia in American hospitals in 1968 was in the range of 6/1.000 admissions, and all bacteremias, about 10/1,000. If this was the case, then at least a quarter of a million bacterenias occurred in American hospitals last year and contributed to a minimum of some 50,000 deaths. We are dealing, therefore, not with a scatteringof local institutional problems, but with a full-blown national epidemic." The emergence of antibiotic-resistant strains of certain Gram-positive organisms (meningococcus, gonococcus, and Staphylococcus, for example) has been noted by many investigators but appears to pose less of a problem than that of the increasing incidence of Gram-negative infections. Finland,, in analyzing his experience at Boston City Hospital, found that there has been a steady increase in the number of bacteremic patients (especially those with Gram-negative organisms), with an 80o increase from 1957 to 1965 (the last year of the study). In addition, he found that the case-fatality rate among all bacteremic pa. tients showed a dramatic decline following the introduction. and use of the sulfonamides and another, but less striking, drop by 1947, after penicillin and streptomycin had achieved widespread use. However, in the ensuing years, in spite of the successive introduction of the many broad-spectrum and antistaphylococcal antibiotics, the mortality has increased slowly but steadily so that by 1965, the mortality (35%) was still nearly the same as that observed in 1941 before petticillin first became available. Finland presumes that the major factor responsible for the changing ecology of the serious bacterial infections and for the marked increase in their occurrence, at least at Boston City Hospital. is the selective pressure of the antibiotics so widely and intensively used in therapy and especially for prophylaxis. Other Serious Adverse Elfects of Antibiotic Use.-Wellknown, serious, adverse effects due to antibiotic therapy include anaphylaxis with penicillin and aplastic anemia with chloramphenicvl. The problem of aplastic ancmia has been well documented; this fatal reaction occurs about once in approximately 60,000 to 80,000 doses. Though fortunately a rare occurrence, it is disheartening that the American Medical Association Blood Dsycrasia Registry reported that a large majority of these usually fatal reactions occurred in patients who received chloramphenicol for either trivial infections, undocumented infections, or infections for which a safer and as effective alternate antibiotic could have been selected." A study of prescribing in a geographically defined community showed that chloramphenicol was the 64th most frequently prescribed drug and the 15th most popular antibiotic. However, when the prescribing profiles of individual physicians were inspected, it was clear that this antibiotic was used as the drug of choice for most common infections by only a few of the practitioners." Using strict criteria, Weinstein et alP and Weinstein and Musher" reported a superinfection rate of 2.2% in more than 3,000 patients treated with antibiotics. Quite striking in this study was the predominance of Gram-negative bacteria involved in the majority of superinfections that were viuch more difficult to manage than the primary disorder was. The author emphasized the need for avoiding antibiotics in untreatable infections (prophylactic use and viral infections), lest a benign and self-limited disease be converted into a serious or even fatal one.
(1973) Examination of the pharmaceutical industry, 1973-74 : hearings before the Subcommittee on Health of the Committee on Labor and Public Welfare, United States Senate, Ninety-third Congress, first and second sessions, on S. 3441 and S. 966 .... Part 2
Medical Progress-Simmons & Stoney, JAMA. March 4, 1974 ' Vol 227. No 9
MEDICAL AND SURGICAL REPORTS OF THE BOSTON CITY HOSPITAL. Second Series,
EDITED BY DAVID W. CHEEVER, M.D., and F. W. DRAPER, M. D. BOSTON: PUBLISHED BY THE BOARD OF TRUSTEES. TRS Suk Ye
DESCRIPTION OF THE HOSPITAL. By Epwarp Cow ss, M. D.
The City Hospital was first occupied in the year 1864, fifteen years after the establishment of such an institution had been proposed in the project of continuing the Cholera Hospital at Fort Hill, in the year 1849. In 1857 the first decided action was taken by the city government, upon the urgent recommendation of Hon. Alexander H. Rice, then Mayor. This, however, accomplished but little more than the obtaining an act of the Legislature authorizing the establishment of “a hospital for the reception of persons who by misfortune or poverty may require relief during temporary sickness.” In 1860 the City Council, responding to the appeal of the Mayor, Hon. F. W. Lincoln, Jr., definitely agreed to the project, and set apart from the city lands, on the South Bay territory, the present site of the hospital. During the next year plans were adopted, and the actual work of erecting buildings was begun. The lot of land upon which the hospital stands is bounded northwesterly on Harrison avenue, 454.83 feet; southwesterly on East Springfield street, 623.68 feet; southeasterly on Albany street, 453 feet; northeasterly on East Concord street, 660.27 feet; and contains in all about 292,000 square feet, or 675 acres. In addition, there was set apart a lot of land containing 69,318 square feet, in the rear of the hospital buildings, and east of Albany street, upon which were built a small-pox hospital, cholera wards, coal sheds, and a stable; but, excepting the latter, these buildings and the land were temporarily leased for other purposes in 1872. The plans for the hospital were made by Mr. G. J. F. Bryant, architect, and were elaborated with much care, and xX DESCRIPTION OF THE HOSPITAL. with the aid and counsel of physicians and others interested in its establishment. The hospital was one of the first built in this country upon the “ pavilion plan,” and was believed to contain all the modern improvements then accepted as essential in hospital construction. It is well known that in the comparatively short ane since the plans of this hospital were adopted, in 1861, very large experience has been gained in hospital construction in our own and in foreign countries, and very great and general interest has been excited in this and other sanitary questions. The experience of ten years here has pointed out some deficiencies and errors of construction in the original buildings of the hospital, and some very important alterations and improvements have been effected. In response also to the rapidly growing demand for increased accommodations, large additions have recently been made to the hospital. The object of this paper is to show what has been done here in improved hospital construction, and to set forth the reasons for the important changes and additions. When substantially completed and occupied, in 1864, the hospital consisted of a central or administration building, two three-story pavilions and the necessary auxiliary buildings, — boiler-house, laundry, etc. To these there was added, in - 1865, a two-story building for isolating wards. Subsequently a small building was erected, at the main entrance to the grounds, containing rooms for the out-patient department ; and an enlargement was made of the boiler-house, with the addition of a dead-house, morgue, and autopsy-room. The buildings stood thus, with little material change, till 1875. Their general arrangement and the use of each are shown in Plate No. 1, excepting that the new buildings, numbered 1 to 5, have been recently erected, of which the first two occupy the places of the curved portions of the original connecting corridors. The principal alterations made in the older buildings were in their basements, for the improvement of their sanitary condition, and will be noticed in connection with the description of the new method of heating and ventilating. Other changes will be alluded to in the desta of the buildings. DESCRIPTION OF THE HOSPITAL. XI The administration building (Plates 1, 2, and 3) is 60 by 80 feet, and contains practically two stories, a basement and an attic; it is surmounted by a high dome, the apex of which is 148 feet above the level of the street. The building is of brick, upon granite basement walls, and finished inside with lathing and plaster. The basement rooms are 13 feet high, with floors 34 feet below the ground level, with an air-space, and concrete upon the earth underneath, and are used as dispensary, laboratory and store-room, dining-rooms for employés, and steward’s office. The culinary work has been removed from the basement of this building to the new kitchen and bakery in the rear. The first and second stories, being respectively 16 feet and 14 feet high, are restored to the uses for which they were originally planned. On the first floor are the trustees’ room, superintendent’s office, room for the reception of visitors and for the library, matron’s room and dining-room. On the second floor are the rooms occupied by the superintendent and his family, for officers, etc. The rooms on the third or attic story are lighted only from the ceiling, and are used as chambers for employés. The operating theatre in the dome, early found to be inadequate and difficult of access, is now disused. This building is connected with the others by corridors, open above and covered in below. The lower floors. of the corridors, being 34 feet below the ground’ level, are at the general level of all the basement floors of the principal buildings, and the floors of the upper or open portion of the corridors are on a level with the first floors of the buildings. - The two pavilions, medical and surgical, are substantially alike in construction. They are 148 feet in length, 48 feet in width, three stories in height, besides the « basements. The walls are of brick, upon granite base, and with lath and plaster finish inside. The basements, formerly occupied by. patients, are now disused. On the first, second, and third floors are wards, each 80 feet long, and 272 feet wide, the two lower being each 16 feet, and the upper being 10 feet high. The first floors are about 6 feet’ above the general ground level. Each ward is lightedb y 14 windows, 7 on XII DESCRIPTION OF THE HOSPITAL. each side, and is arranged for 28 beds. At the entrance to the building on each floor (see Plates 1, 2, and 3) there are upon one side of the hall the patients’ dining-room, medicine closet, dumb-waiter, etc., in place of what was originally the bath-room ; and on the other side of the hall are a patients’ wardrobe, linen-room, and room for special cases requiring removal from the ward, or for paying patients. The linenroom, and patients’ wardrobe for clothing in daily use only, are both well-lighted rooms, and take the place of what was formerly the water-closets, and a dark closet for linen, etc., both without ventilation. A ventilating shaft adjoining the dining-room will independently ventilate all these rooms. The main stairway is also at this end of the building. At the farther end the nurses’ room and a small stairway are on one side of the hall, as originally built ; but on the other side the former arrangement of dining-room, closets for dishes, etc., is replaced by a comparatively isolated and independently ventilated apartment for the water-closets, slop-sink and urinals, and by a bath-room and lavatory. The doors of the two latter rooms close automatically by springs, and the bath-room and lavatory are separated only by a low screen, 7 feet high, so that air can pass freely through it, and light can enter over it, between the rooms and around the exterior of the inner apartment containing the water-closets. The door to the last-named apartment will also close automatically, swinging both ways. Thus will be prevented the danger of currents of air being induced through open doors from the water-closets to the ward. A special arrangement is made for independently ventilating the water-closet apartments by a shaft, 3 feet square, of wood lined with tin, which passes upward through them from the basement through the roof. The shaft contains within it the soilpipe, hot-water pipes, steam-pipes for the supply of the steam-bath in the bath-rooms adjoining, and gas jets for lighting the water-closets, on each floor, through glazed windows in the sides of the shaft. The heat unavoidably radiated from these necessary appliances furnishes a continuous extracting force for the ventilating shaft at all seasons of the year. } DESCRIPTION OF THE HOSPITAL. XIII The boiler-house: and laundry, which are 300 feet from the administration building, and connected with it by a covered way, contain the boilers, the fan for forcing fresh air into the wards (but now disused), the engines, the laundry-machinery, and the washing, ironing and drying rooms. Over the laundry are a number of rooms for employés. In the year 1871 the boiler-room was enlarged, and adjoining it there were placed, on the ground floor, a dead-room and morgue, and on the second floor a commodious and conveniently arranged autopsy-room, with pathological cabinet, etc. Near the building a drive-way from Albany street was opened in 1874, and just within this entrance to the grounds large scales were placed for the weighing of coal and many other articles of hospital supplies. A two-story brick pavilion, located near the southern corner of the grounds, contains the male and female isolating wards, which are shown in Pijtes 1 and 2. The building is 1014 feet long, and 464 feet wide, with a basement or cellar underneath, which brings the first floor to a height of about 2 feet above the ground level. There is a ventilating chamber in the roof, 10 feet wide, extending the whole length of the building. A hall or passage-way, 10 feet wide, divides each story, with rooms on each side, and windows at each end, excepting at the entrance-door on the first floor. There are 10 rooms on each floor, 14 feet by 15 feet in size, and designed to accommodate one or two patients in each. Two additional rooms on each floor are for nurses, kitchen, bathing- room, etc. ; and there are also water-closets and linenrooms. The rooms on the first floor, for male patients, are 14 feet high; and those on the second floor, for females, are 18 feet high. Each room is surrounded by brick walls, upon which hard-finished plastering is laid. An important change made in this building, in the method of heating and supplying fresh air, will be noticed hereafter, in describing the general plan of heating and ventilating. The building is connected with the basements of the main buildings by a covered corridor. The building for out-patients, added in 1867, is located XIV DESCRIPTION OF THE HOSPITAL. in the northern corner of the grounds, and at the main entrance to the hospital. It contains the porter’s room, waiting and examining-room for applicants for admission, large waiting-rooms for out-patients, and physicians’ rooms. Medical out-patients, and those having diseases of the eye, ear, skin, throat, and nervous system, and diseases of women, are treated here, the service being so arranged that each of the classes named receives attention on three days of each week, and on alternate days. The surgical outpatients were formerly treated in rooms in the basement of the surgical pavilion, but new accommodations have been provided for this department. } In 1874 a propagating-house was built along the southern side of the corridor in the rear of the administration building, and a gardener employed by the year to care and provide for the ornamentation of the grounds. The plan has resulted in a great saving from the previous expense for this purpose, besides the accumulation of a valuable stock of plants, etc. The heating of this greenhouse is done by a ° novel method and at a small cost: the water in the cast-iron pipes, circulating about the building in the usual way, is made hot in a common “ feed-water heater” (such as is used by engineers for the saving of the heat of exhaust steam), in size 3 feet high by 14 feet in diameter, and requiring an inappreciable quantity of steam. The hospital stood in 1874 substantially as first. built, except the minor additions and alterations just described. As early as the year 1868 the hospital was felt to be crowded by the number of its patients, there being a daily average of 174 during the year, and the necessity of the enlargement of the hospital was represented by the trustees to the City Council. The rapid growth of the city and a greatly increasing demand for accommodations continued until, in 1874, the number of patients reached a daily average for the year of 230, and a maximum at one time of 285. The capacity of the hospital was at this time reckoned at 230 beds, including the occupation of 40 beds in the. basements of the medical. and surgical pavilions. The insufficiency and great inconvenience of the surgical operating DESCRIPTION OF THE HOSPITAL. | XV theatre in the dome had been early recognized. The great overcrowding of all the wards made the management and service of the hospital very difficult and laborious; and the impossibility of giving proper attention to sanitary requirements, and unavoidable neglect of needed repairs, were positively detrimental to the welfare of the sick. In the beginning of the year 1874 decided steps were taken by the trustees for the enlargement of the hospital, and the City Council appropriated the sum of $190,000 for the purpose. It was not easy to determine the best way in which the desired alterations and enlargement should be made. It was evidently necessary to revise the system of heating and ventilating, and to replace nearly the whole of the steam apparatus for that purpose; it was desirable that a large increase of capacity should be gained, and, at the same time, by a wise economy of expenditure, all essential modern improvements in hospital construction should be secured. While the simpler structures were believed to be the best, it was also demanded that the new buildings should conform architecturally to the older ones. Appreciating the value of the experience of the medical gentlemen long connected with the institution, the Board of Trustees first invited the medical and surgical staff of the hospital to present a general statement of what was needed to be done. Subsequently a committee of the Board of Trustees was appointed “to procure plans for the enlargement and additions to the present hospital buildings, in conformity to the needs therefor, as set. forth in the communication of the medical and surgical staff.” It was decided by the Board that while certain conditions should be fulfilled, as to the architectural appearance of the new buildings, it was also of the first importance to plan and adapt them in their relations to the older buildings, so as to gain both the best results for the sick and the greatest convenience and economy of administration. In accordance with their very considerate and liberal policy, the trustees determined that the plans should first be prepared in detail, at the hospital, under the supervision of those who were practically familiar with its needs. This was done chiefly under the direction AVI DESCRIPTION OF THE HOSPITAL. of one of the Committee on Plans, George W. Pope, Esq., well-known in Boston as a skilful practical builder, to whom the sketch-plans were frequently submitted during a period of several months, while being prepared by a draughtsman at the hospital, under instructions given him by the: Superintendent. , The plans thus prepared were substantially carried out in all their details in the new buildings, and had the full approval of the hospital staff as being the best that could be devised to meet the many and conflicting indications presented in the attempt to engraft new features of construction upon older ones. These sketch-plans were afterwards placed in the hands of the architect, Mr. Carl Fehmer, of Boston, by whom the perfected plans and specifications were prepared, with some modifications only of the architectural exteriors, and with the details of construction. They were finally approved by the Committees on the City Hospital, and on Public Buildings, of the City Council, in March, 1875, and the work of building began in April of that year, reaching completion in the following year. A plan of the principal floor of the new buildings is given in Plate No. 1. They are numbered from 1 to 5, and consist of a surgical and medical building, each three stories high, with basements ; two one-story pavilions, surgical and medical; and a low building along the side of the rear corridor for kitchen, bakery, etc. ‘These buildings are connected with the older ones by additions to the original corridors, and a part of the latter was removed to make room for the two larger buildings. The original plan of the hospital contemplated the erection of two additional pavilions in the rear of the first ones, to be connected in like manner, by corridors curved in reverse directions, with the administration building. The present arrangement of the buildings, as shown in Plate No. 1, is peculiar, and one that would hardly have been made under other circumstances ; but it is found practically to have remarkable advantages in convenience, ease, and economy of management. In devising this arrangement, it was at the outset determined that as large an area of ground as possible should be reserved for DESCRIPTION OF THE HOSPITAL. XVII the present and future construction of one-story pavilions.* It was next agreed that the separate rooms to the limited number required for paying patients, and the smaller wards for children and for ophthalmic and gynecological patients, could be placed in buildings of more than one story. It was necessary, also, that one of the larger buildings should contain, on its first floor, the operating theatre, etc., for the surgical service, and should be conveniently located for easy communication with other buildings. Then it was made a matter of great importance that certain indications should be met as to the architectural appearance of the new build-. ings. The result obtained in this regard is well shown in the frontispiece, in which the surgical and medical buildings appear upon the right and left of the central or administration building. ‘These locations were first chosen chiefly for convenience in administration, and to economize groundspace, but the arrangement was afterwards fully approved by the architect, the new buildings not being treated archi- _tecturally as wings of the central structure, but as separate members of the whole group, which, it is believed, has been greatly improved in appearance by the additions. The advantages of the separation of the pavilions are practically preserved by the distances left between the new and the older structures. The prevailing winds, in the warmer months, being from points between the west. and south, readily traverse the spaces between the buildings as well as the buildings themselves, which, it is also to be noticed, approach each other by their ends, and thus admit of being more in proximity than otherwise. The corridors connecting the one-story buildings with the others offer little obstruction to the currents of air, being very open in their construction. ) The surgical building is 48 feet by 94 feet in general dimensions, with a projection of 8 feet by 48 feet from the front wall, and another of 24 feet by 52 feet from the rear * An acknowledgment is due to Frank H. Hamilton, M. D., of New York, for valuable advice given to the Committee of the Trustees and the writer, in the winter of 1875, as to the merits of such structures, and the importance of including them in the contemplated additions to the hospital. II AVIII DESCRIPTION OF THE HOSPITAL. wall. It is three stories high beside the basement; and the heights of the stories correspond with those of the older buildings, two of them being 16 feet, the upper one 10 feet, and the basement 9 feet. The foundations of the building are laid upon piling. The basement walls are granite, with faced brick inside, and the walls above are of brick, and 20 inches thick. All the walls are hollow, with a four-inch air-space, including the corridor walls, and all are plastered upon the brick, with all the corners of the rooms rounded. ‘There is very little wood-work in the building, except the floors, and about the doors and win- , dows, where it is very plain, being finished with a simple half-round moulding. The doors themselves have plain panels and bevelled stiles without mouldings, and all the wood-work is of clear white pine, filled with shellac and varnished. The base-boards are also bevelled at the top and joined to the hard-pine floors by a quarter circle in a strip of hard pine, and the floors are laid in 24-inch strips, matched and blind-nailed. There are thus very few corners in which dust can collect, and the labor of preserving cleanliness is greatly reduced. The main entrance to the principal floor of this building (Plate No. 1) is at its northern end, from which a corridor 8 feet wide extends through the length of the building, joined at its centre by another corridor which communicates - with the open connecting corridor in front. At the right, of | the entrance is a private consulting-room, 11 feet by 154 feet, for the visiting surgeons, and a larger room for the office of the house surgeons, to which room are adjoined closets, etc. Next, along the corridor, is the main stairway, surrounded entirely by brick walls, and having double doors at the landing of each story, so arranged as to cut off currents of air from one story to another. Between the stairway and the front of the building is the room of the supervising ward-master, who has general supervision of all the surgical wards as to the reception and assignment of patients, the control of the male nurses, and the charge of the general business of the surgical service. Near the stairway, and in the opposite angle of the two corridors, is an elevatorDESCRIPTION OF THE HOSPITAL. XIX way, by which patients are to be carried to the upper stories of this building, and of the surgical pavilion in front of it, over the terrace of the connecting corridor, as shown in Plate No. 2. Beyond the elevator-way, and occupying the remainder of the front half of the first floor, are three waiting- rooms, in which male and female patients are separately placed before surgical operations. These rooms have waterclosets, etc., adjoining two of them, and they serve also as small accident-wards, in connection with the accident-room, for severe cases received by night, or for such as cannot at once be placed in the common wards. On the opposite side of the corridor from the waiting-rooms, and quite isolated from the sight and hearing of their occupants, is the etherizing room. Adjoining this is the operating theatre, a large room about 49 feet by 42 feet in the clear, and 33 feet high, occupying two stories of the building. An enlarged plan and section of this room are shown in Plate No. 4. The arena is ample and roomy, being 17 feet wide from the corridor wall to the semi-circular seats which occupy the rest of the room, with a seating capacity of about 250 persons. A large skylight, 19 feet by 14 feet, gives abundant and satisfactory light. Operations requiring lateral light are done in the accident-room adjoining. Under the seats of the amphitheatre is considerable space occupied by a passageway, 6 feet wide, from which a few steps lead to the front row of seats, two recovery-rooms, a stairway from the students’ entrance in the rear of the building, a splint-room, and a’small bath and linen-room pertaining to the accidentroom. The accident-room is situated immediately at the left of the main entrance to the building, and is large and well lighted, being about 19 feet by 22 feet; it communicates by a wide doorway with the operating theatre. These rooms are amply supplied with hot and cold water, and other conveniences. <A large ventilating chimney is marked V, and is shown also in section in Plate No. 4, Fig. 1. The second floor of the surgical building is shown in Plate No. 2, and on a larger scale in Plate No. 4. The rooms over the accident-room are occupied by the house surgeons, and those numbered 1 to 5 by patients. All the rooms XX DESCRIPTION OF THE HOSPITAL. average in size 154 feet by 10} feet. Adjoining the nurse’s room, occupied by the head-nurse of the ward and one assistant, is a bath-room, containing water-closet, etc. The dining-room is about 16 feet by 14 feet, and contains in one corner a soapstone sink, steam-table and shelves for crockery. A dumb waiter communicates with the diet kitchen in the basement. The bath-room has a bath-tub free from the wall on both sides, a sitz bath, hot and cold shower-bath, steam-bath and wash-bowl. The water-closet apartment is quite isolated by being shut off from the rest of the building behind the brick walls of the stairway, and is entered by a passage-way having two doors closing automatically, so that both shall not be open at the same time. This apartment contains two water-closets, a porcelain slop-sink and a urinal, and is ventilated independently of all other rooms by a special arrangement shown in Plate No. 4, Figs. 1 and 3. A tin-lined shaft, 2 feet square, contains within itself the soil-pipe, hot-water and steam-pipes in constant use, and gas jets on each floor to give light through small windows in the sides of the shaft. The ventilation is efficient at all times. The soil-pipe passes upward above the roof, and is open at its top. A side of the shaft can be easily removed at any time for inspecting or repairing the pipes. All sinks, wash-bowls, etc., are supported on brackets, and the space underneath left open, with the plumbing work exposed. A number of Jennings’ all-earthenware water-closets are in very successful use; these are also left exposed under the seats, which have no risers, thus securing great advantage as to cleanliness. The description here given of the servicerooms applies also to the other upper stories of this and the medical building. The upper floor of this building (Plate No. 3) differs from the one just described in having three small wards for children, one for ten beds, about 49 feet by 15 feet, and two for four beds each, about 18 feet by 14 feet. The basement plan of the surgical building is shown in Plate No. 2, where the use of the rooms numbered from 1 to 5, for surgical out-patients, is indicated. The dressing-room is supplied with appliances, splints, etc.; and adjoining these rooms are separate water-closets for each sex. Patients DESCRIPTION OF THE HOSPITAL. XXI requiring other than minor operations or treatment in the wards are sent to the surgical rooms above, on the first floor. The diet-kitchen (room No. 6) has a cook in attendance for the preparation of special diets for all the surgical wards. The basement floors are all made hard with concrete and cement, upon which hard-pine flooring is laid, excepting in the diet kitchen, where there is a flagging-stone and brick paving. The walls of these rooms are finished by simply painting the faced brick a light color. The medical building (numbered 2 in Plate No. 1) is symmetrical in general appearance and dimensions with the one just described, except that the projection in its rear is 30 feet by 24 feet. A small ward of eleven beds is thus formed on each of the three stories, in size about 264 by 4034 feet. The ward on the first floor is designed for male ophthalmic patients, and contains all the sick who are treated on this floor. Near the main entrance are the offices of the visiting and house physicians. On the opposite side of the corridor is a receiving-room for medical cases, and adjoining it the room of the supervising ward-master of the medical service. Three rooms, marked H in the plan, are occupied by the house physicians. The bath-room for patients on this floor is placed near the ward, but otherwise all the servicerooms of this building are like those in the one previously described. A medicine closet, 20 inches deep, occupies the thickness of the corridor wall near the entrance to the ward on each floor. This closet is furnished with a marble slab, small wash-bowl, hot and cold water, shelving, and gas-light. It is very convenient, and having glass doors, is constantly under inspection, and easily kept in a cleanly and tidy condition. The second floor (Plate No. 2) has seven rooms, each averaging 164 feet by 11 feet, for paying patients of the medical and ophthalmic service. For free patients of the latter class the ward is designed. A large room, G, is for an ophthalmic operating room, but available also as a small ward. The third floor (Plate No. 3) is devoted entirely to the treatment of diseases peculiar to women. ‘There are five rooms for paying patients, and a small ward, of four beds, besides the larger ward containing eleven beds. An operatXXII DESCRIPTION OF THE HOSPITAL. ing-room, at the southern corner of the building, is light and capacious, and, with low window-sills, abundant lateral light is obtained. In the basement of this building is a kitchen for preparing special diets for the medical wards, a room, with a chimney for ventilation, etc., for a laboratory, where the chemical and microscopical examinations may be made, a general linen-room, and a sleeping-room for male nurses. These rooms are finished in the same manner as those in the basement of the surgical building. The water-closet apartments of this building also have a special ventilating shaft, as already described, and the bath-rooms adjoining the nurses’ rooms in each building are ventilated by a chimney warmed by the copper smoke-flue of the range in the basement dietkitchen. The one-story buildings are shown in plan, in Plate No. 1, where they are numbered 3 and 4; and a section and elevation of the surgical pavilion are shown in Plate No. 5. The two buildings are alike in form and arrangement. The underpinning is laid upon a foundation of concrete with no piling. The framing is wood and iron, with a covering of boards and, outside of this, corrugated iron. The roof is slated; the inside of the building has a lath and plaster finish, and the wood-work is very plain, as described in the surgical building. ‘The general dimensions are 137 feet by 402 feet, except that the portion of the building occupied by the ward is narrowed to 28 feet, so that the ward is 94 feet by 264 feet in the clear. The entrance to the building is from the connecting corridor. The hall, 8 feet wide, has, upon the right-hand side, a small special ward or examining room, 15 feet by 11 feet, a drying closet, a medicine closet, and the dining-room, 15 feet by 17 feet, furnished with a soap-stone sink, steam-table, shelving, small broom-closet, and a dumb-waiter by which food is sent from the corridor basement... On the left of the entrance is a linen-room, and a room for patients’ clothing in daily use, other clothing being kept in an appropriate place in the basement. The last-named rooms are each 4 feet by 15 feet, and each is lighted by a window. ‘The patients’ wardrobe has along its sides twenty-eight small stalls, numbered to correspond with — DESCRIPTION OF THE HOSPITAL. XXIII the beds in the ward. Every article of a patient’s clothing as soon as taken off is hung in its proper place in this room. The room for the head-nurse and her assistant is 12 feet by 15 feet, and has a bath-room, etc., adjoining. These servicerooms are 14 feet high to the ceiling, and over them, in this part of the building only, is a second story, reached by a narrow stairway with a door at its foot, where there are four rooms for nurses, and a common bath-room. There is an arrangement for ventilating the water-closets and clothing rooms by an independent shaft enclosing the soil-pipe, etc., as already described. The ward is 94 feet long by 264 feet wide in the clear, and has 7 opposite windows and 14 beds on each side. The windows, having double sashes, are 9 feet high by 4 feet wide, and the space between them is nearly 94 feet. The height of the ward, from the floor to the centre of the arched ceiling, is 22 feet, or an average of about 19 feet. Each bed occupies about 63 feet along the wall, and 134 feet to the centre of the ward. Thus a floor area of 89 square feet and an air-space of about me cubic feet is given to each bed. At the end of the ward is a day-room, 11 feet by 12 feet, lighted by a bay-window. Wide glass doors open into this room from the ward, and in the end wall over these doors there are windows, thus giving the end of the’ large room a light and open appearance. These arrangements are shown in Plate No. 5, Figs. 1, 2,3 and 5. On the right of the day-room is the lavatory, a narrow room with a window, marble slab and wash-bowls. In a separate room adjoining, with doors so arranged that entrance is easy for carrying in a patient on a stretcher, is the bath-room, 9 feet by 13 feet, furnished like the bath-rooms before described. At the opposite corner of the building is the room for water-closets, etc. The entrance from the ward opens by a self-closing door, first into a lobby 3} feet wide, with a window at each end. In one section of the lobby is a narrow stairway, for occasional use, leading to the basement. A low partition and lattice door shuts off this section, but does not obstruct the passage of air from one window to the other. From the XXIV DESCRIPTION OF THE HOSPITAL. lobby a self-closing door opens into the water-closet apartment, the arrangement of which is shown in the plan (Plate No. 5). <A section of the ventilating shaft for the waterclosets is shown in Fig. 4. A steam-pipe heats the shaft, aided by a gas-jet, which lights the room by night. Fresh air is supplied to this room by an independent inlet, and the lobby also has separate air-supply and ventilation. All the spaces under the sinks, washbowls, seats of water-closets, etc., are left open, and the plumbing is exposed to view. The basement, excepting of that part of the building occupied by the service-rooms at its entrance, is an open and free air-space, containing only heating apparatus. The floor is made hard and impenetrable to moisture by concrete and cement, and is on a level with the ground outside. Its numerous windows can be left open many months in the year, and, its doors being locked, it is kept cleanly and free from any intrusion but for proper purposes. The main kitchen of the hospital was formerly under the administration building, and there was great deficiency of space, storage-rooms and proper ventilation. The place of the new kitchen is shown in Plate No. 1, and a plan of it is given in Plate No. 3. Its general dimensions are 45 feet by 30 feet, and it connects with the basement corridors. It is about 10 feet high in the clear, and its roof is nearly on a level with the first floor of the other buildings, so that the winds pass freely over it and between the other buildings. It has brick walls, which are painted inside, and a solid floor of slate tiles and bricks laid in cement. It is well-furnished with a Whiteley’s range and steam-jacket kettles for cooking meats, soup and vegetables; a large tea and coffee apparatus; iron sinks ; shelves for utensils upon a movable table, and a brick oven for roasting meats, etc. All the furnishing of the kitchen, except the range, stands away from the wall. The _ plan shows the arrangement of the bakery, store-rooms for flour and bread, the refrigerator and store-rooms for meats, vegetables, etc. A small cellar and coal-bin, underground, is connected with the kitchen. A large chimney, with the smoke-flue inside of it, over the ovens, ventilates the heated space over them and the kitchen and bakery. Openings are DESCRIPTION OF THE HOSPITAL. XXV left in the brick walls outside, near the eaves, so that air can enter the space between the ceiling and the roof, from which it escapes through ventilators, thus cooling the roof and the rooms below in hot weather. The kitchen is centrally located, and the food is conveniently distributed in covered cars to the various buildings. HEATING AND VENTILATING. The boiler-room (Plate No. 1) contains seven steamboilers. The four older ones are each 16 feet long by 48 inches in diameter, with forty tubes, each 15 feet by 3} inches. The three new boilers are each 15 feet by 48 inches, with forty-nine tubes, 14 feet by 3 inches. The method by which the hospital was formerly heated and ventilated was as follows : *— ** Air forced through ducts, by means of a large fan at the boiler-house, and warmed by coils of steam-pipes placed in these ducts, is carried to every part of the buildings, thus affording the means of heating as well as ventilation. Direct radiation is provided for in a portion of the rooms, to be used in case of necessity. The steam-pipes over which the air passes for heating the different apartments in the central buildings are placed in coils, in chambers connected with the air-ducts. Those for heating the pavilions are located in the air-passages, beneath the floor under the corridors leading to the pavilions. The passage through which the air passes, after having left the main duct on its way to the pavilions, is divided into two compartments, in one of which is located coils of one-inch wrought-iron pipe. The steam, after passing from the boilers in a large iron pipe, is distributed through these coils, being regulated by valves, under charge of the engineer. After passing through the coils, it enters a steam-trap, located at the foot of the coil, which is so constructed that no steam can pass, where, after being converted into water, it is conveyed through a cast-iron pipe to a reservoir, located at the head of the air-duct; from thence it * City Hospital Reports, First Series, page 17. XXVI DESCRIPTION OF THE HOSPITAL. is pumped into the boilers, at a temperature of from one hundred and eighty to one hundred and ninety degrees. Through the other compartment cold ‘air passes. These two compartments are so arranged that the cold and warm air are brought together in the several wards, where they come in contact before entering the room.” The cemented floor of the air-duct here described as passing under the corridor basement-floors, was about 3} feet below the latter, and thus about 7 feet below the ground level. Because of certain faults of arrangement, and in consequence of troubles to be hereafter described, arising from the location of the air-duct at such a depth, this system of heating and ventilation by impulsion-was entirely abandoned in 1875, and the method by aspiration was adopted. The steam-radiators in the various parts of the buildings being raised to the basement ceilings, and the floor of the boiler-room being lowered six feet, the boilers, with the three new ones added to their number, could thus receive the water of the condensed steam flowing back into them without the intervention of a tank and pump, involving much loss of heat. In this manner the four older boilers have, at the date of this writing, been applied for one whole year to the warming of the main buildings of the hospital, excepting the isolating wards. This has ordinarily been done in cold weather by three boilers at low pressure of steam, rarely as high as 5 lbs., and with the index of: the pressure gauge standing for days at zero. In extreme weather, the fourth boiler was put at work on a few occasions. ‘The average daily consumption of coal in these boilers was from 3,000 to 3,500 Ibs. per boiler, never over 4,000 Ibs. in very cold weather. The three new boilers have been applied at high pressure (15 Ibs. to 30 lbs.) to running the laundry machinery, cooking, heating water for all purposes in all the buildings, heating ventiducts of water-closets, the ventilating chambers in the roofs of the medical and surgical buildings, and in the ridges of the one-story pavilions, besides warming the two isolating wards. With these boilers, the use of the tank and pump has been necessary, and two of them have done all the work, except in extreme weather, DESCRIPTION OF THE HOSPITAL. XXVIT consuming daily per boiler but little more coal than the lowpressure boilers. Any one or more of the boilers can be used at high or low pressure. The steam is conveyed to the different buildings in large pipes, the main pipe from the boilers to the administration building being eight inches in diameter. The distribution of the heating apparatus, the method of furnishing the freshair supply and of ventilating are shown in the plans in Plate No. 4. In Fig. 1, a section of a part of the surgical building, 1s shown the arrangement and special ventilation of the water-closets already described, the motive aspirating power in the shaft being furnished by steam-pipes, hot-water pipes and the gas-jets in daily use. The manner of covering the soil-pipe, imbedded in cement, to its exit through the foundation of the building to join the drain outside is here shown. The aspirating chimney of this building, shown in Figs. 1, 2 and 3, is 6 feet square inside, and about 70 feet high from the basement floor to the bottom of the openings in its sides near its top. It was first proposed to place the boilers for heating all the surgical wards in the basement of this building, and to make a similar arrangement for the medical wards also, the smoke-flue to stand within the chimney, and thus furnish motive-power for ventilation; but the plan of concentrating the boilers in the present boiler-room being continued, heat is furnished to the chimney by utilizing the unavoidable radiation from the bath-boiler placed conveniently at its base. The additional steam-pipes to increase the aspirating power of the chimney, shown in Fig. 1, have not yet been found necessary, and there is always found a positive upward current of air. It is believed that decided advantages are gained from the somewhat novel plan of managing the ventilation of these new three-story buildings. The chimney is used only to ventilate the rooms of the basement and first floor; the warm and vitiated air from them, being conveyed laterally, or only a little downward, to the base of the chimney, is practically kept on its way upward and outward. The two upper stories are ventilated by a different plan, their outflowing air being simply aided in its XXVITI DESCRIPTION OF THE HOSPITAL. upward tendency by being drawn into the chamber in the roof (Figs. 1, 2). There is thus no loss of power in first drawing the air downward to the chimney base; there is no danger of the common trouble in such cases of reversed currents of foul air from the first to the upper stories through the ventilating flues of the latter. All communication is thus very perfectly cut off between the lower and the upper stories. The ventilating chamber in the roof can be warmed by steam-pipes, which have been employed only in damp or still warm weather. The air escapes through the sides of the chamber, which receives additional warmth in sunny days through its glazed roof. Each room in the building has one or more separate ventilating flues, extending from: floor to ceiling in the wall next the corridor, and each flue has two openings into it, and within it a valve, so arranged that it can only be moved by a key. The entrance to the flue is thus practically always open either at the top or bottom of the room. ‘Thus all the upper outlets can be closed, compelling ventilation through the lower openings during the winter season, with the certainty of remaining so at the will of the superintendent, and beyond the reach and interference of unwise attendants or meddlesome patients. In the same manner, by simply turning the valves, the ventilation can be made to proceed through the upper openings in summer. It is to be noticed that the air passes downward from the rooms on the first floor, and upward from the upper stories. | Each small room has one, and the larger rooms have several inlet flues in the outer wall of the building for supplying fresh air, also arranged with valves so that the fresh air must enter in a given volume either at the bottom or the top of the room at will. This is illustrated in Fig. 1, in the room on the second floor. The cold air is introduced through openings in the outer basement-walls, passes immediately over the steam coils, of which there is a separate one for every flue, and upward to the rooms, which it enters through the lower or upper register, according to the adjustment of the valve. The most satisfactory method for the winter season has been to introduce fresh air by the upper registers, DESCRIPTION OF THE HOSPITAL. XXIX and extract foul air by the lower ones. In summer the reverse arrangement is the best. The steam-radiators in the basements are encased with galvanized iron, forming a small chamber in which a switchvalve directs the fresh air, so that it passes either through the coil so as to be warmed, or, unwarmed, directly into the flue above. A wire connects the switch-valve with the lower register in the room above, where by the use of a key the valve can be adjusted to alter the temperature of the entering air. The volume of air can only be changed by opening or closing a sliding valve covering the inlet through the basement wall, and this is under the charge of the engineer. The arrangement of the apparatus for introducing, heating and controlling the fresh-air supply is more plainly shown in Plate No. 5, Fig. 5. In the plan of the second floor of the surgical building (Plate No. 4, Fig. 3), the fresh-air inlets and outlets are shown. Some observations made in these rooms, to test the efficiency of the ventilation, have given satisfactory results. In the room numbered 3, where there are about 2,600 cubic feet of air space, and the inlets and outlets have each one square foot of clear openings, the velocity of inflowing and outflowing air, as shown by the air-meter, averaged in a number of observations 150 feet per minute. At this rate, 9,000 cubic feet of air pass through the room, changing its contents between three and four times per hour. The atmosphere out of doors, at the time of the observations, was clear, and quite still, the temperature about 30° F., that of the room 68° F.; and there was no artificial heat in the ventilating chamber in the roof. With added heat by the steampipes in this chamber, its aspirating power is increased, and good ventilation can be obtained at all times. The plan (Plate No. 4, Fig. 3) shows the first floor of the operating theatre, the room being two stories high. The shaded lines and arrows indicate the downward and lateral direction of the foul air, under the floor, to the base of the large chimney, from the ventilators in the corridor-wall and in the risers of the steps leading up to the seats of the amphitheatre. The amphitheatre is capable of seating 250 XXX DESCRIPTION OF THE HOSPITAL. persons, though the number likely to be present will rarely exceed 200. The room contains 55,000 cubic feet of airspace, and its atmosphere is easily changed between two and three times per hour, with ventilating outlets equal to 12 square feet of clear opening, and a usual outflow velocity of not less than 200 feet per minute. It is safe to say that more than 700 cubic feet of air per hour is supplied to each person. The efficiency of the ventilation is well indicated by the notable absence of the odor of ether in the theatre during operations, while at the same time, that odor is very strong within the base of the chimney. Observations made almost daily, during the last year, of the working of the chimney, prove its up-cast draught to be continuous, and without any added heat from the available steam-pipes. The total cubic space ventilated by the chimney in the surgical building equals about 88,000 cubic feet; the area of the chimney is 36 square feet, and the air-meter indicates that a velocity of outflow of at least five feet per second may be constant. The motive-power producing this result is simply the waste-heat unavoidably radiated from the upright bath-boiler standing in the base of the chimney. The velocity mentioned is considerably less than the theoretical velocity of such a chimney, but the means are provided for easily increasing and insuring the constancy of its aspirating power. The method of heating and ventilating the one-story buildings is shown in Plate No. 5, Fig. 5. The arrangement for introducing and controlling the quantity and temperature of the fresh air has already been described. The engineer alone has access to the basement, and the sole charge of the adjustment of the valves controlling the volume of inflowing air. The air enters the wards only through inlets under each window, 14 in all, each inlet equal to 14 square feet of clear opening. The foul air escapes through five large openings along the centre of the arched ceiling, each 3 feet by 6 feet, into the ridge-chamber, and thence either through the free openings in the sides of the chamber above the roof, or through five veritilators, each 2 feet in diameter, on the top of the ridge. The side openings are closed in winter, j DESCRIPTION OF THE HOSPITAL. AXXI when also the openings in the floor of the chamber can be partly or wholly closed, and the ventilation aided by the flues, 14 in number, in the outer walls of the building. The ventilating-chamber is warmed, when necessary, by the steam-pipes shown in the drawing. With the fresh air entering the ward at an average velocity of 160 feet per minute, which, the air-meter indicates, is easily obtained, there are given to each patient 6,000 cubic feet of fresh air per hour, and the whole volume of air in the ward, about 47,600 cubic feet, or 1,700 cubic feet per patient, is changed between three and four times hourly. The average of many observations has given a velocity of the inflowing air of over 200 feet per minute, without discomfort from draughts, equal to about 8,000 cubic feet per hour to each patient. Artificial heat is only occasionally applied to the ventilating-chamber. In cold or windy weather, when the movement of air is rapid, the volume of warm air passed through the ward is very largely increased, and partial closure of the inlets and outlets is required. The experience of a winter’s use of the one-story pavilions proves the heating and ventilating arrangement to be very controllable, and with proper care a very uniform temperature and freedom from draughts has been obtained with the very generous airsupply. In general, it can be said that the peculiar arrangement of the apparatus, so that it cannot be interfered with by persons not appointed to adjust it, removes entirely the usual uncertainties and complications of such appliances, while it simplifies them and makes them easily managed. RECCNSTRUCTION. The faults of the former system of heating and ventilating by impulsion, and the alterations of the older pavilions because of errors of construction, especially of their basements, have been mentioned. These defects are illustrated, in Plate No. 6, by a section of the three-story surgical pavilion, which shows also the new method for furnishing the fresh-air supply, etc. The basement-floors, as already XXXII DESCRIPTION OF THE HOSPITAL. described, were about 3} feet, and the bottom of the freshair ducts about 7 feet below the ground level. The fresh air being warmed just before entering the building, the duct was then divided so that the warm and cold air passed separately into the wards (see page xxv.), where its delivery was controlled by the mixing-valves to produce the desired temperature. While the floor of the air-duct was cemented, the soil was left loose and uneven in the other sub-basement spaces. Lying upon this loose earth, the soil-pipes traversed these spaces from many directions to enter a sort of brick chimney. Of these chimneys there were several, each receiving a number of soil-pipes, and ‘from these the drains passing through the foundation-walls conveyed away the sewage. The walls of the basement story were covered with sheathing, and lath and plaster finishing, behind which were spaces where vermin was harbored, and foul air could rise from under the floors. The soil-pipes from the stories above were encased behind the sheathing in the corners of rooms, as shown in the plan. Certain steam-pipes, water-pipes, etc., necessarily passed along the warm-air duct, and gave off branches passing into the sub-basement air-spaces, so that there was more or less free communication of air through the openings in the wall between the duct and these spaces. The results of such arrangements have been the cause of much criticism of the hospital, and much anxiety in its management. Efforts were made, in 1873, to counteract the evils. In the annual report of the superintendent of the hospital for 1873-74, the writer states that “some extra labor has been employed during nearly all the year in the process of cleansing places difficult of access in and about the institution. The spaces under the basement-floors of all the buildings were thoroughly ‘ policed,’ the surface of the earth was removed, and replaced with clean material ; the connections of soil-pipes with the drains were carefully inspected, and the drains repaired in many places to stop the escape of air from the sewers into the buildings, and all the surfaces of these hidden places, and of the main air-ducts and cellars, were whitened with DESCRIPTION OF THE HOSPITAL. XXXIII lime-wash. The fiues for fresh and foul air, of which there are many, and which require such attention every year, were also carefully and thoroughly cleansed of their accumulated dust, etc. The importance of constant attention to these matters cannot be overestimated; and the annual expenditure of a few hundred dollars in this way will certainly improve the sanitary condition of the hospital, and must even exert an appreciable influence upon the deathrate. “These things are mentioned here also to invite attention to the peculiar difficulty of maintaining a proper condition of things in this respect, owing to peculiarities of arrangement and construction of the buildings. It is hoped that this can be remedied when improvements now proposed are made. “The evils of occupying the basements of the pavilions, as wards for the sick, cannot be too strongly urged; and not only is it absolutely impossible to properly ventilate them, as well as their sub-basements of perfectly confined air-space, but the influence of this state of things upon the sick people in the three stories above must be positively pernicious. It is not the least of the present dangers that new defects in the drains and leakages from the soil-pipes may occur unobserved from time to time in these underground places, to be followed by noxious exhalations from their contents partially absorbed in the soft earth. “The proposed transformation of these basement-wards into open cellars, with free air-space, cemented floors that can be frequently cleansed, and bare walls that can be whitened with lime-wash several times a year, will overcome evils of great and increasing magnitude.” Subsequently there was published, in the annual report of the State Board of Health of Massachusetts, some criticisms of the sanitary condition of the hospital, in a paper on “ Hospitals,” by Dr. George Derby, who ascribed the evils to the common failure of all artificial systems of ventilation. In an article on “ Ventilation of Hospitals,” in the “ American Journal of the Medical Sciences,” for October, 1875, defending artificial ventilation, Dr. Isaac Ray also criticised Il XXXIV DESCRIPTION OF THE HOSPITAL. the hospital; but ascribed its evils to recognized defects of construction, holding the fan to be blameless. An examination of Plate No. 6 will make plain the condition of the sub- basements, and what influence it must have had upon the ‘sick in the hasementar ands themselves, and in the wards above. A marked abatement of the evils followed the process of cleansing in 1873, and the repetitions of this process, but nothing short of radical reconstruction could prevent the danger of their recurrence. As soon as the occupation of the new buildings permitted the abandonment of the old basements as wards for the sick, the long-contemplated alterations were begun. The wood-work was all removed, gravel filled in, and a floor made of concrete and cement, provision made for altering the water-closet system, as already described, and the method of introducing and controlling the fresh-air supply made to correspond to that adopted for the new buildings. In the drawing, the cold-air box leading from the basement window to the steam-radiator is represented as partly cut away, to show the water-closet ventiduct beyond in the farther end of the building. The capacity of the inlet-flues for fresh air is considerably increased, but it now remains to replace the old arrangement for the outlet of foul air by constructing aspirating-chambers or flues. The fresh-air supply of the isolating-wards, instead of being forced by the fan from the cellar of the building through small flues, — equivalent to about 36 square inches for each room, — is now admitted through openings in the outer wall under the window and near the floor in each. A steam-radiator is placed in front of these openings and surrounded by a casing of wood, lined with tin, having a register in front, and covered with a wide marble slab forming a table on a level with the window-sill. These are shown in the plans of the buildings in Plates 1 and 2. A simple arrangement of sliding-valves within the casing controls the temperature and volume of the entering air, and the placing of steam-pipes in the originally ample and well-arranged ventilating chamber in the roof makes the heating and ventiDESCRIPTION OF THE HOSPITAL. XXXV lating of the building efficient and controllable. With an area of inlet-opening of one square foot and an inflowing velocity of 200 feet per minute (it has often been found by the air-meter to be more than 5 feet per second) the air of the room is entirely changed from three to four times per hour. It is believed that this result is attainable at all times. The observations that have been made with the air-meter, etc., were only experimental, and simply to test the general efficiency of the heating and ventilating apparatus ; and it is believed that a properly conducted series of observations will certainly show results no less favorable than are indicated in the data given. In what has been said of the use of the fan it is not intended to imply any condemnation of the system it involves. Local difficulties in properly carrying out such a system were, perhaps, sufficient to account for its failure here. If the fresh-air duct could be made air-tight, and properly accessible for purposes of cleansing of dust, etc., it must be admitted that the fan might be used with advantage for at least the two older pavilions, which now lack all artificial ventilating force. The hospital was built upon well and carefully considered plans, and its general arrangement was excellent, though having some deficiencies which only actual experience in its management could point out and supply. The special defects of construction in some parts of the hospital are not noticed as exceptional, for it is lamentably true that they are too common in private dwellings as well as in public buildings.
EDITED BY DAVID W. CHEEVER, M.D., and F. W. DRAPER, M. D. BOSTON: PUBLISHED BY THE BOARD OF TRUSTEES. TRS Suk Ye
DESCRIPTION OF THE HOSPITAL. By Epwarp Cow ss, M. D.
The City Hospital was first occupied in the year 1864, fifteen years after the establishment of such an institution had been proposed in the project of continuing the Cholera Hospital at Fort Hill, in the year 1849. In 1857 the first decided action was taken by the city government, upon the urgent recommendation of Hon. Alexander H. Rice, then Mayor. This, however, accomplished but little more than the obtaining an act of the Legislature authorizing the establishment of “a hospital for the reception of persons who by misfortune or poverty may require relief during temporary sickness.” In 1860 the City Council, responding to the appeal of the Mayor, Hon. F. W. Lincoln, Jr., definitely agreed to the project, and set apart from the city lands, on the South Bay territory, the present site of the hospital. During the next year plans were adopted, and the actual work of erecting buildings was begun. The lot of land upon which the hospital stands is bounded northwesterly on Harrison avenue, 454.83 feet; southwesterly on East Springfield street, 623.68 feet; southeasterly on Albany street, 453 feet; northeasterly on East Concord street, 660.27 feet; and contains in all about 292,000 square feet, or 675 acres. In addition, there was set apart a lot of land containing 69,318 square feet, in the rear of the hospital buildings, and east of Albany street, upon which were built a small-pox hospital, cholera wards, coal sheds, and a stable; but, excepting the latter, these buildings and the land were temporarily leased for other purposes in 1872. The plans for the hospital were made by Mr. G. J. F. Bryant, architect, and were elaborated with much care, and xX DESCRIPTION OF THE HOSPITAL. with the aid and counsel of physicians and others interested in its establishment. The hospital was one of the first built in this country upon the “ pavilion plan,” and was believed to contain all the modern improvements then accepted as essential in hospital construction. It is well known that in the comparatively short ane since the plans of this hospital were adopted, in 1861, very large experience has been gained in hospital construction in our own and in foreign countries, and very great and general interest has been excited in this and other sanitary questions. The experience of ten years here has pointed out some deficiencies and errors of construction in the original buildings of the hospital, and some very important alterations and improvements have been effected. In response also to the rapidly growing demand for increased accommodations, large additions have recently been made to the hospital. The object of this paper is to show what has been done here in improved hospital construction, and to set forth the reasons for the important changes and additions. When substantially completed and occupied, in 1864, the hospital consisted of a central or administration building, two three-story pavilions and the necessary auxiliary buildings, — boiler-house, laundry, etc. To these there was added, in - 1865, a two-story building for isolating wards. Subsequently a small building was erected, at the main entrance to the grounds, containing rooms for the out-patient department ; and an enlargement was made of the boiler-house, with the addition of a dead-house, morgue, and autopsy-room. The buildings stood thus, with little material change, till 1875. Their general arrangement and the use of each are shown in Plate No. 1, excepting that the new buildings, numbered 1 to 5, have been recently erected, of which the first two occupy the places of the curved portions of the original connecting corridors. The principal alterations made in the older buildings were in their basements, for the improvement of their sanitary condition, and will be noticed in connection with the description of the new method of heating and ventilating. Other changes will be alluded to in the desta of the buildings. DESCRIPTION OF THE HOSPITAL. XI The administration building (Plates 1, 2, and 3) is 60 by 80 feet, and contains practically two stories, a basement and an attic; it is surmounted by a high dome, the apex of which is 148 feet above the level of the street. The building is of brick, upon granite basement walls, and finished inside with lathing and plaster. The basement rooms are 13 feet high, with floors 34 feet below the ground level, with an air-space, and concrete upon the earth underneath, and are used as dispensary, laboratory and store-room, dining-rooms for employés, and steward’s office. The culinary work has been removed from the basement of this building to the new kitchen and bakery in the rear. The first and second stories, being respectively 16 feet and 14 feet high, are restored to the uses for which they were originally planned. On the first floor are the trustees’ room, superintendent’s office, room for the reception of visitors and for the library, matron’s room and dining-room. On the second floor are the rooms occupied by the superintendent and his family, for officers, etc. The rooms on the third or attic story are lighted only from the ceiling, and are used as chambers for employés. The operating theatre in the dome, early found to be inadequate and difficult of access, is now disused. This building is connected with the others by corridors, open above and covered in below. The lower floors. of the corridors, being 34 feet below the ground’ level, are at the general level of all the basement floors of the principal buildings, and the floors of the upper or open portion of the corridors are on a level with the first floors of the buildings. - The two pavilions, medical and surgical, are substantially alike in construction. They are 148 feet in length, 48 feet in width, three stories in height, besides the « basements. The walls are of brick, upon granite base, and with lath and plaster finish inside. The basements, formerly occupied by. patients, are now disused. On the first, second, and third floors are wards, each 80 feet long, and 272 feet wide, the two lower being each 16 feet, and the upper being 10 feet high. The first floors are about 6 feet’ above the general ground level. Each ward is lightedb y 14 windows, 7 on XII DESCRIPTION OF THE HOSPITAL. each side, and is arranged for 28 beds. At the entrance to the building on each floor (see Plates 1, 2, and 3) there are upon one side of the hall the patients’ dining-room, medicine closet, dumb-waiter, etc., in place of what was originally the bath-room ; and on the other side of the hall are a patients’ wardrobe, linen-room, and room for special cases requiring removal from the ward, or for paying patients. The linenroom, and patients’ wardrobe for clothing in daily use only, are both well-lighted rooms, and take the place of what was formerly the water-closets, and a dark closet for linen, etc., both without ventilation. A ventilating shaft adjoining the dining-room will independently ventilate all these rooms. The main stairway is also at this end of the building. At the farther end the nurses’ room and a small stairway are on one side of the hall, as originally built ; but on the other side the former arrangement of dining-room, closets for dishes, etc., is replaced by a comparatively isolated and independently ventilated apartment for the water-closets, slop-sink and urinals, and by a bath-room and lavatory. The doors of the two latter rooms close automatically by springs, and the bath-room and lavatory are separated only by a low screen, 7 feet high, so that air can pass freely through it, and light can enter over it, between the rooms and around the exterior of the inner apartment containing the water-closets. The door to the last-named apartment will also close automatically, swinging both ways. Thus will be prevented the danger of currents of air being induced through open doors from the water-closets to the ward. A special arrangement is made for independently ventilating the water-closet apartments by a shaft, 3 feet square, of wood lined with tin, which passes upward through them from the basement through the roof. The shaft contains within it the soilpipe, hot-water pipes, steam-pipes for the supply of the steam-bath in the bath-rooms adjoining, and gas jets for lighting the water-closets, on each floor, through glazed windows in the sides of the shaft. The heat unavoidably radiated from these necessary appliances furnishes a continuous extracting force for the ventilating shaft at all seasons of the year. } DESCRIPTION OF THE HOSPITAL. XIII The boiler-house: and laundry, which are 300 feet from the administration building, and connected with it by a covered way, contain the boilers, the fan for forcing fresh air into the wards (but now disused), the engines, the laundry-machinery, and the washing, ironing and drying rooms. Over the laundry are a number of rooms for employés. In the year 1871 the boiler-room was enlarged, and adjoining it there were placed, on the ground floor, a dead-room and morgue, and on the second floor a commodious and conveniently arranged autopsy-room, with pathological cabinet, etc. Near the building a drive-way from Albany street was opened in 1874, and just within this entrance to the grounds large scales were placed for the weighing of coal and many other articles of hospital supplies. A two-story brick pavilion, located near the southern corner of the grounds, contains the male and female isolating wards, which are shown in Pijtes 1 and 2. The building is 1014 feet long, and 464 feet wide, with a basement or cellar underneath, which brings the first floor to a height of about 2 feet above the ground level. There is a ventilating chamber in the roof, 10 feet wide, extending the whole length of the building. A hall or passage-way, 10 feet wide, divides each story, with rooms on each side, and windows at each end, excepting at the entrance-door on the first floor. There are 10 rooms on each floor, 14 feet by 15 feet in size, and designed to accommodate one or two patients in each. Two additional rooms on each floor are for nurses, kitchen, bathing- room, etc. ; and there are also water-closets and linenrooms. The rooms on the first floor, for male patients, are 14 feet high; and those on the second floor, for females, are 18 feet high. Each room is surrounded by brick walls, upon which hard-finished plastering is laid. An important change made in this building, in the method of heating and supplying fresh air, will be noticed hereafter, in describing the general plan of heating and ventilating. The building is connected with the basements of the main buildings by a covered corridor. The building for out-patients, added in 1867, is located XIV DESCRIPTION OF THE HOSPITAL. in the northern corner of the grounds, and at the main entrance to the hospital. It contains the porter’s room, waiting and examining-room for applicants for admission, large waiting-rooms for out-patients, and physicians’ rooms. Medical out-patients, and those having diseases of the eye, ear, skin, throat, and nervous system, and diseases of women, are treated here, the service being so arranged that each of the classes named receives attention on three days of each week, and on alternate days. The surgical outpatients were formerly treated in rooms in the basement of the surgical pavilion, but new accommodations have been provided for this department. } In 1874 a propagating-house was built along the southern side of the corridor in the rear of the administration building, and a gardener employed by the year to care and provide for the ornamentation of the grounds. The plan has resulted in a great saving from the previous expense for this purpose, besides the accumulation of a valuable stock of plants, etc. The heating of this greenhouse is done by a ° novel method and at a small cost: the water in the cast-iron pipes, circulating about the building in the usual way, is made hot in a common “ feed-water heater” (such as is used by engineers for the saving of the heat of exhaust steam), in size 3 feet high by 14 feet in diameter, and requiring an inappreciable quantity of steam. The hospital stood in 1874 substantially as first. built, except the minor additions and alterations just described. As early as the year 1868 the hospital was felt to be crowded by the number of its patients, there being a daily average of 174 during the year, and the necessity of the enlargement of the hospital was represented by the trustees to the City Council. The rapid growth of the city and a greatly increasing demand for accommodations continued until, in 1874, the number of patients reached a daily average for the year of 230, and a maximum at one time of 285. The capacity of the hospital was at this time reckoned at 230 beds, including the occupation of 40 beds in the. basements of the medical. and surgical pavilions. The insufficiency and great inconvenience of the surgical operating DESCRIPTION OF THE HOSPITAL. | XV theatre in the dome had been early recognized. The great overcrowding of all the wards made the management and service of the hospital very difficult and laborious; and the impossibility of giving proper attention to sanitary requirements, and unavoidable neglect of needed repairs, were positively detrimental to the welfare of the sick. In the beginning of the year 1874 decided steps were taken by the trustees for the enlargement of the hospital, and the City Council appropriated the sum of $190,000 for the purpose. It was not easy to determine the best way in which the desired alterations and enlargement should be made. It was evidently necessary to revise the system of heating and ventilating, and to replace nearly the whole of the steam apparatus for that purpose; it was desirable that a large increase of capacity should be gained, and, at the same time, by a wise economy of expenditure, all essential modern improvements in hospital construction should be secured. While the simpler structures were believed to be the best, it was also demanded that the new buildings should conform architecturally to the older ones. Appreciating the value of the experience of the medical gentlemen long connected with the institution, the Board of Trustees first invited the medical and surgical staff of the hospital to present a general statement of what was needed to be done. Subsequently a committee of the Board of Trustees was appointed “to procure plans for the enlargement and additions to the present hospital buildings, in conformity to the needs therefor, as set. forth in the communication of the medical and surgical staff.” It was decided by the Board that while certain conditions should be fulfilled, as to the architectural appearance of the new buildings, it was also of the first importance to plan and adapt them in their relations to the older buildings, so as to gain both the best results for the sick and the greatest convenience and economy of administration. In accordance with their very considerate and liberal policy, the trustees determined that the plans should first be prepared in detail, at the hospital, under the supervision of those who were practically familiar with its needs. This was done chiefly under the direction AVI DESCRIPTION OF THE HOSPITAL. of one of the Committee on Plans, George W. Pope, Esq., well-known in Boston as a skilful practical builder, to whom the sketch-plans were frequently submitted during a period of several months, while being prepared by a draughtsman at the hospital, under instructions given him by the: Superintendent. , The plans thus prepared were substantially carried out in all their details in the new buildings, and had the full approval of the hospital staff as being the best that could be devised to meet the many and conflicting indications presented in the attempt to engraft new features of construction upon older ones. These sketch-plans were afterwards placed in the hands of the architect, Mr. Carl Fehmer, of Boston, by whom the perfected plans and specifications were prepared, with some modifications only of the architectural exteriors, and with the details of construction. They were finally approved by the Committees on the City Hospital, and on Public Buildings, of the City Council, in March, 1875, and the work of building began in April of that year, reaching completion in the following year. A plan of the principal floor of the new buildings is given in Plate No. 1. They are numbered from 1 to 5, and consist of a surgical and medical building, each three stories high, with basements ; two one-story pavilions, surgical and medical; and a low building along the side of the rear corridor for kitchen, bakery, etc. ‘These buildings are connected with the older ones by additions to the original corridors, and a part of the latter was removed to make room for the two larger buildings. The original plan of the hospital contemplated the erection of two additional pavilions in the rear of the first ones, to be connected in like manner, by corridors curved in reverse directions, with the administration building. The present arrangement of the buildings, as shown in Plate No. 1, is peculiar, and one that would hardly have been made under other circumstances ; but it is found practically to have remarkable advantages in convenience, ease, and economy of management. In devising this arrangement, it was at the outset determined that as large an area of ground as possible should be reserved for DESCRIPTION OF THE HOSPITAL. XVII the present and future construction of one-story pavilions.* It was next agreed that the separate rooms to the limited number required for paying patients, and the smaller wards for children and for ophthalmic and gynecological patients, could be placed in buildings of more than one story. It was necessary, also, that one of the larger buildings should contain, on its first floor, the operating theatre, etc., for the surgical service, and should be conveniently located for easy communication with other buildings. Then it was made a matter of great importance that certain indications should be met as to the architectural appearance of the new build-. ings. The result obtained in this regard is well shown in the frontispiece, in which the surgical and medical buildings appear upon the right and left of the central or administration building. ‘These locations were first chosen chiefly for convenience in administration, and to economize groundspace, but the arrangement was afterwards fully approved by the architect, the new buildings not being treated archi- _tecturally as wings of the central structure, but as separate members of the whole group, which, it is believed, has been greatly improved in appearance by the additions. The advantages of the separation of the pavilions are practically preserved by the distances left between the new and the older structures. The prevailing winds, in the warmer months, being from points between the west. and south, readily traverse the spaces between the buildings as well as the buildings themselves, which, it is also to be noticed, approach each other by their ends, and thus admit of being more in proximity than otherwise. The corridors connecting the one-story buildings with the others offer little obstruction to the currents of air, being very open in their construction. ) The surgical building is 48 feet by 94 feet in general dimensions, with a projection of 8 feet by 48 feet from the front wall, and another of 24 feet by 52 feet from the rear * An acknowledgment is due to Frank H. Hamilton, M. D., of New York, for valuable advice given to the Committee of the Trustees and the writer, in the winter of 1875, as to the merits of such structures, and the importance of including them in the contemplated additions to the hospital. II AVIII DESCRIPTION OF THE HOSPITAL. wall. It is three stories high beside the basement; and the heights of the stories correspond with those of the older buildings, two of them being 16 feet, the upper one 10 feet, and the basement 9 feet. The foundations of the building are laid upon piling. The basement walls are granite, with faced brick inside, and the walls above are of brick, and 20 inches thick. All the walls are hollow, with a four-inch air-space, including the corridor walls, and all are plastered upon the brick, with all the corners of the rooms rounded. ‘There is very little wood-work in the building, except the floors, and about the doors and win- , dows, where it is very plain, being finished with a simple half-round moulding. The doors themselves have plain panels and bevelled stiles without mouldings, and all the wood-work is of clear white pine, filled with shellac and varnished. The base-boards are also bevelled at the top and joined to the hard-pine floors by a quarter circle in a strip of hard pine, and the floors are laid in 24-inch strips, matched and blind-nailed. There are thus very few corners in which dust can collect, and the labor of preserving cleanliness is greatly reduced. The main entrance to the principal floor of this building (Plate No. 1) is at its northern end, from which a corridor 8 feet wide extends through the length of the building, joined at its centre by another corridor which communicates - with the open connecting corridor in front. At the right, of | the entrance is a private consulting-room, 11 feet by 154 feet, for the visiting surgeons, and a larger room for the office of the house surgeons, to which room are adjoined closets, etc. Next, along the corridor, is the main stairway, surrounded entirely by brick walls, and having double doors at the landing of each story, so arranged as to cut off currents of air from one story to another. Between the stairway and the front of the building is the room of the supervising ward-master, who has general supervision of all the surgical wards as to the reception and assignment of patients, the control of the male nurses, and the charge of the general business of the surgical service. Near the stairway, and in the opposite angle of the two corridors, is an elevatorDESCRIPTION OF THE HOSPITAL. XIX way, by which patients are to be carried to the upper stories of this building, and of the surgical pavilion in front of it, over the terrace of the connecting corridor, as shown in Plate No. 2. Beyond the elevator-way, and occupying the remainder of the front half of the first floor, are three waiting- rooms, in which male and female patients are separately placed before surgical operations. These rooms have waterclosets, etc., adjoining two of them, and they serve also as small accident-wards, in connection with the accident-room, for severe cases received by night, or for such as cannot at once be placed in the common wards. On the opposite side of the corridor from the waiting-rooms, and quite isolated from the sight and hearing of their occupants, is the etherizing room. Adjoining this is the operating theatre, a large room about 49 feet by 42 feet in the clear, and 33 feet high, occupying two stories of the building. An enlarged plan and section of this room are shown in Plate No. 4. The arena is ample and roomy, being 17 feet wide from the corridor wall to the semi-circular seats which occupy the rest of the room, with a seating capacity of about 250 persons. A large skylight, 19 feet by 14 feet, gives abundant and satisfactory light. Operations requiring lateral light are done in the accident-room adjoining. Under the seats of the amphitheatre is considerable space occupied by a passageway, 6 feet wide, from which a few steps lead to the front row of seats, two recovery-rooms, a stairway from the students’ entrance in the rear of the building, a splint-room, and a’small bath and linen-room pertaining to the accidentroom. The accident-room is situated immediately at the left of the main entrance to the building, and is large and well lighted, being about 19 feet by 22 feet; it communicates by a wide doorway with the operating theatre. These rooms are amply supplied with hot and cold water, and other conveniences. <A large ventilating chimney is marked V, and is shown also in section in Plate No. 4, Fig. 1. The second floor of the surgical building is shown in Plate No. 2, and on a larger scale in Plate No. 4. The rooms over the accident-room are occupied by the house surgeons, and those numbered 1 to 5 by patients. All the rooms XX DESCRIPTION OF THE HOSPITAL. average in size 154 feet by 10} feet. Adjoining the nurse’s room, occupied by the head-nurse of the ward and one assistant, is a bath-room, containing water-closet, etc. The dining-room is about 16 feet by 14 feet, and contains in one corner a soapstone sink, steam-table and shelves for crockery. A dumb waiter communicates with the diet kitchen in the basement. The bath-room has a bath-tub free from the wall on both sides, a sitz bath, hot and cold shower-bath, steam-bath and wash-bowl. The water-closet apartment is quite isolated by being shut off from the rest of the building behind the brick walls of the stairway, and is entered by a passage-way having two doors closing automatically, so that both shall not be open at the same time. This apartment contains two water-closets, a porcelain slop-sink and a urinal, and is ventilated independently of all other rooms by a special arrangement shown in Plate No. 4, Figs. 1 and 3. A tin-lined shaft, 2 feet square, contains within itself the soil-pipe, hot-water and steam-pipes in constant use, and gas jets on each floor to give light through small windows in the sides of the shaft. The ventilation is efficient at all times. The soil-pipe passes upward above the roof, and is open at its top. A side of the shaft can be easily removed at any time for inspecting or repairing the pipes. All sinks, wash-bowls, etc., are supported on brackets, and the space underneath left open, with the plumbing work exposed. A number of Jennings’ all-earthenware water-closets are in very successful use; these are also left exposed under the seats, which have no risers, thus securing great advantage as to cleanliness. The description here given of the servicerooms applies also to the other upper stories of this and the medical building. The upper floor of this building (Plate No. 3) differs from the one just described in having three small wards for children, one for ten beds, about 49 feet by 15 feet, and two for four beds each, about 18 feet by 14 feet. The basement plan of the surgical building is shown in Plate No. 2, where the use of the rooms numbered from 1 to 5, for surgical out-patients, is indicated. The dressing-room is supplied with appliances, splints, etc.; and adjoining these rooms are separate water-closets for each sex. Patients DESCRIPTION OF THE HOSPITAL. XXI requiring other than minor operations or treatment in the wards are sent to the surgical rooms above, on the first floor. The diet-kitchen (room No. 6) has a cook in attendance for the preparation of special diets for all the surgical wards. The basement floors are all made hard with concrete and cement, upon which hard-pine flooring is laid, excepting in the diet kitchen, where there is a flagging-stone and brick paving. The walls of these rooms are finished by simply painting the faced brick a light color. The medical building (numbered 2 in Plate No. 1) is symmetrical in general appearance and dimensions with the one just described, except that the projection in its rear is 30 feet by 24 feet. A small ward of eleven beds is thus formed on each of the three stories, in size about 264 by 4034 feet. The ward on the first floor is designed for male ophthalmic patients, and contains all the sick who are treated on this floor. Near the main entrance are the offices of the visiting and house physicians. On the opposite side of the corridor is a receiving-room for medical cases, and adjoining it the room of the supervising ward-master of the medical service. Three rooms, marked H in the plan, are occupied by the house physicians. The bath-room for patients on this floor is placed near the ward, but otherwise all the servicerooms of this building are like those in the one previously described. A medicine closet, 20 inches deep, occupies the thickness of the corridor wall near the entrance to the ward on each floor. This closet is furnished with a marble slab, small wash-bowl, hot and cold water, shelving, and gas-light. It is very convenient, and having glass doors, is constantly under inspection, and easily kept in a cleanly and tidy condition. The second floor (Plate No. 2) has seven rooms, each averaging 164 feet by 11 feet, for paying patients of the medical and ophthalmic service. For free patients of the latter class the ward is designed. A large room, G, is for an ophthalmic operating room, but available also as a small ward. The third floor (Plate No. 3) is devoted entirely to the treatment of diseases peculiar to women. ‘There are five rooms for paying patients, and a small ward, of four beds, besides the larger ward containing eleven beds. An operatXXII DESCRIPTION OF THE HOSPITAL. ing-room, at the southern corner of the building, is light and capacious, and, with low window-sills, abundant lateral light is obtained. In the basement of this building is a kitchen for preparing special diets for the medical wards, a room, with a chimney for ventilation, etc., for a laboratory, where the chemical and microscopical examinations may be made, a general linen-room, and a sleeping-room for male nurses. These rooms are finished in the same manner as those in the basement of the surgical building. The water-closet apartments of this building also have a special ventilating shaft, as already described, and the bath-rooms adjoining the nurses’ rooms in each building are ventilated by a chimney warmed by the copper smoke-flue of the range in the basement dietkitchen. The one-story buildings are shown in plan, in Plate No. 1, where they are numbered 3 and 4; and a section and elevation of the surgical pavilion are shown in Plate No. 5. The two buildings are alike in form and arrangement. The underpinning is laid upon a foundation of concrete with no piling. The framing is wood and iron, with a covering of boards and, outside of this, corrugated iron. The roof is slated; the inside of the building has a lath and plaster finish, and the wood-work is very plain, as described in the surgical building. ‘The general dimensions are 137 feet by 402 feet, except that the portion of the building occupied by the ward is narrowed to 28 feet, so that the ward is 94 feet by 264 feet in the clear. The entrance to the building is from the connecting corridor. The hall, 8 feet wide, has, upon the right-hand side, a small special ward or examining room, 15 feet by 11 feet, a drying closet, a medicine closet, and the dining-room, 15 feet by 17 feet, furnished with a soap-stone sink, steam-table, shelving, small broom-closet, and a dumb-waiter by which food is sent from the corridor basement... On the left of the entrance is a linen-room, and a room for patients’ clothing in daily use, other clothing being kept in an appropriate place in the basement. The last-named rooms are each 4 feet by 15 feet, and each is lighted by a window. ‘The patients’ wardrobe has along its sides twenty-eight small stalls, numbered to correspond with — DESCRIPTION OF THE HOSPITAL. XXIII the beds in the ward. Every article of a patient’s clothing as soon as taken off is hung in its proper place in this room. The room for the head-nurse and her assistant is 12 feet by 15 feet, and has a bath-room, etc., adjoining. These servicerooms are 14 feet high to the ceiling, and over them, in this part of the building only, is a second story, reached by a narrow stairway with a door at its foot, where there are four rooms for nurses, and a common bath-room. There is an arrangement for ventilating the water-closets and clothing rooms by an independent shaft enclosing the soil-pipe, etc., as already described. The ward is 94 feet long by 264 feet wide in the clear, and has 7 opposite windows and 14 beds on each side. The windows, having double sashes, are 9 feet high by 4 feet wide, and the space between them is nearly 94 feet. The height of the ward, from the floor to the centre of the arched ceiling, is 22 feet, or an average of about 19 feet. Each bed occupies about 63 feet along the wall, and 134 feet to the centre of the ward. Thus a floor area of 89 square feet and an air-space of about me cubic feet is given to each bed. At the end of the ward is a day-room, 11 feet by 12 feet, lighted by a bay-window. Wide glass doors open into this room from the ward, and in the end wall over these doors there are windows, thus giving the end of the’ large room a light and open appearance. These arrangements are shown in Plate No. 5, Figs. 1, 2,3 and 5. On the right of the day-room is the lavatory, a narrow room with a window, marble slab and wash-bowls. In a separate room adjoining, with doors so arranged that entrance is easy for carrying in a patient on a stretcher, is the bath-room, 9 feet by 13 feet, furnished like the bath-rooms before described. At the opposite corner of the building is the room for water-closets, etc. The entrance from the ward opens by a self-closing door, first into a lobby 3} feet wide, with a window at each end. In one section of the lobby is a narrow stairway, for occasional use, leading to the basement. A low partition and lattice door shuts off this section, but does not obstruct the passage of air from one window to the other. From the XXIV DESCRIPTION OF THE HOSPITAL. lobby a self-closing door opens into the water-closet apartment, the arrangement of which is shown in the plan (Plate No. 5). <A section of the ventilating shaft for the waterclosets is shown in Fig. 4. A steam-pipe heats the shaft, aided by a gas-jet, which lights the room by night. Fresh air is supplied to this room by an independent inlet, and the lobby also has separate air-supply and ventilation. All the spaces under the sinks, washbowls, seats of water-closets, etc., are left open, and the plumbing is exposed to view. The basement, excepting of that part of the building occupied by the service-rooms at its entrance, is an open and free air-space, containing only heating apparatus. The floor is made hard and impenetrable to moisture by concrete and cement, and is on a level with the ground outside. Its numerous windows can be left open many months in the year, and, its doors being locked, it is kept cleanly and free from any intrusion but for proper purposes. The main kitchen of the hospital was formerly under the administration building, and there was great deficiency of space, storage-rooms and proper ventilation. The place of the new kitchen is shown in Plate No. 1, and a plan of it is given in Plate No. 3. Its general dimensions are 45 feet by 30 feet, and it connects with the basement corridors. It is about 10 feet high in the clear, and its roof is nearly on a level with the first floor of the other buildings, so that the winds pass freely over it and between the other buildings. It has brick walls, which are painted inside, and a solid floor of slate tiles and bricks laid in cement. It is well-furnished with a Whiteley’s range and steam-jacket kettles for cooking meats, soup and vegetables; a large tea and coffee apparatus; iron sinks ; shelves for utensils upon a movable table, and a brick oven for roasting meats, etc. All the furnishing of the kitchen, except the range, stands away from the wall. The _ plan shows the arrangement of the bakery, store-rooms for flour and bread, the refrigerator and store-rooms for meats, vegetables, etc. A small cellar and coal-bin, underground, is connected with the kitchen. A large chimney, with the smoke-flue inside of it, over the ovens, ventilates the heated space over them and the kitchen and bakery. Openings are DESCRIPTION OF THE HOSPITAL. XXV left in the brick walls outside, near the eaves, so that air can enter the space between the ceiling and the roof, from which it escapes through ventilators, thus cooling the roof and the rooms below in hot weather. The kitchen is centrally located, and the food is conveniently distributed in covered cars to the various buildings. HEATING AND VENTILATING. The boiler-room (Plate No. 1) contains seven steamboilers. The four older ones are each 16 feet long by 48 inches in diameter, with forty tubes, each 15 feet by 3} inches. The three new boilers are each 15 feet by 48 inches, with forty-nine tubes, 14 feet by 3 inches. The method by which the hospital was formerly heated and ventilated was as follows : *— ** Air forced through ducts, by means of a large fan at the boiler-house, and warmed by coils of steam-pipes placed in these ducts, is carried to every part of the buildings, thus affording the means of heating as well as ventilation. Direct radiation is provided for in a portion of the rooms, to be used in case of necessity. The steam-pipes over which the air passes for heating the different apartments in the central buildings are placed in coils, in chambers connected with the air-ducts. Those for heating the pavilions are located in the air-passages, beneath the floor under the corridors leading to the pavilions. The passage through which the air passes, after having left the main duct on its way to the pavilions, is divided into two compartments, in one of which is located coils of one-inch wrought-iron pipe. The steam, after passing from the boilers in a large iron pipe, is distributed through these coils, being regulated by valves, under charge of the engineer. After passing through the coils, it enters a steam-trap, located at the foot of the coil, which is so constructed that no steam can pass, where, after being converted into water, it is conveyed through a cast-iron pipe to a reservoir, located at the head of the air-duct; from thence it * City Hospital Reports, First Series, page 17. XXVI DESCRIPTION OF THE HOSPITAL. is pumped into the boilers, at a temperature of from one hundred and eighty to one hundred and ninety degrees. Through the other compartment cold ‘air passes. These two compartments are so arranged that the cold and warm air are brought together in the several wards, where they come in contact before entering the room.” The cemented floor of the air-duct here described as passing under the corridor basement-floors, was about 3} feet below the latter, and thus about 7 feet below the ground level. Because of certain faults of arrangement, and in consequence of troubles to be hereafter described, arising from the location of the air-duct at such a depth, this system of heating and ventilation by impulsion-was entirely abandoned in 1875, and the method by aspiration was adopted. The steam-radiators in the various parts of the buildings being raised to the basement ceilings, and the floor of the boiler-room being lowered six feet, the boilers, with the three new ones added to their number, could thus receive the water of the condensed steam flowing back into them without the intervention of a tank and pump, involving much loss of heat. In this manner the four older boilers have, at the date of this writing, been applied for one whole year to the warming of the main buildings of the hospital, excepting the isolating wards. This has ordinarily been done in cold weather by three boilers at low pressure of steam, rarely as high as 5 lbs., and with the index of: the pressure gauge standing for days at zero. In extreme weather, the fourth boiler was put at work on a few occasions. ‘The average daily consumption of coal in these boilers was from 3,000 to 3,500 Ibs. per boiler, never over 4,000 Ibs. in very cold weather. The three new boilers have been applied at high pressure (15 Ibs. to 30 lbs.) to running the laundry machinery, cooking, heating water for all purposes in all the buildings, heating ventiducts of water-closets, the ventilating chambers in the roofs of the medical and surgical buildings, and in the ridges of the one-story pavilions, besides warming the two isolating wards. With these boilers, the use of the tank and pump has been necessary, and two of them have done all the work, except in extreme weather, DESCRIPTION OF THE HOSPITAL. XXVIT consuming daily per boiler but little more coal than the lowpressure boilers. Any one or more of the boilers can be used at high or low pressure. The steam is conveyed to the different buildings in large pipes, the main pipe from the boilers to the administration building being eight inches in diameter. The distribution of the heating apparatus, the method of furnishing the freshair supply and of ventilating are shown in the plans in Plate No. 4. In Fig. 1, a section of a part of the surgical building, 1s shown the arrangement and special ventilation of the water-closets already described, the motive aspirating power in the shaft being furnished by steam-pipes, hot-water pipes and the gas-jets in daily use. The manner of covering the soil-pipe, imbedded in cement, to its exit through the foundation of the building to join the drain outside is here shown. The aspirating chimney of this building, shown in Figs. 1, 2 and 3, is 6 feet square inside, and about 70 feet high from the basement floor to the bottom of the openings in its sides near its top. It was first proposed to place the boilers for heating all the surgical wards in the basement of this building, and to make a similar arrangement for the medical wards also, the smoke-flue to stand within the chimney, and thus furnish motive-power for ventilation; but the plan of concentrating the boilers in the present boiler-room being continued, heat is furnished to the chimney by utilizing the unavoidable radiation from the bath-boiler placed conveniently at its base. The additional steam-pipes to increase the aspirating power of the chimney, shown in Fig. 1, have not yet been found necessary, and there is always found a positive upward current of air. It is believed that decided advantages are gained from the somewhat novel plan of managing the ventilation of these new three-story buildings. The chimney is used only to ventilate the rooms of the basement and first floor; the warm and vitiated air from them, being conveyed laterally, or only a little downward, to the base of the chimney, is practically kept on its way upward and outward. The two upper stories are ventilated by a different plan, their outflowing air being simply aided in its XXVITI DESCRIPTION OF THE HOSPITAL. upward tendency by being drawn into the chamber in the roof (Figs. 1, 2). There is thus no loss of power in first drawing the air downward to the chimney base; there is no danger of the common trouble in such cases of reversed currents of foul air from the first to the upper stories through the ventilating flues of the latter. All communication is thus very perfectly cut off between the lower and the upper stories. The ventilating chamber in the roof can be warmed by steam-pipes, which have been employed only in damp or still warm weather. The air escapes through the sides of the chamber, which receives additional warmth in sunny days through its glazed roof. Each room in the building has one or more separate ventilating flues, extending from: floor to ceiling in the wall next the corridor, and each flue has two openings into it, and within it a valve, so arranged that it can only be moved by a key. The entrance to the flue is thus practically always open either at the top or bottom of the room. ‘Thus all the upper outlets can be closed, compelling ventilation through the lower openings during the winter season, with the certainty of remaining so at the will of the superintendent, and beyond the reach and interference of unwise attendants or meddlesome patients. In the same manner, by simply turning the valves, the ventilation can be made to proceed through the upper openings in summer. It is to be noticed that the air passes downward from the rooms on the first floor, and upward from the upper stories. | Each small room has one, and the larger rooms have several inlet flues in the outer wall of the building for supplying fresh air, also arranged with valves so that the fresh air must enter in a given volume either at the bottom or the top of the room at will. This is illustrated in Fig. 1, in the room on the second floor. The cold air is introduced through openings in the outer basement-walls, passes immediately over the steam coils, of which there is a separate one for every flue, and upward to the rooms, which it enters through the lower or upper register, according to the adjustment of the valve. The most satisfactory method for the winter season has been to introduce fresh air by the upper registers, DESCRIPTION OF THE HOSPITAL. XXIX and extract foul air by the lower ones. In summer the reverse arrangement is the best. The steam-radiators in the basements are encased with galvanized iron, forming a small chamber in which a switchvalve directs the fresh air, so that it passes either through the coil so as to be warmed, or, unwarmed, directly into the flue above. A wire connects the switch-valve with the lower register in the room above, where by the use of a key the valve can be adjusted to alter the temperature of the entering air. The volume of air can only be changed by opening or closing a sliding valve covering the inlet through the basement wall, and this is under the charge of the engineer. The arrangement of the apparatus for introducing, heating and controlling the fresh-air supply is more plainly shown in Plate No. 5, Fig. 5. In the plan of the second floor of the surgical building (Plate No. 4, Fig. 3), the fresh-air inlets and outlets are shown. Some observations made in these rooms, to test the efficiency of the ventilation, have given satisfactory results. In the room numbered 3, where there are about 2,600 cubic feet of air space, and the inlets and outlets have each one square foot of clear openings, the velocity of inflowing and outflowing air, as shown by the air-meter, averaged in a number of observations 150 feet per minute. At this rate, 9,000 cubic feet of air pass through the room, changing its contents between three and four times per hour. The atmosphere out of doors, at the time of the observations, was clear, and quite still, the temperature about 30° F., that of the room 68° F.; and there was no artificial heat in the ventilating chamber in the roof. With added heat by the steampipes in this chamber, its aspirating power is increased, and good ventilation can be obtained at all times. The plan (Plate No. 4, Fig. 3) shows the first floor of the operating theatre, the room being two stories high. The shaded lines and arrows indicate the downward and lateral direction of the foul air, under the floor, to the base of the large chimney, from the ventilators in the corridor-wall and in the risers of the steps leading up to the seats of the amphitheatre. The amphitheatre is capable of seating 250 XXX DESCRIPTION OF THE HOSPITAL. persons, though the number likely to be present will rarely exceed 200. The room contains 55,000 cubic feet of airspace, and its atmosphere is easily changed between two and three times per hour, with ventilating outlets equal to 12 square feet of clear opening, and a usual outflow velocity of not less than 200 feet per minute. It is safe to say that more than 700 cubic feet of air per hour is supplied to each person. The efficiency of the ventilation is well indicated by the notable absence of the odor of ether in the theatre during operations, while at the same time, that odor is very strong within the base of the chimney. Observations made almost daily, during the last year, of the working of the chimney, prove its up-cast draught to be continuous, and without any added heat from the available steam-pipes. The total cubic space ventilated by the chimney in the surgical building equals about 88,000 cubic feet; the area of the chimney is 36 square feet, and the air-meter indicates that a velocity of outflow of at least five feet per second may be constant. The motive-power producing this result is simply the waste-heat unavoidably radiated from the upright bath-boiler standing in the base of the chimney. The velocity mentioned is considerably less than the theoretical velocity of such a chimney, but the means are provided for easily increasing and insuring the constancy of its aspirating power. The method of heating and ventilating the one-story buildings is shown in Plate No. 5, Fig. 5. The arrangement for introducing and controlling the quantity and temperature of the fresh air has already been described. The engineer alone has access to the basement, and the sole charge of the adjustment of the valves controlling the volume of inflowing air. The air enters the wards only through inlets under each window, 14 in all, each inlet equal to 14 square feet of clear opening. The foul air escapes through five large openings along the centre of the arched ceiling, each 3 feet by 6 feet, into the ridge-chamber, and thence either through the free openings in the sides of the chamber above the roof, or through five veritilators, each 2 feet in diameter, on the top of the ridge. The side openings are closed in winter, j DESCRIPTION OF THE HOSPITAL. AXXI when also the openings in the floor of the chamber can be partly or wholly closed, and the ventilation aided by the flues, 14 in number, in the outer walls of the building. The ventilating-chamber is warmed, when necessary, by the steam-pipes shown in the drawing. With the fresh air entering the ward at an average velocity of 160 feet per minute, which, the air-meter indicates, is easily obtained, there are given to each patient 6,000 cubic feet of fresh air per hour, and the whole volume of air in the ward, about 47,600 cubic feet, or 1,700 cubic feet per patient, is changed between three and four times hourly. The average of many observations has given a velocity of the inflowing air of over 200 feet per minute, without discomfort from draughts, equal to about 8,000 cubic feet per hour to each patient. Artificial heat is only occasionally applied to the ventilating-chamber. In cold or windy weather, when the movement of air is rapid, the volume of warm air passed through the ward is very largely increased, and partial closure of the inlets and outlets is required. The experience of a winter’s use of the one-story pavilions proves the heating and ventilating arrangement to be very controllable, and with proper care a very uniform temperature and freedom from draughts has been obtained with the very generous airsupply. In general, it can be said that the peculiar arrangement of the apparatus, so that it cannot be interfered with by persons not appointed to adjust it, removes entirely the usual uncertainties and complications of such appliances, while it simplifies them and makes them easily managed. RECCNSTRUCTION. The faults of the former system of heating and ventilating by impulsion, and the alterations of the older pavilions because of errors of construction, especially of their basements, have been mentioned. These defects are illustrated, in Plate No. 6, by a section of the three-story surgical pavilion, which shows also the new method for furnishing the fresh-air supply, etc. The basement-floors, as already XXXII DESCRIPTION OF THE HOSPITAL. described, were about 3} feet, and the bottom of the freshair ducts about 7 feet below the ground level. The fresh air being warmed just before entering the building, the duct was then divided so that the warm and cold air passed separately into the wards (see page xxv.), where its delivery was controlled by the mixing-valves to produce the desired temperature. While the floor of the air-duct was cemented, the soil was left loose and uneven in the other sub-basement spaces. Lying upon this loose earth, the soil-pipes traversed these spaces from many directions to enter a sort of brick chimney. Of these chimneys there were several, each receiving a number of soil-pipes, and ‘from these the drains passing through the foundation-walls conveyed away the sewage. The walls of the basement story were covered with sheathing, and lath and plaster finishing, behind which were spaces where vermin was harbored, and foul air could rise from under the floors. The soil-pipes from the stories above were encased behind the sheathing in the corners of rooms, as shown in the plan. Certain steam-pipes, water-pipes, etc., necessarily passed along the warm-air duct, and gave off branches passing into the sub-basement air-spaces, so that there was more or less free communication of air through the openings in the wall between the duct and these spaces. The results of such arrangements have been the cause of much criticism of the hospital, and much anxiety in its management. Efforts were made, in 1873, to counteract the evils. In the annual report of the superintendent of the hospital for 1873-74, the writer states that “some extra labor has been employed during nearly all the year in the process of cleansing places difficult of access in and about the institution. The spaces under the basement-floors of all the buildings were thoroughly ‘ policed,’ the surface of the earth was removed, and replaced with clean material ; the connections of soil-pipes with the drains were carefully inspected, and the drains repaired in many places to stop the escape of air from the sewers into the buildings, and all the surfaces of these hidden places, and of the main air-ducts and cellars, were whitened with DESCRIPTION OF THE HOSPITAL. XXXIII lime-wash. The fiues for fresh and foul air, of which there are many, and which require such attention every year, were also carefully and thoroughly cleansed of their accumulated dust, etc. The importance of constant attention to these matters cannot be overestimated; and the annual expenditure of a few hundred dollars in this way will certainly improve the sanitary condition of the hospital, and must even exert an appreciable influence upon the deathrate. “These things are mentioned here also to invite attention to the peculiar difficulty of maintaining a proper condition of things in this respect, owing to peculiarities of arrangement and construction of the buildings. It is hoped that this can be remedied when improvements now proposed are made. “The evils of occupying the basements of the pavilions, as wards for the sick, cannot be too strongly urged; and not only is it absolutely impossible to properly ventilate them, as well as their sub-basements of perfectly confined air-space, but the influence of this state of things upon the sick people in the three stories above must be positively pernicious. It is not the least of the present dangers that new defects in the drains and leakages from the soil-pipes may occur unobserved from time to time in these underground places, to be followed by noxious exhalations from their contents partially absorbed in the soft earth. “The proposed transformation of these basement-wards into open cellars, with free air-space, cemented floors that can be frequently cleansed, and bare walls that can be whitened with lime-wash several times a year, will overcome evils of great and increasing magnitude.” Subsequently there was published, in the annual report of the State Board of Health of Massachusetts, some criticisms of the sanitary condition of the hospital, in a paper on “ Hospitals,” by Dr. George Derby, who ascribed the evils to the common failure of all artificial systems of ventilation. In an article on “ Ventilation of Hospitals,” in the “ American Journal of the Medical Sciences,” for October, 1875, defending artificial ventilation, Dr. Isaac Ray also criticised Il XXXIV DESCRIPTION OF THE HOSPITAL. the hospital; but ascribed its evils to recognized defects of construction, holding the fan to be blameless. An examination of Plate No. 6 will make plain the condition of the sub- basements, and what influence it must have had upon the ‘sick in the hasementar ands themselves, and in the wards above. A marked abatement of the evils followed the process of cleansing in 1873, and the repetitions of this process, but nothing short of radical reconstruction could prevent the danger of their recurrence. As soon as the occupation of the new buildings permitted the abandonment of the old basements as wards for the sick, the long-contemplated alterations were begun. The wood-work was all removed, gravel filled in, and a floor made of concrete and cement, provision made for altering the water-closet system, as already described, and the method of introducing and controlling the fresh-air supply made to correspond to that adopted for the new buildings. In the drawing, the cold-air box leading from the basement window to the steam-radiator is represented as partly cut away, to show the water-closet ventiduct beyond in the farther end of the building. The capacity of the inlet-flues for fresh air is considerably increased, but it now remains to replace the old arrangement for the outlet of foul air by constructing aspirating-chambers or flues. The fresh-air supply of the isolating-wards, instead of being forced by the fan from the cellar of the building through small flues, — equivalent to about 36 square inches for each room, — is now admitted through openings in the outer wall under the window and near the floor in each. A steam-radiator is placed in front of these openings and surrounded by a casing of wood, lined with tin, having a register in front, and covered with a wide marble slab forming a table on a level with the window-sill. These are shown in the plans of the buildings in Plates 1 and 2. A simple arrangement of sliding-valves within the casing controls the temperature and volume of the entering air, and the placing of steam-pipes in the originally ample and well-arranged ventilating chamber in the roof makes the heating and ventiDESCRIPTION OF THE HOSPITAL. XXXV lating of the building efficient and controllable. With an area of inlet-opening of one square foot and an inflowing velocity of 200 feet per minute (it has often been found by the air-meter to be more than 5 feet per second) the air of the room is entirely changed from three to four times per hour. It is believed that this result is attainable at all times. The observations that have been made with the air-meter, etc., were only experimental, and simply to test the general efficiency of the heating and ventilating apparatus ; and it is believed that a properly conducted series of observations will certainly show results no less favorable than are indicated in the data given. In what has been said of the use of the fan it is not intended to imply any condemnation of the system it involves. Local difficulties in properly carrying out such a system were, perhaps, sufficient to account for its failure here. If the fresh-air duct could be made air-tight, and properly accessible for purposes of cleansing of dust, etc., it must be admitted that the fan might be used with advantage for at least the two older pavilions, which now lack all artificial ventilating force. The hospital was built upon well and carefully considered plans, and its general arrangement was excellent, though having some deficiencies which only actual experience in its management could point out and supply. The special defects of construction in some parts of the hospital are not noticed as exceptional, for it is lamentably true that they are too common in private dwellings as well as in public buildings.
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Hospital Boilers, Incinerators, Coal, & landfill
As hospital services expanded or transferred to other BUMC buildings in the ‘80s and ‘90s, the Talbot Building was largely abandoned for years. Ozonoff recalls the Departments of Environmental Health and Epidemiology moving into the central wing of the third floor in the early ’90s—but had to eventually move out because of unsafe conditions. “There was a lot of mold on the floors above us, and it was causing respiratory problems for some building occupants,” says Ozonoff, who occupied the original, unrenovated space that is now the Board Room. Ironically, he says, there was asbestos on heating pipes in the office that belonged to Anthony Robbins, former professor of environmental health, who had previously served as the director of the National Institute for Occupational Safety and Health. Ozonoff shared other details about his old office, such as a bookcase that used to be attached to one wall, and small openings around the building that allowed birds to sneak inside. “When they removed the bookcase during the [1998] renovation, they found a bunch of bird skeletons behind the case,” he says. “It was an interesting place to be.”
The building finally underwent a major renovation in January 1998, to prepare for SPH to officially move into the building, under the leadership of Robert Meenan (MED’72, GSM’89), the former SPH dean who led the school through a significant growth during his 22 years in the position, starting with relocating the school to Talbot. Internally, the building received comprehensive updates to modernize the offices, and pedestrian walkways were constructed to connect open spaces. “They don’t make buildings like this anymore,” says Michael McCrae-Hastings, who has worked as a public safety officer on the BUMC campus since 1994. “Nowadays everything is made with plastic and fiber, but this building made of real bricks and real mortar and real wood, and it will probably be around for another 100 years.” He says the school “didn’t take any shortcuts” during the much-needed renovations in ’98. Prior to those renovations, he recalls being able to see the first level of the building through open gaps in the floor of the lobby area.
Boston University, School of Public Health, ‘They Don’t Make Buildings Like This Anymore’, September 6, 2019, https://www.bu.edu/sph/news/articles/2019/they-dont-make-buildings-like-this-anymore/
Again, the amount of carbonic acid gas in country pastures, or in the woods, is only a small fraction of 1 per cent.; in cities and towns, 2 to 8 per cent. The amount of carbonic acid gas, found not from borings upon the ground, but from various places throughout the basement. showed that there was 5 to 6 per cent. of carbonic acid gas. These conditions caused great deterioration in the Hospital buildings, but they would not have been recognized except for actual scientific tests."
(Committee of the Hospital Staff, A History of Boston City Hospital from its Foundation until 1904, 1906).
The building finally underwent a major renovation in January 1998, to prepare for SPH to officially move into the building, under the leadership of Robert Meenan (MED’72, GSM’89), the former SPH dean who led the school through a significant growth during his 22 years in the position, starting with relocating the school to Talbot. Internally, the building received comprehensive updates to modernize the offices, and pedestrian walkways were constructed to connect open spaces. “They don’t make buildings like this anymore,” says Michael McCrae-Hastings, who has worked as a public safety officer on the BUMC campus since 1994. “Nowadays everything is made with plastic and fiber, but this building made of real bricks and real mortar and real wood, and it will probably be around for another 100 years.” He says the school “didn’t take any shortcuts” during the much-needed renovations in ’98. Prior to those renovations, he recalls being able to see the first level of the building through open gaps in the floor of the lobby area.
Boston University, School of Public Health, ‘They Don’t Make Buildings Like This Anymore’, September 6, 2019, https://www.bu.edu/sph/news/articles/2019/they-dont-make-buildings-like-this-anymore/
Again, the amount of carbonic acid gas in country pastures, or in the woods, is only a small fraction of 1 per cent.; in cities and towns, 2 to 8 per cent. The amount of carbonic acid gas, found not from borings upon the ground, but from various places throughout the basement. showed that there was 5 to 6 per cent. of carbonic acid gas. These conditions caused great deterioration in the Hospital buildings, but they would not have been recognized except for actual scientific tests."
(Committee of the Hospital Staff, A History of Boston City Hospital from its Foundation until 1904, 1906).
1885
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1906
1927
In 1962, the Legislature enacted the so-called Roxbury [*3] Canal Statute, Stat. 1962, c. 762, which authorized the Massachusetts Department of Public Works to acquire through eminent domain whatever land it needed to improve the Roxbury Canal and other nearby waterways by providing for the discharge of storm water, surface drainage, and sewage overflow. When the waterway improvements were completed, this statute required the Commonwealth to convey to the City of Boston, without consideration, title to the land within the conduit system.
In 1965, the Boston Redevelopment Authority ("BRA") adopted the South End Urban Renewal Plan. Under this Renewal Plan, future development of the site where the Research Park is now located was to focus on medical and institutional uses, rather than industrial uses. In 1966, the Legislature enlarged the amount of land within the scope of the Roxbury Canal Statute, directing the Commonwealth, upon completion of the conduit system, to convey to the City of Boston, without consideration, the area in the South End bounded by Massachusetts Avenue, Albany Street, Dover Street, and the John F. Fitzgerald Expressway (Interstate 93). The 1966 amendment further directed the City to then convey this land to the BRA for [*4] urban renewal in accordance with the Renewal Plan. Stat. 1966, c. 567.
In 1991, Boston University proposed, and the BRA approved, a Master Plan for the Planned Development of Area 41, which comprised BioSquare Phase I of the BioSquare Research Park, along with the associated changes in zoning. Phase I included the phased development of four research buildings, a 250-room hotel, and a parking lot located on roughly 8.5 acres of land on Albany Street. On December 12, 1991, after the BRA approved BioSquare Phase I, Boston University and the BRA entered into a Land Disposition Agreement. Under this Agreement, the BRA agreed to convey to Boston University the parcels of land that the BRA would obtain through the amended Roxbury Canal Statute. These parcels would comprise the site for the approved Phase I and the anticipated Phase II of the BioSquare Research Park.
On August 31, 1999, University Associates, the affiliate of Boston University that was developing the entire BioSquare Project, submitted to the Massachusetts Executive Office of Environmental Affairs ("EOEA") its Environmental Notification Form ("ENF"), proposing to commence Phase II of the Research Park. At the time this ENF [*5] was submitted, Phase II did not include the Biolab. Rather, the Phase II described in the ENF contemplated two research buildings, one with 400,000 square feet of space and the other with 140,500 square feet, a parking garage, and a helipad.
What distinguishes this Project from various other projects that have built medical research facilities in a City renown for its medical research is the inclusion of a BSL-4 laboratory in the Biolab, where medical research will be conducted on the most dangerous disease-causing organisms and toxins known to mankind, including but not limited to the Ebola virus, smallpox, anthrax, and the Botulinum toxin. There is no higher level of security for a laboratory beyond BSL-4. Presently, there are only three BSL-4 laboratories in the United States: one operated by the Centers for Disease Control ("CDC") in Atlanta, another operated by the U.S. Army Research Institute on Infectious Diseases at Fort Detrick in Frederick, Maryland, and a third operated by the Southwest Institute for Biomedical Research in San Antonio, Texas.
The proposed Biolab, as discussed earlier, plainly poses a small risk of potentially catastrophic harm to the environment and [*52] public health if one considers the admittedly small risk of an accidental or malevolent release of a contagious pathogen. Equally plainly, there is the possibility that the extent of the contagion that may result from such a release may be different if the BSL-4 were located in a less urban location. For instance, while an infected laboratory worker may go home from the Biolab in the South End by bus, subway, or train, raising the immediate risk of infecting hundreds of fellow riders, that worker may have no realistic choice but to go home by car if the Biolab were located in a suburban or rural location. If the "worst case" scenario were truly the dropping of a vial of anthrax within the Biolab, there may be no need to consider alternative sites because the risk that anyone would become ill by inhaling anthrax in even a densely populated community is negligible. But when one recognizes that the true "worst case" scenario involves the risk of contagion, not inhalation, then the density of the population surrounding the Biolab may have greater consequences for the extent of the harm arising from that "worst case." Therefore, the failure of the Final EIR to consider any "worst case" [*53] scenario involving the risk of contagion is interwoven with its failure to consider whether locating the Biolab, or at least the BSL-4 laboratory, in an alternative feasible, but less urban, location would significantly reduce the potential magnitude of catastrophic harm that may arise from the inadvertent release of a contagious pathogen from the facility.
The Secretary, in certifying the Draft EIR, wrote that the Final EIR should respond to the detailed comment letter submitted by ACE, and that letter specifically asked that the EIR analyze alternative locations for the BSL-4 laboratory. See AR 23 & 120-121. Yet, the Final EIR never considered any alternative feasible location. Indeed, University Associates' only discussion of an alternative location in the Final EIR came in response to a letter, not from ACE, but from the Worcester Square Area Neighborhood Association, in which University Associates wrote that locating the Biolab in a rural area "would fail to take advantage of the essential benefit of shared intellectual and capital resources achieved by locating the facility within the City of Boston at the Boston University Medical Center Campus." AR at 1213.
In short, not [*54] only did the Final EIR fail to analyze any "worst case" scenario that involved the risk of contagion arising from the accidental or malevolent release of a pathogen, but it also failed to analyze whether that "worst case" scenario would be materially less catastrophic if the Biolab were located in a feasible alternative location in a less densely populated area. In other words, the Final EIR fails to answer two questions that virtually anyone learning of the proposed Biolab reasonably would ask:i. What is the worst that could happen if a laboratory worker were infected with a contagious pathogen he was studying? ii. Would the impact be significantly less if the Biolab were located outside of a city? 9
This Court finds that, by certifying that the Final EIR adequately and properly complied with MEPA and the MEPA regulations even though it failed even to consider these two questions, the Secretary failed to accomplish the purpose of MEPA review that she acknowledged in that certification--"to ensure that a project proponent studies feasible alternatives to a proposed project; fully discloses environmental impacts of a proposed project; and incorporates all feasible means to avoid, minimize, or mitigate Damage to the Environment as defined by the MEPA statute." AR at 26. The standard of review of the Secretary's certification, however, requires more than that in order to vacate her certification and remand it to the Secretary--it requires a judicial finding that her certification was arbitrary or capricious, that is, that it lacked a rational basis.
This Court finds that the Secretary's certification of the Final EIR lacked the necessary rational basis. The Biolab, with its BSL-4 laboratory, poses the potential for extraordinary societal benefit and, if enormous care is not taken, [*56] extraordinary risks to the environment and public health. Even if all reasonable measures are taken to prevent the release of a contagious pathogen, it is inevitable that some amount of residual risk will remain if those measures fail. The Final EIR is intended to identify the risks of a failure, analyze them, and evaluate ways to mitigate them. This Court finds that no EIR regarding this Biolab project can rationally be found to comply adequately with MEPA that failed to consider any "worst case" scenario that involved the risk of contagion arising from the accidental or malevolent release of a contagious pathogen, and that failed to analyze whether that "worst case" scenario would be materially less catastrophic if the Biolab were located in a feasible alternative location in a less densely populated area.
Ten Residents of Boston v. Boston Redevelopment Auth. , Superior Court of Massachusetts, At Suffolk, July 31, 2006, Decided ; August 2, 2006, Docket Number: 05-0109 BLS2
In 1965, the Boston Redevelopment Authority ("BRA") adopted the South End Urban Renewal Plan. Under this Renewal Plan, future development of the site where the Research Park is now located was to focus on medical and institutional uses, rather than industrial uses. In 1966, the Legislature enlarged the amount of land within the scope of the Roxbury Canal Statute, directing the Commonwealth, upon completion of the conduit system, to convey to the City of Boston, without consideration, the area in the South End bounded by Massachusetts Avenue, Albany Street, Dover Street, and the John F. Fitzgerald Expressway (Interstate 93). The 1966 amendment further directed the City to then convey this land to the BRA for [*4] urban renewal in accordance with the Renewal Plan. Stat. 1966, c. 567.
In 1991, Boston University proposed, and the BRA approved, a Master Plan for the Planned Development of Area 41, which comprised BioSquare Phase I of the BioSquare Research Park, along with the associated changes in zoning. Phase I included the phased development of four research buildings, a 250-room hotel, and a parking lot located on roughly 8.5 acres of land on Albany Street. On December 12, 1991, after the BRA approved BioSquare Phase I, Boston University and the BRA entered into a Land Disposition Agreement. Under this Agreement, the BRA agreed to convey to Boston University the parcels of land that the BRA would obtain through the amended Roxbury Canal Statute. These parcels would comprise the site for the approved Phase I and the anticipated Phase II of the BioSquare Research Park.
On August 31, 1999, University Associates, the affiliate of Boston University that was developing the entire BioSquare Project, submitted to the Massachusetts Executive Office of Environmental Affairs ("EOEA") its Environmental Notification Form ("ENF"), proposing to commence Phase II of the Research Park. At the time this ENF [*5] was submitted, Phase II did not include the Biolab. Rather, the Phase II described in the ENF contemplated two research buildings, one with 400,000 square feet of space and the other with 140,500 square feet, a parking garage, and a helipad.
What distinguishes this Project from various other projects that have built medical research facilities in a City renown for its medical research is the inclusion of a BSL-4 laboratory in the Biolab, where medical research will be conducted on the most dangerous disease-causing organisms and toxins known to mankind, including but not limited to the Ebola virus, smallpox, anthrax, and the Botulinum toxin. There is no higher level of security for a laboratory beyond BSL-4. Presently, there are only three BSL-4 laboratories in the United States: one operated by the Centers for Disease Control ("CDC") in Atlanta, another operated by the U.S. Army Research Institute on Infectious Diseases at Fort Detrick in Frederick, Maryland, and a third operated by the Southwest Institute for Biomedical Research in San Antonio, Texas.
The proposed Biolab, as discussed earlier, plainly poses a small risk of potentially catastrophic harm to the environment and [*52] public health if one considers the admittedly small risk of an accidental or malevolent release of a contagious pathogen. Equally plainly, there is the possibility that the extent of the contagion that may result from such a release may be different if the BSL-4 were located in a less urban location. For instance, while an infected laboratory worker may go home from the Biolab in the South End by bus, subway, or train, raising the immediate risk of infecting hundreds of fellow riders, that worker may have no realistic choice but to go home by car if the Biolab were located in a suburban or rural location. If the "worst case" scenario were truly the dropping of a vial of anthrax within the Biolab, there may be no need to consider alternative sites because the risk that anyone would become ill by inhaling anthrax in even a densely populated community is negligible. But when one recognizes that the true "worst case" scenario involves the risk of contagion, not inhalation, then the density of the population surrounding the Biolab may have greater consequences for the extent of the harm arising from that "worst case." Therefore, the failure of the Final EIR to consider any "worst case" [*53] scenario involving the risk of contagion is interwoven with its failure to consider whether locating the Biolab, or at least the BSL-4 laboratory, in an alternative feasible, but less urban, location would significantly reduce the potential magnitude of catastrophic harm that may arise from the inadvertent release of a contagious pathogen from the facility.
The Secretary, in certifying the Draft EIR, wrote that the Final EIR should respond to the detailed comment letter submitted by ACE, and that letter specifically asked that the EIR analyze alternative locations for the BSL-4 laboratory. See AR 23 & 120-121. Yet, the Final EIR never considered any alternative feasible location. Indeed, University Associates' only discussion of an alternative location in the Final EIR came in response to a letter, not from ACE, but from the Worcester Square Area Neighborhood Association, in which University Associates wrote that locating the Biolab in a rural area "would fail to take advantage of the essential benefit of shared intellectual and capital resources achieved by locating the facility within the City of Boston at the Boston University Medical Center Campus." AR at 1213.
In short, not [*54] only did the Final EIR fail to analyze any "worst case" scenario that involved the risk of contagion arising from the accidental or malevolent release of a pathogen, but it also failed to analyze whether that "worst case" scenario would be materially less catastrophic if the Biolab were located in a feasible alternative location in a less densely populated area. In other words, the Final EIR fails to answer two questions that virtually anyone learning of the proposed Biolab reasonably would ask:i. What is the worst that could happen if a laboratory worker were infected with a contagious pathogen he was studying? ii. Would the impact be significantly less if the Biolab were located outside of a city? 9
This Court finds that, by certifying that the Final EIR adequately and properly complied with MEPA and the MEPA regulations even though it failed even to consider these two questions, the Secretary failed to accomplish the purpose of MEPA review that she acknowledged in that certification--"to ensure that a project proponent studies feasible alternatives to a proposed project; fully discloses environmental impacts of a proposed project; and incorporates all feasible means to avoid, minimize, or mitigate Damage to the Environment as defined by the MEPA statute." AR at 26. The standard of review of the Secretary's certification, however, requires more than that in order to vacate her certification and remand it to the Secretary--it requires a judicial finding that her certification was arbitrary or capricious, that is, that it lacked a rational basis.
This Court finds that the Secretary's certification of the Final EIR lacked the necessary rational basis. The Biolab, with its BSL-4 laboratory, poses the potential for extraordinary societal benefit and, if enormous care is not taken, [*56] extraordinary risks to the environment and public health. Even if all reasonable measures are taken to prevent the release of a contagious pathogen, it is inevitable that some amount of residual risk will remain if those measures fail. The Final EIR is intended to identify the risks of a failure, analyze them, and evaluate ways to mitigate them. This Court finds that no EIR regarding this Biolab project can rationally be found to comply adequately with MEPA that failed to consider any "worst case" scenario that involved the risk of contagion arising from the accidental or malevolent release of a contagious pathogen, and that failed to analyze whether that "worst case" scenario would be materially less catastrophic if the Biolab were located in a feasible alternative location in a less densely populated area.
Ten Residents of Boston v. Boston Redevelopment Auth. , Superior Court of Massachusetts, At Suffolk, July 31, 2006, Decided ; August 2, 2006, Docket Number: 05-0109 BLS2
Thorndike Memorial Laboratory at Boston City Hospital, circa 1980. The Thorndike was the first clinical research laboratory at a U.S. municipal hospital and was the site of Finland’s infectious disease research.... Finland had started at Boston City Hospital in the mid-1920s, conducting controlled clinical trials of antipneumococcal antiserum for the treatment of pneumonia. Throughout the next five decades, nearly every successful antimicrobial agent, from sulfa drugs to penicillin and broad-spectrum antibiotics, seemed to require what Robert Petersdorf—himself a renowned infectious disease expert and, at one time, the president of Brigham and Women’s Hospital—called the “Finland stamp of approval.” In the process, Finland worked to instill caution and rigor in the emerging post–World War II field of clinical pharmacology by demanding objectivity and rigor from investigators.
To Finland and Back: The field of infectious disease research at HMS is filled with luminaries and rich in legacy, Harvard, Summer 2013, https://magazine.hms.harvard.edu/articles/finland-and-back
Peabody’s studies of the bone marrow in pernicious anemia were outstanding, but his chief work was to organize and head (until his untimely death) the Thorndike Memorial Laboratory at the Boston City Hospital. This was to become a famous training center for many future distinguished men of medicine: Soma Weiss, Chester Keefer, William B. Castle, and Charles A. Doan, to mention but a few. At the Boston City Hospital, some years before the Thorndike Laboratory was organized, Dr. Ralph C. Larrabee had inaugurated one of the first (perhaps the first) “Blood Laboratory” in the country. Here hematologic studies of the various “blood” cases on the wards and blood grouping tests prior to the increasing numbers of blood transfusions that were being given, were made....Between 1930 to 1940, Boston was a veritable beehive of hematologic activity, with several active foci at various hospitals and medical schools. At the Boston City Hospital, there were Minot and Castle; at the Children’s Hospital Louis K. Diamond, who did much to advance pediatric hematology; at the Beth Israel, the writer.
This is a personal memoir of the experience of bedside rounds at the old Boston City Hospital when Derek Denny-Brown was the director of the Harvard Neurological Unit. This was preimaging neurology at a time when the life of residents and the diseases and treatments were markedly different from today....Taking care of the needy patients at Boston City Hospital with no worry about length of stay or other financial matters was a wonderful privilege. The residents also had the opportunity to perform all neurological testing such as perimetry, tangent screen visual fields, urodynamics, iophendylate myelograms, ophthalmodynamometry, pneumoencephalography, carotid “stick” angiograms and even EEGs. They also were expected to present these data on rounds. Trainees also had to accept that Boston City Hospital was a tough place to work. After advancing through the required training in internal medicine, starting over on the lowest rung as a junior “nerve” resident required lots of scut work such as doing the admission lab work, drawing bloods starting IV’s and even transporting patients. No time was spent gazing at computer screens. The resident’s white jackets appeared tie-dyed with the bright colors of Gram, Wright and acid fast stains. The Hospital was a scruffy, poorly maintained institution sprawling among a dozen buildings; connected by a maze of dark dank subterranean tunnels. Many employees were the special needs relatives of Boston politicians and liked proving their unshakable job security was greater than the professional staff...
Sabin TD (2018) Rounds with Derek Denny-Brown at Boston City Hospital in 1965. Int J Exp Clin Res: IJEACR-132. DOI: 10.29011/IJEACR-132. 000032
Folkman’s research focused on angiogenesis, angiogenesis inhibitors, and antiangiogenesis therapy for the treatment of cancer, a method by which certain factors can be used to shut down abnormal blood vessel growth. He first began studying angiogenesis while at the Naval Medical Research Institute and he continued this research at Boston City Hospital and Boston Children’s Hospital.
M. Judah Folkman Collection, 1950-2006. WAM 21055; 21317-21323 https://collections.countway.harvard.edu/onview/collections/show/150
Cheever went on to become a prominent Boston surgeon, playing a pivotal role in the development of Boston City Hospital. He eventually became chair in surgery at Harvard Medical School, succeeding Bigelow and preceding J. Collins Warren at the Massachusetts General Hospital. He was also editor of the Boston Medical and Surgical Journal (a predecessor of the New England Journal of Medicine) and president of the American Surgical Association.
Cheever's double operation: the first Le Fort I osteotomy, Plast Reconstr Surg, . 2008 Apr;121(4):1375-1381. doi: 10.1097/01.prs.0000304442.15532.40.
the Harvard Surgical Service at Boston City Hospital welcomed me into their program soon to be headed by William McDer¬ mott. When finishing at Boston City Hospital, several of us, Gene McDonough, Harry Goldsmith, and Sterling Tignor, discussed the idea of training at Memorial Hospital and then returning to Boston City Hospital to develop a combined surgical cancer program. I was particularly attracted to the idea of bringing rational thought to surgical management of cancer, which I felt was notably absent at that time... surgical mentors, as Brad Aust so beautifully did last year: Frank Glenn was chairman at Cornell University when I was a student and gave a glimpse ofthe discipline and precision of a Halsted-style residency. Gardner Child contin¬ ued this lesson, only in the jungles of Boston City Hospital rather than the manicured magnificence of New York Hospi¬ tal. Bill McDermott, my later chief at Boston City Hospital and the New England Deaconess Hospital, demonstrated the political and intellectual skills, as well as the Irish love of language, thatenabled himto thrivein the disparate worlds of Harvard University and the Boston City Hospital simulta¬ neously.
Cady, Blake; The Society of Surgical Oncology at a Crossroads: Thoughts for the Future, Arch. Surg. Vol 125, Feb. 1990. https://www.surgonc.org/wp-content/uploads/2019/02/1989-cady.pdf
There had been one attempt to change that and that was in the early-to- mid-1920s in this country when Dr. [James] Conant and the Rockefeller Institute decided that neurology was very much in the backwaters in this country. They had seen what it was on the Continent and they set up a Rockefeller Institute center at Harvard that was run by Dr. Stanley Cobb. It was an attempt to change that for the first time. Someone was specifically brought in to change the situation. He [Cobb] was over sent to Europe – England, France, Germany – to learn about Continental neurology. He came back here [1925] to set up a center for neurology. That became the City Hospital Neurological Unit, which was Rockefeller-sponsored. He [Cobb] picked epilepsy as his primary interest and he brought many people together to do research on this. They thought that epilepsy was related to blood flow at that time. He then developed a center where people did research as well as neurology.... Cobb was not a charismatic [dynamic] leader. He was local. He was respected very much, but he was out of his environment at the City Hospital. He was a Boston Brahmin and didn’t fit well in the rough and tumble world of political medicine that City Hospital was at that time.
American Academy of Neurology Oral History Project Interview with H. Richard Tyler, MD Professor of Neurology emeritus, Harvard Medical School Senior Physician, Neurology, Brigham and Women’s Hospital Boston, Massachusetts Dr. Tyler’s Home Brookline, Massachusetts August 26, 2013, https://www.aan.com/siteassets/home-page/footer/about-the-aan/history/13hrichardtylertranscriptfinal_ft.pdf
Councilman’s initial clinical appointment in Boston in 1892 was Chief of Pathology at BCH. He placed FB Mallory, who was already at HMS, as an assistant in Pathology. Over time, Mallory played the larger role at the hospital and was appointed Chief in 1908. When the Peter Bent Brigham Hospital was opened in 1913, Councilman became its first Chief of Pathology. ‘Like father like son.’ Tracy Burr Mallory (left) and George Kenneth Mallory (right), the two sons of Frank Burr Mallory who, like their father, headed major pathology departments in Boston. Courtesy of Mr Kenneth Mallory... Mallory held the position of Chief of Pathology at Boston City from 1908 to his retirement in 1932, and he continued on the staff as a Consultant until his death in 1941. He was promoted to Associate Professor at HMS in 1901. He resigned his Harvard appointment in 1919 as a result of a dispute with the University but they were later reconciled and Mallory was then appointed Professor in 1928 and Professor Emeritus on reaching retirement age in 1932.... A number of individuals who trained at the BCH went on to illustrious careers at the MGH. One was Tracy Burr Mallory (1896–1951) (Figure 8a), who trained with his father (FB Mallory) and the famous microbiologist at Harvard, Hans Zinsser. Tracy Mallory was the chief of Pathology at the MGH from 1926 to 1951. In this role, he started the MGH pathology residency training program and became the editor of the Clinico-Pathological Conferences of the MGH published in the New England Journal of Medicine, serving in that role from 1935 to 1951. During World War II, Mallory was the Chief Pathologist for Mediterranean theater and he published a number of important papers on the pathology of war injuries and their sequelae.
Other notables who went from BCH to influence pathology at MGH were in the field of neuropathology—a subspecialty that had the largest semi-independent development from the rest of pathology in the first half of the 20th century. The neuropathology laboratory at MGH was started in 1927 by Charles S Kubik (1891–1982) (Figure 16), who had trained with J Godwin Greenfield in London, but the trainees of the BCH rapidly influenced the laboratory. Kubik was joined in 1930 by the psychiatrist-neurologist-neuropathologist Stanley Cobb (1887–1968), who had started the Harvard Neurological Unit at the BCH and who became the chair of Psychiatry at MGH. Subsequently, the neurologist-neuropathologist Raymond D Adams (1911–2008) (Figure 2), who had trained at BCH and who had been on the faculty there for a number of years, moved to the MGH in 1951 to become the chief of Neurology, a position he held until 1977. He was the Bullard Professor of Neuropathology at Harvard and was one of the leading neurologists of the second half of the twentieth century45—one of the ‘triumvirate’ of great MGH neurologist-neuropathologists of that era: Adams, C Miller Fisher (1913–2012) and EP Richardson, Jr (1918–1998).47 The BCH department also provided important seeds for the development of neuropathology in other hospitals in Boston, particularly the psychiatric and state hospital system. An important trainee of FB Mallory who, despite his relatively short life, influenced the pathology (primarily neuropathology) being done at the various psychiatric and state hospitals in the Boston area was Elmer Ernest Southard (1876–1920) (Figure 17). Southard was reportedly a wonderful teacher. Among his colleagues and those who followed him at these hospitals were individuals who contributed in major ways to neuropathology, particularly maldevelopmental, metabolic, and inherited conditions: Myrtelle Canavan (1879–1953) (Figure 17), whose name today is mostly remembered for Canavan disease; Harry C Solomon (1889–1982) (Figure 17), a psychiatrist who co-authored important books on syphilis, first (in 1917) with EE Southard and later (in 1946) with Raymond Adams and H Houston Merritt when both were at BCH; and indirectly, Paul Yakovlev (1894–1983), who was an enormously productive individual, having amassed a collection of some 250 000 slides by the time his collection was transferred to the Armed Forces Institute of Pathology. Pathology at Tufts University began with Timothy Leary (1870–1950?) (Figures 2 and 18). Leary had been the first trainee of FB Mallory at the BCH. He moved to Tufts in 1900 and was the head of Pathology there until 1929. During this time, he ran a private laboratory at the medical school and, for unclear reasons in 1929, fell out with the medical school. He returned to the Mallory Institute and was a medical examiner there through the 1930s and 1940s, when he was widely recognized as an authority in forensic medicine. Following Leary at Tufts was H Edward MacMahon (1901–1996) (Figures 2 and 19). He was originally from Aylmer, Ontario, and received his medical degree from the University of Western Ontario in 1925. He trained at the Montreal General Hospital before coming to train further with FB Mallory at the BCH.
Louis, D., O'Brien, M. & Young, R. The flowering of pathology as a medical discipline in Boston, 1892-c.1950: W.T. Councilman, FB Mallory, JH Wright, SB Wolbach and their descendants. Mod Pathol 29, 944–961 (2016). https://doi.org/10.1038/modpathol.2016.91
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State Morgue & The Graveyards
In one respect the selection of the site for this cemetery was particularly unfortunate. The soil was springy and exceedingly damp, and therefore required drainage. It is said that when Judge Sullivan, at the close of the last century, repaired the Bellingham tomb, near the westerly wall, he found the coffin and remains of the old Governor—who died on the seventh of December, 1672, in the eighty-first year of his age—floating around in the ancient vault. On the removal of the Granary Building to its newposition, in 1737, the drain which had formerly been discharged upon the Common was stopped, and the tombs thereby filled with water; and a new drain was laid communicating with the common sewer, which emptied itself at the dock near the head of Bull's Wharf; and consequently the tombs were in a degree relieved from the excessive accumulation of water. In the summer of 1868, when workmen were engaged digging for the foundation for the Brewer fountain, remains of the old drain were discovered and laid open to view. Water was first played from this beautiful fountain on the third of June, 1868.
A TOPOGRAPHICAL HISTORICAL DESCEIPTION BOSTON. BT NATHANIEL B. SHURTLEFF. BOSTON: PRINTBD BT BEQUEST OF THE CITY COUNCIL. 1871.
In its earlier years it was the scene of many of the capital executions; for near its most easterly part, which formerly extended to tide-water, usually stood the gallows, and the culprits were generally buried in deep graves within the cemetery near the place of their execution. Soon after the building of the Leverett street jail, hangings were performed more privately, and the gallows on the neck discontinued. In stUl earlier times the gallows stood further north, near the present position of Maiden street; and, in the well remembered execution of Samuel Tulley for piracy, it stood at South Boston, and for Henry Phillips, the murderer of Dennegri, at the Roebuck Tavern. As late as the year 1837, there was very little comeliness to the South Burying-Ground. A large portion of it was marshy, and consequently wet; and until a large quantity of proper soil was carted upon it, as was done that year, and the surface graded, the place was hardly fit for the purposes of sepulture, although, even then, the front part of it was nearly filled.
A TOPOGRAPHICAL HISTORICAL DESCEIPTION BOSTON. BT NATHANIEL B. SHURTLEFF. BOSTON: PRINTBD BT BEQUEST OF THE CITY COUNCIL. 1871.
The South Burial Ground was opened in 1810 on city-owned land to alleviate overcrowded conditions in the older Boston graveyards.
The burial ground was first called the "Neck Burying Ground" due to its location on the narrow strip of marshland, Roxbury Neck,
which connected the peninsula of Boston to the mainland. The burial ground is located on Washington Street in the South End, and is bounded by East Newton, East Concord and James Streets. A single entrance leads into the burial ground from Washington Street; at one time, there was another directly opposite, from James Street. The original configuration of the ground was a square bisected by two pathways, with twenty free-standing tombs arranged in groups of five (see map). In 1827, the town of Boston began to construct granite tombs around the perimeter of the burial ground, starting at the northeast corner. By 1839, 146 tombs had been built which enclosed the ground on all four sides. These tombs, along with the twenty tombs within the burial ground, were sold
by the city to private individuals.
In the early years of the burial ground's history, hanged pirates and criminals were buried in unmarked graves at this site on Roxbury Neck, as the gallows were located near the eastern edge of the ground. However, the majority of those interred in the South Burial Ground, from its official opening in 1810 to its discontinuation in 1866, were members of the respectable working class who paid a small fee to the city for a gravesite. Although burials were recorded by the city, the exact location was not, and expensive gravestones were seldom used to mark gravesites for family use over a twenty-year period. Only a handful have survived to this day.
Also, the marshy land within the burial ground was filled and graded several times over the years, which permitted interments in successive layers, but undoubtedly buried many grave markers. Grave interments ended in 1835. The city performed a final filling and grading in 1837 (perhaps the synunetrical design dates from this period). Interments continued in the privately-owned tombs for about thirty years. According to the testimony of a city official in 1883, approximately 4,610 bodies had been buried in graves prior to l SJl, and 6,480 bodies had been interred in the tombs. If correct, this estimate means over 11,000 are buried in the earth or tombs within this nineteenth-century burial ground.
The terms concerned residents used one hundred years ago to describe the burial ground are equally appropriate today. From the
sidewalk, it is difficult for the casual passer-by to identify this burial ground as anything but a weed-choked vacant lot. Tall graniteblock walls surround the ground, creating a fortress-like barrier. The single entrance, once guarded by the iron gates of the United States Bank, is now blocked by a bent and padlocked chain-link gate, which holds a faded sign with some sketchy historical information. On view through the gate, especially during summer months, is a tangle of tall weeds and trash.
HISTORIC BURIAL GROUNDS INVENTORY PROJECT, South Burial Ground, South End, Boston, Massachusetts, August 31, 1984·
A TOPOGRAPHICAL HISTORICAL DESCEIPTION BOSTON. BT NATHANIEL B. SHURTLEFF. BOSTON: PRINTBD BT BEQUEST OF THE CITY COUNCIL. 1871.
In its earlier years it was the scene of many of the capital executions; for near its most easterly part, which formerly extended to tide-water, usually stood the gallows, and the culprits were generally buried in deep graves within the cemetery near the place of their execution. Soon after the building of the Leverett street jail, hangings were performed more privately, and the gallows on the neck discontinued. In stUl earlier times the gallows stood further north, near the present position of Maiden street; and, in the well remembered execution of Samuel Tulley for piracy, it stood at South Boston, and for Henry Phillips, the murderer of Dennegri, at the Roebuck Tavern. As late as the year 1837, there was very little comeliness to the South Burying-Ground. A large portion of it was marshy, and consequently wet; and until a large quantity of proper soil was carted upon it, as was done that year, and the surface graded, the place was hardly fit for the purposes of sepulture, although, even then, the front part of it was nearly filled.
A TOPOGRAPHICAL HISTORICAL DESCEIPTION BOSTON. BT NATHANIEL B. SHURTLEFF. BOSTON: PRINTBD BT BEQUEST OF THE CITY COUNCIL. 1871.
The South Burial Ground was opened in 1810 on city-owned land to alleviate overcrowded conditions in the older Boston graveyards.
The burial ground was first called the "Neck Burying Ground" due to its location on the narrow strip of marshland, Roxbury Neck,
which connected the peninsula of Boston to the mainland. The burial ground is located on Washington Street in the South End, and is bounded by East Newton, East Concord and James Streets. A single entrance leads into the burial ground from Washington Street; at one time, there was another directly opposite, from James Street. The original configuration of the ground was a square bisected by two pathways, with twenty free-standing tombs arranged in groups of five (see map). In 1827, the town of Boston began to construct granite tombs around the perimeter of the burial ground, starting at the northeast corner. By 1839, 146 tombs had been built which enclosed the ground on all four sides. These tombs, along with the twenty tombs within the burial ground, were sold
by the city to private individuals.
In the early years of the burial ground's history, hanged pirates and criminals were buried in unmarked graves at this site on Roxbury Neck, as the gallows were located near the eastern edge of the ground. However, the majority of those interred in the South Burial Ground, from its official opening in 1810 to its discontinuation in 1866, were members of the respectable working class who paid a small fee to the city for a gravesite. Although burials were recorded by the city, the exact location was not, and expensive gravestones were seldom used to mark gravesites for family use over a twenty-year period. Only a handful have survived to this day.
Also, the marshy land within the burial ground was filled and graded several times over the years, which permitted interments in successive layers, but undoubtedly buried many grave markers. Grave interments ended in 1835. The city performed a final filling and grading in 1837 (perhaps the synunetrical design dates from this period). Interments continued in the privately-owned tombs for about thirty years. According to the testimony of a city official in 1883, approximately 4,610 bodies had been buried in graves prior to l SJl, and 6,480 bodies had been interred in the tombs. If correct, this estimate means over 11,000 are buried in the earth or tombs within this nineteenth-century burial ground.
The terms concerned residents used one hundred years ago to describe the burial ground are equally appropriate today. From the
sidewalk, it is difficult for the casual passer-by to identify this burial ground as anything but a weed-choked vacant lot. Tall graniteblock walls surround the ground, creating a fortress-like barrier. The single entrance, once guarded by the iron gates of the United States Bank, is now blocked by a bent and padlocked chain-link gate, which holds a faded sign with some sketchy historical information. On view through the gate, especially during summer months, is a tangle of tall weeds and trash.
HISTORIC BURIAL GROUNDS INVENTORY PROJECT, South Burial Ground, South End, Boston, Massachusetts, August 31, 1984·
Organized in 1810 under the authorization of Boston's Board of Selectmen, the South End or Neck Burial Ground, together with the Porter House at East Springfield and Washington Street provide rare physical evidence document Washington Street during the Federal period. One of 16 historic burial grounds in Boston, the South End Cemetery predates the filling that occurred a few decades later, on either side of the Neck. A narrow isthmus of land linking ti Shawmut (Boston) peninsula with Roxbury and the main land, Washington Street was Boston's only overland roac until parallel streets to the east and west were set out during the second quarter of the 19th century. Unsubstantiated lore states that pirates and criminals were buried here as early as c. 1700 after being cut down from gallows located near the site of the present Cathedral of the Holy Cross. Set out, in part, to help alleviate the crowdt conditions in downtown grave yards, the South End Burial Ground was also geared towards a growing community mechanics, merchants and artisans who after the Revolution began to construct residences, businesses and wharves along the South Cove side of the Neck. Etched on the dozen or so free standing grave stones of this cemetery are th names of early - 19th - century residents such as Andrews, Bennet, Brigham. Gardiner, Lovering, Lynch, Townsend and Washburn. Members of the Aaron Willard family of clockmakers and William Porter, distiller and owner of the 1806 Porter houses are buried here, as well as members of the Stephen Minot family. Proprietors of tl George Tavern near the Neck's Roxbury gate, Minots had resided on the Neck since the first quarter of the 18th
century. Set out into quadrants in 1810, The South End Burial Ground's plan reflected the French garden approach, divided into parterres with a small fountain at the center. Enclosed in 1827 on its James, East Concord and Washington Street sides by a 10' granite wall containing over 100 burial vaults, these walls were built in response to the realities of the marshy, flood- prone terrain that characterized the Neck. These granite burial vaults are more commonly found in the American south. By 1835, below- ground burials were prohibited from occurring here by law. According to architectural historian Kimberly Alexander Shilland, seven successive layers of bodies lie beneath the uneven terrain of the South End Burial ground. Periodic out- breaks of Small pox and other diseases during the 1830s and especially in 1840 resulted in the mass burials of hundreds of victims. Additionally, during the mid 19th century, those who could not afford burial from the Home for Indigent Women, Crippled Children's Home and other charitable organizations were buried here en mass. During the late 1850s, more than 300 bodies of the poor were disinterred and removed for reburial at Deer Island. According to Kimberley Alexander Shilland, little in the way of records remains for those interred below ground. By the late 19th century, interments became restricted to those who already had family buried here. The cemetery had fallen into a state of decay,
BOS.825, South End Burial Ground, Address: Washington St (1998)
century. Set out into quadrants in 1810, The South End Burial Ground's plan reflected the French garden approach, divided into parterres with a small fountain at the center. Enclosed in 1827 on its James, East Concord and Washington Street sides by a 10' granite wall containing over 100 burial vaults, these walls were built in response to the realities of the marshy, flood- prone terrain that characterized the Neck. These granite burial vaults are more commonly found in the American south. By 1835, below- ground burials were prohibited from occurring here by law. According to architectural historian Kimberly Alexander Shilland, seven successive layers of bodies lie beneath the uneven terrain of the South End Burial ground. Periodic out- breaks of Small pox and other diseases during the 1830s and especially in 1840 resulted in the mass burials of hundreds of victims. Additionally, during the mid 19th century, those who could not afford burial from the Home for Indigent Women, Crippled Children's Home and other charitable organizations were buried here en mass. During the late 1850s, more than 300 bodies of the poor were disinterred and removed for reburial at Deer Island. According to Kimberley Alexander Shilland, little in the way of records remains for those interred below ground. By the late 19th century, interments became restricted to those who already had family buried here. The cemetery had fallen into a state of decay,
BOS.825, South End Burial Ground, Address: Washington St (1998)
The place of burial should be selected in a somewhat secluded, and not in the most conspicuous part of the town, and should be combined with such natural scenery as will tend to inspire those feelings of solemnity and decorum which properly belong to the " city of the dead."... It should never be within a populous city or village. Such a site is now generally regarded as dangerous to the health of the living though in this State we have not as yet experienced, to a great extent, the evils which have existed in London and other large cities in England, as the following statements will show : 1 — "When the living hody is exposed to putrid emanations in a highly concentrated state, the effects are immediate and deadly ; when more diluted they still taint the system, inducing a morbid condition, which renders it more prone to disease in general, but especially to all the forms of epidemic disease, and which further predisposes it to pass into a state verging upon if not actually that of putrefaction. The most recent examination of the grave-yards of the metropolis appears to us to show that they contain putrefying matter enough to communicate this putrefying process to those who are exposed to it. It is stated by Sir James Macgregor, that on one occasion in Spain, soon after 20,000 men had been put into the ground within the space of two or three months, the troops that remained exposed to the emanations of the soil, and that drank the water from the wells sunk in the neighborhood of the spot, were attacked by malignant fevers and by dysentery ; and that the fevers constantly put on the dysenteric character. In the metropolis, on spaces of ground not exceeding in all 218 acres, closely surrounded by the abodes of the living, crowded together in dense masses, upwards of 50,000 dead bodies are buried every year. In Bethnal Green burial-ground alone, consisting of an area of about two acres and a half, there have been interred, since its opening in the year 1746, upwards of 56,000 dead bodies. In Bunhill Fields burial-ground, City Road, consisting of an area of less than four acres, there have been interred, from April, 1713, to August, 1832, according to the registry, which, however, in the earlier years was very imperfectly kept, 107,416 dead bodies. But in St. Pancras church-yard, one-half of which has been used as a burial-place for at least six centuries, there have been deposited the remains of more than twenty generations ; and in this space of ground, which does not even now exceed four acres, and a large portion of which was considered as full to excess twenty years ago, there have been interred since that period upwards of 26,000 bodies. Estimating the duration of a generation at 30 years, there must have been interred in the small space of 218 acres, in the last generation, a million and a half of dead bodies ; and within the next 30 years, more than another million and a half of the dead,—that is, a large proportion of those who now people the metropolis,—will have to be crowded into those same church-yards, unless other and better provision for interment be made. The placing of the dead body in a grave, and covering it with a few feet of earth, does not prevent the gases generated by decomposition, together with the putrescent matters which they hold in suspension, from permeating the surrounding soil, and escaping into the air above and the water beneath. Under the pressure of only three-fourths of an inch of water, gas, common coal-gas, for instance,—rapidly makes its way to the surface through a stratum of sand or gravel several feet in thickness ; the soil appearing to oppose scarcely any resistance to its passage. The evolution of the gases of decomposition takes place with so much force, that they often expand and occasionally burst the leaden coffin in which the body is confined ; and when, as in a common grave, they pass gradually and without restraint into the surrounding earth, they are only in part absorbed by the soil, and some of them are scarcely absorbed at all, but are diffused in every direction, though it would appear in the upward direction chiefly, thus directly polluting the air. Such, indeed, is the tendency of these gases to reach the surface, that it does not appear to be possible to prevent the occurrence. ' If,' says Mr. Leigh, a chemist at Manchester, who appears to have paid particular attention to this subject, ' bodies were interred eight or ten feet deep, in sandy or gravelly soils, I am convinced little would be gained by it ; the gases would find a ready exit from almost any practicable depth ;' while it is obvious that their occasional escape would be still more easy through the fissures which are so common in clayey soils. ' I have examined,' says Dr. Lyon Playfair, ' various church-yards and burial-grounds, for the purpose of ascer- taining whether the layer of earth above the bodies is sufficient to absorb the putrid gases evolved. The slightest inspectio shows that they are not thoroughly absorbed by the soil lying over the bodies. I know several church-yards from which most foetid smells are evolved ; and gases with similar odor are emitted from the sides of sewers passing in the vicinity of church-yards, although they may be more than thirty feet from them. If these gases are thus evolved laterally, they must be equally emitted in an upward direction.' Some of these gases, as has been stated, are either not absorbed at all, or only very sparingly,—carbonic acid gas, for example ; yet so abundant is its evolution, that, in old church-yards or near ' grave-pits,' the ground is absolutely saturated with it, so that, when a deep grave is dug, such an amount of it is rapidly collected, that the workmen cannot descend without danger. Dr. Reid states, as the result of his own observation, that on sinking a pit in the earth, near which a number of bodies were interred, the pit in a few hours became filled with such an amount of carbonic acid gas, arising from the decomposition of the neighboring bodies, that the workmen could not reenter it without danger ; that lives have been lost by the incautious descent into such a pit, only a few hours after it has been opened ; that a well of carbonic acid gas is thus formed, into which a constant stream of the same gas continues perpetually to filter from the adjacent earth ; and that, in fact, the earth around these pits is loaded with carbonic acid gas, as other places are with water. Dr. Playfair estimates that the amount of the gases evolved annually from the decomposition of 1,117 corpses per acre, which is very far short of the number actually interred in the metropolitan grave-yards, is not less than 55,261 cubic feet but as 52,000 interments take place annually in the metropolis, according to this ratio the amount of gases emitted is equal to 2,572,580 cubic feet, the whole of which, beyond what is absorbed by the soil, must pass into the water below or the atmosphere above." " Whatever portion of these gases is not absorbed by the earth,—earth already surcharged with the accumulations of centuries,—and whatever part does not mix with and contaminate the water, must be emitted into the atmosphere, bearing with them, as we know, putrescent matters perceptible to sense. The atmosphere in which epidemic diseases most readily diffuse their poison and multiply their victims, is one in which organic matters are undergoing decomposition. Whence these may be derived signifies little. Whether the matter passing into decay be an accumulation of soaking straw and cabbage leaves in some miserable cellar, or the garbage of a slaughterhouse, or an overflowing cess-pool, or dead dogs floated at high water into the mouth of a sewer, or stinking fish, or the remnants of human corpses undergoing their last chemical changes in consecrated earth, the previous history of the decomposed material is of no moment whatever. The pathologist knows iio difference of operation between one decaying substance and another ; so soon as he recognizes organic matter undergoing decomposition, so soon he recognizes the most fertile soil for the increase of epidemic diseases.
The city poor were interred in the tombs in the South BurialGround until August 27, 1849 ; since then, at East Boston.
REPORT OF THE SANITARY COMMISSION OF MASSACHUSETTS 1850 BY LEMUEL SHATTUCK CAMBRIDGE HARVARD UNIVERSITY PRESS
The city poor were interred in the tombs in the South BurialGround until August 27, 1849 ; since then, at East Boston.
REPORT OF THE SANITARY COMMISSION OF MASSACHUSETTS 1850 BY LEMUEL SHATTUCK CAMBRIDGE HARVARD UNIVERSITY PRESS
South End Burial Ground: Thousands of Unknown, Untold Stories
It’s a rare occasion when one gets to see over the 8-foot tall concrete wall on Washington Street that is the South End Burial Ground, but once inside, the pastoral green lawn empties out into a thousand unknown stories. It’s likely the city’s first working-class cemetery, born out of desperation in 1810 for lack of places to put the deceased, and likely containing an estimated 10,000 graves – with more than 90 percent unmarked. "It predates everything around here,” said Kelly Thomas, project manager for the City’s 16 historic burial grounds. “It’s a green space in a very urban environment, which is appreciated. The ones downtown are large tourist draws. Then, what I think of first and foremost is it is a burial spot. Basically everyone who lived in Boston until Mt. Auburn was built in 1831 was buried here or in Boston. The cemetery component is what’s very important to me.” The South End Burial Ground came after King’s Chapel, the Granary and Copp’s Hill in the North End, but it was more of a pressing need.
The Alderman of Boston at the time had set aside money to purchase the land just outside of “The Neck” – which ran along Washington Street and was the only land connection to Boston.“This was discussed a lot so it was a priority matter,” said Thomas. “They needed a place to put dead people. They had run out of room downtown. There was no place to go. They were very concerned and it was a major issue at the time.” When one walks into the Burial Grounds, they see tombs on three sides of the square grounds, with the fourth side being made up of the old St. James Hotel, which faces Franklin Square. There are not rows of gravestones as one might expect though, just open fields with a few tombs in the center and 11 headstones.“It’s estimated that 10,000 are buried here,” said Thomas. “They truly needed the space. They were burying people four deep downtown. The first burials here were all in the ground and the tombs didn’t exist then. They started building tombs in 1829 so there were first a number of years when they dug in rows. By 1839 it was completely enclosed. By 1831, there were 4,610 bodies in graves. Now, about 99 percent of all the burials here are unknown and unmarked. There are only 11 headstones. It really is quite a mysterious location.”
Thomas said virtually no one of any renown is buried there, and most of the plots were reserved for the working class, while a number were reserved for the poor and indigent. There is an area for infants as well, due to the fact that far more children and babies died during those days.In 1820, she said, records indicate that a tomb cost $220 or $250 for a corner. The average salary for a male in that same year, she said, was $325 – making a place to be buried very expensive but attainable in the South End.She said the only person who they know is buried there of significance is the former superintendent of the City’s cemeteries. Samuel Hawes was so much a believer in his newest cemetery in the South End that he decided to be buried there with the masses.“However, most people here were working-class people or poor people who couldn’t afford graves,” Thomas said.
“There are so many untold stories here. There are no grave markers. We don’t even know the names of the people who were buried here.” That, she said, likely was a great liability – as the City in the 1800s began selling off some of the lots abutting Franklin Square. And that didn’t mean that they removed the graves and the remains of people before building. First, a piano factory bought some plots on the northeast corner and began constructing the factory there. It was said they didn’t bother removing any of the dead. Then, in the 1860s, the St. James Hotel purchased 11,000 sq. ft. on the outside edge facing Franklin Square. They were required to move the bodies then, but Thomas said there are accounts from eyewitnesses that both the piano factory construction and the hotel construction hit coffin after coffin.
Thomas said there are accounts of people gathering to watch the excavation because they were unearthing so many dead people.“ It wasn’t like it is today with so many laws and protections,” she said. “It was guys carting off bones and coffins in wheelbarrows. We don’t know if they re-buried them, threw them all in a pit or dumped them in Boston Harbor.”
The hotel failed rather quickly, and in 1882, the New England Conservatory bought the building and another 11,000 sq. ft. of the burial ground at the bargain basement price of 28 cents per square foot. They also built upon the remains, but were required to move the bodies in 1884 to Deer Island. That filled out the entire northern side of the ground with buildings, which today contain a large amount of apartments and condos. The site fell into major disrepair in the 1960s and 1970s with graffiti, overgrown vegetation and broken tombs.
A restoration effort in the 1980s created her position and led to major improvements there and elsewhere in the City’s historic burial grounds. Standing in the sunny green landscape, with cars rushing by on Washington Street, and the stories of those who once lived before underneath, Thomas said it can get surreal.“ Sometimes I feel like there’s an alternate reality,” she said. “You walk into a site and its 2017, but you can’t help but think of the stories in your mind of all these people that were once walking around and how they lived their lives. Just the quantity of 10,000 people in this small plot of land. That’s a lot of dead people.” The last burial in the Grounds came in 1866.
https://thebostonsun.com/2017/08/10/south-end-burial-groundthousands-of-unknown-untold-stories/
It’s a rare occasion when one gets to see over the 8-foot tall concrete wall on Washington Street that is the South End Burial Ground, but once inside, the pastoral green lawn empties out into a thousand unknown stories. It’s likely the city’s first working-class cemetery, born out of desperation in 1810 for lack of places to put the deceased, and likely containing an estimated 10,000 graves – with more than 90 percent unmarked. "It predates everything around here,” said Kelly Thomas, project manager for the City’s 16 historic burial grounds. “It’s a green space in a very urban environment, which is appreciated. The ones downtown are large tourist draws. Then, what I think of first and foremost is it is a burial spot. Basically everyone who lived in Boston until Mt. Auburn was built in 1831 was buried here or in Boston. The cemetery component is what’s very important to me.” The South End Burial Ground came after King’s Chapel, the Granary and Copp’s Hill in the North End, but it was more of a pressing need.
The Alderman of Boston at the time had set aside money to purchase the land just outside of “The Neck” – which ran along Washington Street and was the only land connection to Boston.“This was discussed a lot so it was a priority matter,” said Thomas. “They needed a place to put dead people. They had run out of room downtown. There was no place to go. They were very concerned and it was a major issue at the time.” When one walks into the Burial Grounds, they see tombs on three sides of the square grounds, with the fourth side being made up of the old St. James Hotel, which faces Franklin Square. There are not rows of gravestones as one might expect though, just open fields with a few tombs in the center and 11 headstones.“It’s estimated that 10,000 are buried here,” said Thomas. “They truly needed the space. They were burying people four deep downtown. The first burials here were all in the ground and the tombs didn’t exist then. They started building tombs in 1829 so there were first a number of years when they dug in rows. By 1839 it was completely enclosed. By 1831, there were 4,610 bodies in graves. Now, about 99 percent of all the burials here are unknown and unmarked. There are only 11 headstones. It really is quite a mysterious location.”
Thomas said virtually no one of any renown is buried there, and most of the plots were reserved for the working class, while a number were reserved for the poor and indigent. There is an area for infants as well, due to the fact that far more children and babies died during those days.In 1820, she said, records indicate that a tomb cost $220 or $250 for a corner. The average salary for a male in that same year, she said, was $325 – making a place to be buried very expensive but attainable in the South End.She said the only person who they know is buried there of significance is the former superintendent of the City’s cemeteries. Samuel Hawes was so much a believer in his newest cemetery in the South End that he decided to be buried there with the masses.“However, most people here were working-class people or poor people who couldn’t afford graves,” Thomas said.
“There are so many untold stories here. There are no grave markers. We don’t even know the names of the people who were buried here.” That, she said, likely was a great liability – as the City in the 1800s began selling off some of the lots abutting Franklin Square. And that didn’t mean that they removed the graves and the remains of people before building. First, a piano factory bought some plots on the northeast corner and began constructing the factory there. It was said they didn’t bother removing any of the dead. Then, in the 1860s, the St. James Hotel purchased 11,000 sq. ft. on the outside edge facing Franklin Square. They were required to move the bodies then, but Thomas said there are accounts from eyewitnesses that both the piano factory construction and the hotel construction hit coffin after coffin.
Thomas said there are accounts of people gathering to watch the excavation because they were unearthing so many dead people.“ It wasn’t like it is today with so many laws and protections,” she said. “It was guys carting off bones and coffins in wheelbarrows. We don’t know if they re-buried them, threw them all in a pit or dumped them in Boston Harbor.”
The hotel failed rather quickly, and in 1882, the New England Conservatory bought the building and another 11,000 sq. ft. of the burial ground at the bargain basement price of 28 cents per square foot. They also built upon the remains, but were required to move the bodies in 1884 to Deer Island. That filled out the entire northern side of the ground with buildings, which today contain a large amount of apartments and condos. The site fell into major disrepair in the 1960s and 1970s with graffiti, overgrown vegetation and broken tombs.
A restoration effort in the 1980s created her position and led to major improvements there and elsewhere in the City’s historic burial grounds. Standing in the sunny green landscape, with cars rushing by on Washington Street, and the stories of those who once lived before underneath, Thomas said it can get surreal.“ Sometimes I feel like there’s an alternate reality,” she said. “You walk into a site and its 2017, but you can’t help but think of the stories in your mind of all these people that were once walking around and how they lived their lives. Just the quantity of 10,000 people in this small plot of land. That’s a lot of dead people.” The last burial in the Grounds came in 1866.
https://thebostonsun.com/2017/08/10/south-end-burial-groundthousands-of-unknown-untold-stories/
hospital Building, Merger, & Parternship Histories
"Boston Public Health Commission: formed in 1996 as a result of the merger between the Boston Department of Health and Hospitals and Boston University Medical Center. The consolidation of these two institutions also created the Boston Medical Center, which subsumed the former Boston City Hospital. In addition, the histories of the Department of Health and Boston City Hospital from 1865-1965 (with gaps), the history of the Department of Health and Hospitals from 1965-1996, and the restructuring of Boston City Hospital and Boston Specialty and Rehabilitation Hospital (Mattapan Chronic Disease Hospitals) from the 1970s-1996 is documented. This collection also records the community activism of city residents, including those in the South End and Mattapan, regarding hospital closings, building facilities producing hazardous materials, and the smoking ban. Series I includes the minute books of the predecessor boards and departments Board of Health, Health Commissioner, Trustees of Health and Hospitals, Board of Health and Hospitals as well as the Public Health Commission. The Board of Trustees minutes and records can be found in the Boston City Hospital collection (7020.001)."
City of Boston Archives: Public Health Commission Board records, Record Group Identifier: 7000.001, https://archives.boston.gov/repositories/2/resources/408
BOSTON MEDICAL CENTER
1 BOSTON MEDICAL CENTER PLACE, BOSTON, MA 02118
FRS ID110041979366
RCRA MAD091492108
CAA MA0000002511900616
https://echo.epa.gov/detailed-facility-report?fid=110041979366
City of Boston Archives: Public Health Commission Board records, Record Group Identifier: 7000.001, https://archives.boston.gov/repositories/2/resources/408
BOSTON MEDICAL CENTER
1 BOSTON MEDICAL CENTER PLACE, BOSTON, MA 02118
FRS ID110041979366
RCRA MAD091492108
CAA MA0000002511900616
https://echo.epa.gov/detailed-facility-report?fid=110041979366
The urban space formed by the original complex was perhaps its most significant feature and the separations between these minimally connected buildings, the key aspect of their design as a nineteenth century hospital complex. The integrity of this space is severely impaired by the absence of the original Administration Building, and its connecting colonnades, and mildly affected by the fragmentary condition of F,G,H. Taken together B,C,D and F,G,H help define the original forecourt. However the combination of the loss of the original domed Administration Building which linked them with the infilling of the original forecourt with the new Administration Building in 1930 has destroyed the integrity of the original space.
BOS.1479, Bryant, Gridley Pavilion - Boston City Hospital, 830 Harrison Ave / East Springfield St and East Concord St (1988)
Boston University Medical Center serves as a management entity for two corporations. The Boston University Medical School's three schools and the University Hospital. There are currently 2,100 employees, about 1,800 FTE, at the University Hospital, and 2,400 (same FTE) employees at the B. U. Medical Campus. University Hospital, a member of the Boston University Medical Center, is comprised of 10 buildings located between Harrison Avenue and Albany Street. Parking is provided in the Doctors Office Building and in lots A and C on Albany Street. The main entrance to University Hospital is the Atrium Pavilion on E. Newton Street. Construction of the Atrium Pavilion, including dining facilities, will be completed late this year. The Boston University School of Medicine is comprised of seven buildings located primarily between Harrison Avenue and Albany Street and in the former Baltimore Brush building at 801 Albany Street.
SOUTH END MEDICAL AREA PLANNING STUDY SUMMARY REPORT: INVENTORY OF EXISTING CONDITIONS SURVEY OF PROPOSED DEVELOPMENT, PUBLIC IMPROVEMENTS, AND NEIGHBORHOOD CONCERNS (Aug. 1988)
BOS.1479, Bryant, Gridley Pavilion - Boston City Hospital, 830 Harrison Ave / East Springfield St and East Concord St (1988)
Boston University Medical Center serves as a management entity for two corporations. The Boston University Medical School's three schools and the University Hospital. There are currently 2,100 employees, about 1,800 FTE, at the University Hospital, and 2,400 (same FTE) employees at the B. U. Medical Campus. University Hospital, a member of the Boston University Medical Center, is comprised of 10 buildings located between Harrison Avenue and Albany Street. Parking is provided in the Doctors Office Building and in lots A and C on Albany Street. The main entrance to University Hospital is the Atrium Pavilion on E. Newton Street. Construction of the Atrium Pavilion, including dining facilities, will be completed late this year. The Boston University School of Medicine is comprised of seven buildings located primarily between Harrison Avenue and Albany Street and in the former Baltimore Brush building at 801 Albany Street.
SOUTH END MEDICAL AREA PLANNING STUDY SUMMARY REPORT: INVENTORY OF EXISTING CONDITIONS SURVEY OF PROPOSED DEVELOPMENT, PUBLIC IMPROVEMENTS, AND NEIGHBORHOOD CONCERNS (Aug. 1988)
Boston City Hospital was the first municipal hospital in the United States, opening in 1864. Boston City Council voted 9-4 on June 29 of 1996 in favor of a merging Boston City Hospital and the Boston University Medical Center to create the new Boston Medical Center. BMC Board and Autonomy: 30 Trustees − 10 appointed by the mayor of Boston. Financial Relationship with County/City: Limited; debt service on City of Boston owned property. Assets − Some BMC/some City of Boston − Includes physical plant 90 year lease from City of Boston (Boston Public Health Service Commission)
Due to the need in the mid 1800's for a hospital to care for the sick poor, the city initiated plans for the construction of a city hospital. Chapter 113 of the Acts of 1858 established a City Hospital. Construction began in 1861 and the Boston City Hospital opened on June 1, 1864. The Hospital was under the charge of a Board of Trustees. Over time, besides the main hospital, the Trustees had charge of the South Department for contagious diseases, the Sanatorium Division at 249 River Street, Mattapan (for tuberculosis patients), Long Island Division (for chronic diseases) and East Boston Relief Station. Relief Stations were closed to patients on March 15, 1938; East Boston Relief Station was reopened on a twenty-four hour basis on October 15, 1945. The trustees were initially incorporated by Chapter 174 of the Acts of 1880 and authorized to receive and hold real and personal estate bequeathed or devised to said corporation to an amount not exceeding $1,000,000. By the 1950s, the trustees were authorized to receive and hold real and personal estate bequeathed or devised to said hospital corporation to an amount not exceeding $10,000,000. The Hospital Department and the Health Department were merged as the Health and Hospitals Department by Chapter 656 of the Acts of 1965. The Board of Health and Hospitals by this same statute was incorporated as the Board of Trustees of Health and Hospitals. From 1970 through the early 1990s, great effort was made to reorganize and modernize Boston City Hospital's physical plant, including building a new Boston City Hospital. However, in 1996, the Mayor's Special Commission on Health Care was formed to study the challenges of health care provision and administration in the twenty-first century and the Commission recommended that the Department of Health and Hospitals merge with Boston University Medical Center. The consolidation of the Department of Health and Hospitals and the Boston University Medical Center created the Boston Medical Center, which subsumed the former Boston City Hospital.
Boston City Archives, Guide to the Boston City Hospital collection 7020.001 This finding aid was produced using Archives, Space on October 23, 2015.
November 26, 1896
Phi Alpha Gamma, Boston University School of Medicine
In October 1902, the Beta chapter opened its chapter house at 18 Worcester Square
1874 Massachusetts Homeopathic Hospital (South End)
In 1962 Massachusetts Memorial Hospitals merged with the Boston University Medical Center
The hospital's main building survives, and is known as the Talbot Building; it now houses the Boston University School of Public Health. Immediately after his expulsion from the Massachusetts Medical Society, Dr. Talbot negotiated an alliance between the New England Female Medical College and Boston University under the auspices of the Massachusetts Homeopathic Medical Society, established the Boston University School of Medicine in 1873 and became its first dean, managing to hold on to the job for 24 years.
It was not until 1886, 13 years later, that BUSM's(homeopathic) medical students were permitted to receive instruction on BCH wards. The Board apparently reasoned that since the BCH was a public institution, it could not deny places to students of any institution chartered by the Commonwealth. Some expressed surprise that BUSM was given this responsibility. For all of its 109 years, the public has largely and appropriately identified the BCH with Harvard Medical School. The past century of medical progress at the BCH must be considered one of the proudest achievements of that school.
in 1918 by formally dropping its association with homeopathy, some of its faculty undoubtedly continued to practice homeopathic medicine,
https://www.massmed.org/About/MMS-Leadership/History/The-Boston-City-Hospital--A-Tale-of-Three-Cities/
Boston City Archives, Guide to the Boston City Hospital collection 7020.001 This finding aid was produced using Archives, Space on October 23, 2015.
November 26, 1896
Phi Alpha Gamma, Boston University School of Medicine
In October 1902, the Beta chapter opened its chapter house at 18 Worcester Square
1874 Massachusetts Homeopathic Hospital (South End)
In 1962 Massachusetts Memorial Hospitals merged with the Boston University Medical Center
The hospital's main building survives, and is known as the Talbot Building; it now houses the Boston University School of Public Health. Immediately after his expulsion from the Massachusetts Medical Society, Dr. Talbot negotiated an alliance between the New England Female Medical College and Boston University under the auspices of the Massachusetts Homeopathic Medical Society, established the Boston University School of Medicine in 1873 and became its first dean, managing to hold on to the job for 24 years.
It was not until 1886, 13 years later, that BUSM's(homeopathic) medical students were permitted to receive instruction on BCH wards. The Board apparently reasoned that since the BCH was a public institution, it could not deny places to students of any institution chartered by the Commonwealth. Some expressed surprise that BUSM was given this responsibility. For all of its 109 years, the public has largely and appropriately identified the BCH with Harvard Medical School. The past century of medical progress at the BCH must be considered one of the proudest achievements of that school.
in 1918 by formally dropping its association with homeopathy, some of its faculty undoubtedly continued to practice homeopathic medicine,
https://www.massmed.org/About/MMS-Leadership/History/The-Boston-City-Hospital--A-Tale-of-Three-Cities/
The Boston City Hospital: A Tale of Three Cities: Annual Oration 1973, Ephraim Friedman, M.D., The Decision.
On February 28, 1973, the Board of Trustees of the Department of Health and Hospitals of the City of Boston decided, after months of negotiation, to vest with the Boston University School of Medicine (BUSM) the responsibility for professional staffing of the Boston City Hospital (BCH). Most agree that the Board's action was probably more important than any other taken in the Hospital's 109-year history. The interschool competition that preceded the decision was one of the fiercest ever in an institution that has brought academic politics to the level of a fine art.
It is not my intention to abuse this forum by indulging in partisan academic politics; not only would it be improper, but nothing I might reveal could compete for your attention with Watergate. Yet this particular event is worthy of your attention; in part, because it represents a milestone in the history of a great medical institution but also because the scenario includes all the elements and forces operating in the current national health-care crisis, particularly as it affects academic health centers.
The BCH has always had an impact on medicine much out of proportion to its size. One can neither dismiss lightly an institution housing the Thorndike, Mallory, Channing and Sears Laboratories nor treat cavalierly an institution that can count among its own a "who's who" of the past century of American medicine: formidable names such as Mallory, Sears, Finland, Peabody, Castle, Weiss, Cheever, Cobb, Minot, Blumgart, Keefer, Dowling, Faulkner, Wilkins, Foley, Strauss, Kimelstiel, Wilson, Ingelfinger, Bakst, Jeghers, Denny-Brown, Biguria, O'Hara, Berson, Monroe, Putnam, Dunphy, Councilman, Watson, Lahey, Churchill, Tenney, Thorndike, Strieder and Parker. Added to this list should be the myriad of deans, department chairmen, and investigators who were trained at this institution. The BCH has been a national resource; what happens at that Hospital has to be of national interest....
Some expressed surprise that BUSM was given this responsibility. For all of its 109 years, the public has largely and appropriately identified the BCH with Harvard Medical School. The past century of medical progress at the BCH must be considered one of the proudest achievements of that school. The affiliation of Tufts University School of Medicine dates back to 1897, and that of BUSM to 1930; their roles at the BCH, until the past three decades, have been secondary.
To many, particularly those closest to the BCH scene, the recent turn of events came as no surprise. The BUSM had matured and grown in stature in recent decades, and its role at the BCH had expanded correspondingly. The BU Medical Service in particular has had an outstanding track record of accomplishment. Its geographic proximity helped. What was indeed surprising and requires explanation was the absence of a formal affiliation between the two institutions for more than 1/2 of the century of their coexistence across East Concord Street.
The explanation for this paradox is elusive, but the best speculation points to the Massachusetts Medical Society as the culprit. One hundred years ago the Society, after a notorious trial lasting for two years, expelled seven Boston physicians for practicing homeopathy. The leader of this group of "irregulars," as they were called, was Dr. Israel Tisdale Talbot, who presented the following unsuccessful defense: Our only professional pledge is to cure our patients by the best means in our power. For this purpose we stand as physicians, ready to receive any new truths; and we ask you to be as ready to receive, to examine what we have so carefully studied and believe to be true. When it is clearly proved that any drug or remedy in any case or form whatever is the best thing for the patient, it is the physician's duty to his patient and to his profession to administer such remedy, but until such a demonstration is given, it is equally his duty to give what he thinks is best, be it homeopathic, allopathic or heteropathic.
Although homeopathy is today little more than a historical curiosity, many of its tenets have a peculiarly modern ring to them, especially the criticism of the practice of prescribing large doses of potent drugs for relatively minor ailments. Dr. Oliver Wendell Holmes, in 1860, spoke to the same issue: "I firmly believe that if the whole materia media as now used (with few exceptions) could be sunk to the bottom of the sea, it would be all the better for mankind — and all the worse for the fishes."
Immediately after his expulsion from the Massachusetts Medical Society, Dr. Talbot negotiated an alliance between the New England Female Medical College and Boston University under the auspices of the Massachusetts Homeopathic Medical Society, established the Boston University School of Medicine in 1873 and became its first dean, managing to hold on to the job for 24 years.
It was not until 1886, 13 years later, that BUSM's (homeopathic) medical students were permitted to receive instruction on BCH wards. The Board apparently reasoned that since the BCH was a public institution, it could not deny places to students of any institution chartered by the Commonwealth. BUSM's women students were given access to BCH wards at about the same time, presumably for the same reason. There could have been no quarrel with the quality of the BUSM students, for its standards for admission and graduation were unusually high, in contrast to the disgraceful laxity in this regard of most schools of that time. The BUSM was the first American medical school to require three full years of training, the first to introduce an optional four-year course and the first to make the latter compulsory. BUSM faculty, however, may not have taught BUSM students at the BCH since the Massachusetts Medical Society bylaws required the disciplining of "regular" physicians who had professional associations, even consultations, with "irregulars" — i.e., homeopaths. Thus, although BUSM became "regular" in 1918 by formally dropping its association with homeopathy, some of its faculty undoubtedly continued to practice homeopathic medicine, and it is a reasonable speculation that it was this sectarian taint that interfered for so long with a formal affiliation with the BCH. Thus, the Massachusetts Medical Society was not only indirectly responsible for the establishment of the BUSM, but it was probably instrumental in delaying an affiliation between it and the BCH for 1/2 a century. It is, therefore, not only fitting and proper but somewhat ironic that the Massachusetts Medical Society would invite the dean of the BUSM, during the School's centennial year, to discuss the events leading up to and the importance of the new relation of BUSM with the BCH.
Whatever the reasons, it required nearly another decade of persistent effort on the part of the then Dean of the BUSM, Dr. Alexander Begg, to arrange a formal affiliation of BUSM with the BCH. The Fifth (BU) Medical Service was established in 1930, followed 20 years later by the Third (BU) Surgical Service. BUSM faculty successively assumed administrative leadership of the BCH departments of Pediatrics, Urology, and Thoracic Surgery in the fifties and the departments of Radiology, Pathology, Obstetrics and Gynecology, Rehabilitation Medicine, Ophthalmology and pediatric Surgery in the sixties. It was thereafter only a question of time before the progressive renaissance of BUSM as well as its geographical proximity to the BCH would manifest themselves in the recent action of the BCH Board.
https://www.massmed.org/About/MMS-Leadership/History/The-Boston-City-Hospital--A-Tale-of-Three-Cities/
On February 28, 1973, the Board of Trustees of the Department of Health and Hospitals of the City of Boston decided, after months of negotiation, to vest with the Boston University School of Medicine (BUSM) the responsibility for professional staffing of the Boston City Hospital (BCH). Most agree that the Board's action was probably more important than any other taken in the Hospital's 109-year history. The interschool competition that preceded the decision was one of the fiercest ever in an institution that has brought academic politics to the level of a fine art.
It is not my intention to abuse this forum by indulging in partisan academic politics; not only would it be improper, but nothing I might reveal could compete for your attention with Watergate. Yet this particular event is worthy of your attention; in part, because it represents a milestone in the history of a great medical institution but also because the scenario includes all the elements and forces operating in the current national health-care crisis, particularly as it affects academic health centers.
The BCH has always had an impact on medicine much out of proportion to its size. One can neither dismiss lightly an institution housing the Thorndike, Mallory, Channing and Sears Laboratories nor treat cavalierly an institution that can count among its own a "who's who" of the past century of American medicine: formidable names such as Mallory, Sears, Finland, Peabody, Castle, Weiss, Cheever, Cobb, Minot, Blumgart, Keefer, Dowling, Faulkner, Wilkins, Foley, Strauss, Kimelstiel, Wilson, Ingelfinger, Bakst, Jeghers, Denny-Brown, Biguria, O'Hara, Berson, Monroe, Putnam, Dunphy, Councilman, Watson, Lahey, Churchill, Tenney, Thorndike, Strieder and Parker. Added to this list should be the myriad of deans, department chairmen, and investigators who were trained at this institution. The BCH has been a national resource; what happens at that Hospital has to be of national interest....
Some expressed surprise that BUSM was given this responsibility. For all of its 109 years, the public has largely and appropriately identified the BCH with Harvard Medical School. The past century of medical progress at the BCH must be considered one of the proudest achievements of that school. The affiliation of Tufts University School of Medicine dates back to 1897, and that of BUSM to 1930; their roles at the BCH, until the past three decades, have been secondary.
To many, particularly those closest to the BCH scene, the recent turn of events came as no surprise. The BUSM had matured and grown in stature in recent decades, and its role at the BCH had expanded correspondingly. The BU Medical Service in particular has had an outstanding track record of accomplishment. Its geographic proximity helped. What was indeed surprising and requires explanation was the absence of a formal affiliation between the two institutions for more than 1/2 of the century of their coexistence across East Concord Street.
The explanation for this paradox is elusive, but the best speculation points to the Massachusetts Medical Society as the culprit. One hundred years ago the Society, after a notorious trial lasting for two years, expelled seven Boston physicians for practicing homeopathy. The leader of this group of "irregulars," as they were called, was Dr. Israel Tisdale Talbot, who presented the following unsuccessful defense: Our only professional pledge is to cure our patients by the best means in our power. For this purpose we stand as physicians, ready to receive any new truths; and we ask you to be as ready to receive, to examine what we have so carefully studied and believe to be true. When it is clearly proved that any drug or remedy in any case or form whatever is the best thing for the patient, it is the physician's duty to his patient and to his profession to administer such remedy, but until such a demonstration is given, it is equally his duty to give what he thinks is best, be it homeopathic, allopathic or heteropathic.
Although homeopathy is today little more than a historical curiosity, many of its tenets have a peculiarly modern ring to them, especially the criticism of the practice of prescribing large doses of potent drugs for relatively minor ailments. Dr. Oliver Wendell Holmes, in 1860, spoke to the same issue: "I firmly believe that if the whole materia media as now used (with few exceptions) could be sunk to the bottom of the sea, it would be all the better for mankind — and all the worse for the fishes."
Immediately after his expulsion from the Massachusetts Medical Society, Dr. Talbot negotiated an alliance between the New England Female Medical College and Boston University under the auspices of the Massachusetts Homeopathic Medical Society, established the Boston University School of Medicine in 1873 and became its first dean, managing to hold on to the job for 24 years.
It was not until 1886, 13 years later, that BUSM's (homeopathic) medical students were permitted to receive instruction on BCH wards. The Board apparently reasoned that since the BCH was a public institution, it could not deny places to students of any institution chartered by the Commonwealth. BUSM's women students were given access to BCH wards at about the same time, presumably for the same reason. There could have been no quarrel with the quality of the BUSM students, for its standards for admission and graduation were unusually high, in contrast to the disgraceful laxity in this regard of most schools of that time. The BUSM was the first American medical school to require three full years of training, the first to introduce an optional four-year course and the first to make the latter compulsory. BUSM faculty, however, may not have taught BUSM students at the BCH since the Massachusetts Medical Society bylaws required the disciplining of "regular" physicians who had professional associations, even consultations, with "irregulars" — i.e., homeopaths. Thus, although BUSM became "regular" in 1918 by formally dropping its association with homeopathy, some of its faculty undoubtedly continued to practice homeopathic medicine, and it is a reasonable speculation that it was this sectarian taint that interfered for so long with a formal affiliation with the BCH. Thus, the Massachusetts Medical Society was not only indirectly responsible for the establishment of the BUSM, but it was probably instrumental in delaying an affiliation between it and the BCH for 1/2 a century. It is, therefore, not only fitting and proper but somewhat ironic that the Massachusetts Medical Society would invite the dean of the BUSM, during the School's centennial year, to discuss the events leading up to and the importance of the new relation of BUSM with the BCH.
Whatever the reasons, it required nearly another decade of persistent effort on the part of the then Dean of the BUSM, Dr. Alexander Begg, to arrange a formal affiliation of BUSM with the BCH. The Fifth (BU) Medical Service was established in 1930, followed 20 years later by the Third (BU) Surgical Service. BUSM faculty successively assumed administrative leadership of the BCH departments of Pediatrics, Urology, and Thoracic Surgery in the fifties and the departments of Radiology, Pathology, Obstetrics and Gynecology, Rehabilitation Medicine, Ophthalmology and pediatric Surgery in the sixties. It was thereafter only a question of time before the progressive renaissance of BUSM as well as its geographical proximity to the BCH would manifest themselves in the recent action of the BCH Board.
https://www.massmed.org/About/MMS-Leadership/History/The-Boston-City-Hospital--A-Tale-of-Three-Cities/
The Denny-Brown collection spans a 19-year period from 1945 to 1964 and consists of 16 boxes of pathological slides (n=2500), containing sections of brains in three planes (transverse, sagittal, and horizontal). The collection includes nearly all phases of neurology with an emphasis in basic studies on the basal ganglia, related tumors, posture, and movements. Films documenting the cerebral activity of human and nonhuman primates and cats, case file notes, and videos depicting human neurological disease are also associated with the collection. This collection was prepared by Dr. Derek Denny-Brown (1901-1981) from the 1940s to 1960s while he was a professor of neurology at Harvard Medical School and director of Harvard’s Neurologic
National Museum of Health and Medicine, 2024 Guide to the Collections, Neuroanatomical Collection
https://medicalmuseum.health.mil/assets/documents/collections/NMHM_Guide_To_Collections.pdf
Pathology building at Boston City Hospital This building was built in 1896, and was located on the corner of Albany Street and Massachusetts Avenue. Dr. Frank Burr Mallory, a famous American pathologist who, among many contributions, had discovered Mallory bodies, worked in this building at Boston City Hospital. Over three decades later, a new pathology building, named Mallory Institute of Pathology, was built in honor of Dr. Mallory. The first pathology building is now replaced by Menino Pavilion and Dowling Building. https://blogs.bu.edu/busmhs/files/2015/12/Aceso-Fall-2015.pdf
The end of the 19th century was a pivotal period for American medicine, which had yet to contribute to the great advances in medical discovery that were occurring in Europe, particularly in Germany. Pathology, a specialty that included the microscopic examination of diseased tissues and the new science of bacteriology, counted among its practitioners such luminaries as Rudolph Virchow and his student Robert Koch. This emerging specialty was seen as important to creating a new era in American medicine. Johns Hopkins had chosen a pathologist, William H Welch, who had studied with the greats in Germany, as its founding Dean of the medical school, and under his leadership, this new medical institution was already considered to be in the vanguard of medical progress and reform. [5] With an eye to this and breaking with a tradition of hiring leadership from within, Harvard recruited William T Councilman, a protégé of Welsh’s, as the Shattuck Professor of Pathology (Pathological Anatomy) and Chief of Pathology at Boston City Hospital (BCH). [6] On Councilman’s arrival in Boston, he appointed the 30 year old Mallory as his assistant. FB Mallory belonged to the first generation of full time pathologists in the United States. He commenced his career apprenticed to the brilliant and visionary Councilman. In 1893 he spent a year in Europe, with the highly regarded pathologists, Chiari in Prague and Ziegler in Freiburg, Germany. [2,3] There were no training programs in the US in those early days. Mallory, on his return, dedicated himself to the mission of training future generations of American pathologists. In a 1906 report he described his department at Boston City Hospital as being organized “along the lines of a professional training school”. [7] More than 120 graduates emerged from his program over the course of his career. [2] They included many distinguished future leaders in pathology and chiefs of pathology at major US teaching hospitals, whose success contributed to his fame. Leafing, or as I should say, scrolling through the pages of the online text, one is struck by the completeness of the morphological description of disease in this 100 year old book. As is currently the practice in modern textbooks of pathology, or a modern pathology syllabus, the labor is divided into general pathology and specific organ pathology. The main topics in general pathology are those processes that underlie all diseases: cell injury and death, inflammation, repair, agents of injury and disease and neoplasia. The chapter headings would be familiar to a present day 2nd year Boston University medical student who had completed the foundation module of the DRX course, and she would be perhaps surprised to find that a substantial part of the foundation had been in place a hundred years ago. In Mallory’s textbook she could, to take one example, find a fully adequate description of the histological patterns of tissue necrosis, including coagulation, liquefactive, caseation and fat necrosis. In addition she would encounter still current definitions of terms related to cell degeneration and death, including the euphonious nuclear alterations termed pyknosis, karyorrhexis and karyolysis. Today’s student would undoubtedly also be struck by the amount of text devoted to infection as the cause of disease. This focus is hardly surprising, however, since as Pathologist to Boston City Hospital, Mallory’s main preoccupation and that of his clinical colleagues was infectious disease. In a contemporary photograph of Mallory at work in his laboratory (Figure 3), he is not looking down a microscope, but making notes as he examines bacterial culture plates. He states in a 1906 report that up to 150 throat swabs for diphtheria might be plated in a single day in his laboratory. Diphtheria and scarlet fever had entire wards devoted to afflicted patients at BCH at the turn of the last century. [7] This experience enabled Mallory to author authoritative descriptive studies of the pathology of several major infectious diseases, including pertussis, typhoid, scarlet fever, diphtheria and measles. [1114] The beautiful camera lucida color drawings of the potentially lethal small intestinal ulcers of typhoid fever in his1898 paper in the Journal of Experimental Medicine are representative of the quality and elegance of the illustrations throughout his published work and are worth an online visit. [13] Tuberculosis (Figure 4) also receives extensive coverage in his text, as you might expect, given that deaths from TB in the decades preceding 1914 exceeded those from heart disease, [15] although their mortality rate trajectories at this point in time were about to cross (Figure 5). Other prevalent infectious diseases of the time included pneumococcal pneumonia and the various manifestations of syphilis.
This was the heyday of descriptive pathology, based largely on gross autopsy findings and their microscopic description. The center of gravity of Mallory’s laboratory and of pathology laboratories in other leading medical institutions in the United States and Europe of the time was the autopsy room. In the BCH of his day the standing of Pathology as a specialty was reflected in the magnificence of the building that housed it. The Pathology building (see cover page), opened in 1896, was 2 stories over basement and had about 25,000 sq ft of floor space. The postmortem room was placed within an auditorium extending through 2 floors and had seating for 70 observers. Here Mallory would have presided over autopsy examinations performed on BCH patients who died from the common fatal diseases of the time and examination of their tissues with the available technologies, informed by the given knowledge of the period, was the fountain from which his scholarship flowed (Figure 3). Ironically, perhaps, this ascendancy of descriptive pathology reached its zenith in Mallory’s era. While making major contributions to medical knowledge and the causation of disease, in the face of questions regarding the underlying molecular mechanisms it was, by its nature, generally mute. It would be several decades before the technology to interrogate tissue sections with molecule specific probes would be available to give it a voice. Overreliance on observation and description occasionally got the great pathologists of the period onto the wrong track. William T Councilman, relying on his detailed pathological studies of numerous cases, announced (erroneously) to the world that the agent of smallpox was a parasite [16]; and Mallory was similarly drawn in to proposing that a parasite was the germ of scarlet fever based on his histological studies. [14]
https://blogs.bu.edu/busmhs/files/2015/12/Aceso-Fall-2015.pdf
Councilman WT, Mallory FB, Pearce RM. A Study of the Bacteriology and Pathology of Two Hundred and Twenty Fatal Cases of Diphtheria. Journal Boston Society Medical Science, V. 139321, 1900.
Councilman W, Mallory F, Wright J. Epidemic CerebroSpinal Meningitis And Its Relation To Other Forms Of Meningitis. Boston: Wright & Potter printing Co., State printers; 1898
Mallory F. A Histologic Study of Typhoid Fever. Journal of Experimental Medicine. 1898;3(6):611638.
Mallory FB. Scarlet Fever. ProtozoonLike Bodies found in Four Cases. The Journal of Medical Research. 1904;10(4):483492.3. [15] United States Mortality Statistics 1914, Fifteenth Annual Report, Department of Commerce, Bureau of Census, Sam L Rogers Director.
Councilman WT, Magrath GB, Brinckerhoff WR. A Preliminary Communication on the Etiology of Smallpox . The Journal of Medical Research. 1903;9(3):372375.
Principles of Pathologic Histology.
Pathological Technique, A Practical Manual for Workers in Pathological Histology and Bacteriology
Finland, Maxwell - It was in 1948 that I was first made aware much of what we were doing in the hospital was considered to be epidemiology.
The Journal of Infectious Diseases, Vol. 128, No. 1 (Jul., 1973), pp. 76-124
The Boston Public Health Act of 1995, the home rule petition submitted by the Mayor that permits the creation of a new health care system for the City of Boston should be approved by the City Council. This home rule petition represents a critical step forward in the effort to ensure the mission of Boston City Hospital (BCH) at a time of significant change and contraction in the health care market. The petition is the first step in the establishment of a new health care system involving the creation of a Public Health Commission, a new private medical center and the affiliation of eight neighborhood health centers. The petition creates the Public Health Commission as successor to the Department of Health and Hospitals (DH&H) and authorizes the City to negotiate a merger agreement with Boston University Medical Center Hospital (BUMCH). This negotiation will result in the creation of a private, nonprofit corporation, the Boston Medical Center, which will maintain a public mission established through a merger of BCH and Boston Specialty and Rehabilitation Hospital (BSRH) with BUMCH. The merger agreement will have to be presented to the Mayor and City Council for approval once it is negotiated. Eight Boston neighborood health centers have agreed to affiliate with the Commission and the Medical Center to create the new health care network for Boston
The totality of this plan, combining the elements that retain the public involvement and mission, the capacity to be more cost effective and competitive and the ability to provide the critical mass of patient volume, may be the only way this new entity can be competitive and survive in this changing environment. Also of importance is that the final plan will improve the City's financial position by placing a limit that is fixed in term and amount regarding Boston's fiscal obligation to the new medical center. Maintaining a competitive edge is the key to health care survival in the 1990s and the plan before the City Council is the City's best option for its long term interests. The growth and clout of managed care and the expected reductions in federal health care funding point to increasing funding pressures on public hospitals. In 1994, BCH relied on Medicaid, Medicare and the Free Care Pool for 86.1% of its total net revenues. These are the revenues that are most vulnerable to cuts by Congress and the President as they agree to reduce the federal deficit. Establishing a new health care system in Boston that will be competitive and still maintain the mission to serve the poor and indigent will not come without difficulty and hardship. Nevertheless, these steps are necessary to ensure that both the hospitals and the mission will survive in this competitive health care environment. Approval of this petition now will allow the merger negotiations to be completed so that a final detailed agreement can be presented for a subsequent vote by the Council. Amendments to the jjetition should be limited to maintain its flexibility. This issue must be thought of in economic, not political terms.
The Boston Public Health Act of 1995 This petition has two objectives: (1) to establish a change in the governance structure of the DH&H through the creation of the Public Health Commission and (2) to authorize the City to enter into negotiations with BUMCH or any other hospital for the purpose of merging or consolidating its operations with those of BCH and the BSRH. Once a detailed agreement is negotiated, it must be presented to the Council for final approval. The new health system will be accountable to the Mayor and City Council through the annual appropriation process and other procedures in the law. The home rule petition provides for the creation of a new quasi-independent agency of the City called the Boston Public Health Commission. The Commission will be the successor to DH&H and the Trustees of Health and Hospitals on July 1, 1996. The Commission will be governed by a Board of Trustees of seven members, six of whom are appointed by the Mayor. The seventh member is the CEO of the consolidated Medical Center or the City's Collector-Treasurer if no merger take place. Civil Service laws will not apply to new Commission employees but pension, benefit and collective bargaining rights remain the same. The Commission is responsible for; • Retaining title to DH&H projjerty and assuming the City's debt service obligations to DH&H. • Contracting with the consolidated Medical Center to operate BCH and BSRH. The lease will pay for the BCH debt service. • Contracting with the Medical Center for medical services for its programs. • Administering the Emergency Medical Services (EMS).
The petition authorizes the City to negotiate a merger agreement with BUMCH to create a private, nonprofit corporation modeled after the neighborhood health centers. This new corporation, called the Boston Medical Center, will be a private employer driven by a public mission. The merger partner for BCH must accept the mission statement of BCH. The new Medical Center will operate BCH and BSRH under contract and BUMCH. It will provide public health medical services under contract with the Boston Public Health Commission. A Board of Trustees of 30 members apjxiinted by the Mayor, BUMCH and neighborhood health centers will govern the Medical Center. A Public Health Advisory Board will be established to provide citizen input and review of the Commission's performance and budget. Similar to the MWRA Advisory Board, this Board will encourage coordination among the Commission, public health providers and funding sources in addressing the City's public health needs. The Medical Center ’s programs relating to public health will also be reviewed by this Board.
The home rule pietition is essential to enable the Public Health Commission and Medical Center to be competitive in this new environment by providing opportunities to improve service and cost efficiency. The restrictions and constraints on public institutions, such as BCH, put them at a disadvantage in responding rapidly and creatively to the changing health care market. The survival of the hospitals will depend on their ability to be competitive as price and patient volume continue to decrease. The Medical Center as a private, nonprofit corporation affords the best opportunity to be compietitive in Boston. The merger will establish the critical mass of patient volume that will enable the new Medical Center to be more cost effective and viable. New physician linkages are essential to open new markets and such linkages are easier to establish in a private setting. The costs for Boston City Hospital are among the highest in the state and aggressive cost control must continue if it is to suiA'ive. The merger offers the opportunity to achieve greater cost efficiencies. Based on 1993 data, BCH’s inpatient cost per discharge is 10% higher than other Boston Teaching Hospitals and 16% higher than at comparable community hospitals. That is an indicator of the degree to which BCH must respond to the competitive rate pressures. On the other hand, the inpatient cost per discharge at BUMCH is 6% lower. Adding to these pressures is the fact that the other Boston Teaching Hospitals have set goals to reduce operating costs by 20-30% over the next few years. That will set new comparative benchmarks in the marketplace. While there are reasons for cost differences, the key to the future is the willingness of the payors to pay higher costs for special services at BCH.
This home rule petition will enable an agreement to be negotiated that should improve the City’s financial position. Currently, the operational and capital obligation on Boston for DH&H is unlimited. It is exjjected that the hospital merger agreement will fix the City’s financial obligations to the Medical Center and to certain services of the Public Health Commission in term and amount for both operational and capital e.xpenses. Over the three years from fiscal 1992 through fiscal 1994, the City’s assistance to DH&H averaged $34.2 million. The bulk of that assistance was for public health services with the balance allocated to BCH, BSRH, EMS and Long Island Shelter. The City will continue to be responsible for funding public health services and Long Island Shelter but its assistance to the other services will be defined in the merger agreement. With the approval of the home rule petition, the City’s debt service obligations for the new BCH facility will transfer to the Public Health Commission and over 2,500 employees will transfer to either the Commission or the Medical Center.
The New Boston Public Health Network Should Be Approved, Boston Municipal Research Bureau (June 29 1995).
The totality of this plan, combining the elements that retain the public involvement and mission, the capacity to be more cost effective and competitive and the ability to provide the critical mass of patient volume, may be the only way this new entity can be competitive and survive in this changing environment. Also of importance is that the final plan will improve the City's financial position by placing a limit that is fixed in term and amount regarding Boston's fiscal obligation to the new medical center. Maintaining a competitive edge is the key to health care survival in the 1990s and the plan before the City Council is the City's best option for its long term interests. The growth and clout of managed care and the expected reductions in federal health care funding point to increasing funding pressures on public hospitals. In 1994, BCH relied on Medicaid, Medicare and the Free Care Pool for 86.1% of its total net revenues. These are the revenues that are most vulnerable to cuts by Congress and the President as they agree to reduce the federal deficit. Establishing a new health care system in Boston that will be competitive and still maintain the mission to serve the poor and indigent will not come without difficulty and hardship. Nevertheless, these steps are necessary to ensure that both the hospitals and the mission will survive in this competitive health care environment. Approval of this petition now will allow the merger negotiations to be completed so that a final detailed agreement can be presented for a subsequent vote by the Council. Amendments to the jjetition should be limited to maintain its flexibility. This issue must be thought of in economic, not political terms.
The Boston Public Health Act of 1995 This petition has two objectives: (1) to establish a change in the governance structure of the DH&H through the creation of the Public Health Commission and (2) to authorize the City to enter into negotiations with BUMCH or any other hospital for the purpose of merging or consolidating its operations with those of BCH and the BSRH. Once a detailed agreement is negotiated, it must be presented to the Council for final approval. The new health system will be accountable to the Mayor and City Council through the annual appropriation process and other procedures in the law. The home rule petition provides for the creation of a new quasi-independent agency of the City called the Boston Public Health Commission. The Commission will be the successor to DH&H and the Trustees of Health and Hospitals on July 1, 1996. The Commission will be governed by a Board of Trustees of seven members, six of whom are appointed by the Mayor. The seventh member is the CEO of the consolidated Medical Center or the City's Collector-Treasurer if no merger take place. Civil Service laws will not apply to new Commission employees but pension, benefit and collective bargaining rights remain the same. The Commission is responsible for; • Retaining title to DH&H projjerty and assuming the City's debt service obligations to DH&H. • Contracting with the consolidated Medical Center to operate BCH and BSRH. The lease will pay for the BCH debt service. • Contracting with the Medical Center for medical services for its programs. • Administering the Emergency Medical Services (EMS).
The petition authorizes the City to negotiate a merger agreement with BUMCH to create a private, nonprofit corporation modeled after the neighborhood health centers. This new corporation, called the Boston Medical Center, will be a private employer driven by a public mission. The merger partner for BCH must accept the mission statement of BCH. The new Medical Center will operate BCH and BSRH under contract and BUMCH. It will provide public health medical services under contract with the Boston Public Health Commission. A Board of Trustees of 30 members apjxiinted by the Mayor, BUMCH and neighborhood health centers will govern the Medical Center. A Public Health Advisory Board will be established to provide citizen input and review of the Commission's performance and budget. Similar to the MWRA Advisory Board, this Board will encourage coordination among the Commission, public health providers and funding sources in addressing the City's public health needs. The Medical Center ’s programs relating to public health will also be reviewed by this Board.
The home rule pietition is essential to enable the Public Health Commission and Medical Center to be competitive in this new environment by providing opportunities to improve service and cost efficiency. The restrictions and constraints on public institutions, such as BCH, put them at a disadvantage in responding rapidly and creatively to the changing health care market. The survival of the hospitals will depend on their ability to be competitive as price and patient volume continue to decrease. The Medical Center as a private, nonprofit corporation affords the best opportunity to be compietitive in Boston. The merger will establish the critical mass of patient volume that will enable the new Medical Center to be more cost effective and viable. New physician linkages are essential to open new markets and such linkages are easier to establish in a private setting. The costs for Boston City Hospital are among the highest in the state and aggressive cost control must continue if it is to suiA'ive. The merger offers the opportunity to achieve greater cost efficiencies. Based on 1993 data, BCH’s inpatient cost per discharge is 10% higher than other Boston Teaching Hospitals and 16% higher than at comparable community hospitals. That is an indicator of the degree to which BCH must respond to the competitive rate pressures. On the other hand, the inpatient cost per discharge at BUMCH is 6% lower. Adding to these pressures is the fact that the other Boston Teaching Hospitals have set goals to reduce operating costs by 20-30% over the next few years. That will set new comparative benchmarks in the marketplace. While there are reasons for cost differences, the key to the future is the willingness of the payors to pay higher costs for special services at BCH.
This home rule petition will enable an agreement to be negotiated that should improve the City’s financial position. Currently, the operational and capital obligation on Boston for DH&H is unlimited. It is exjjected that the hospital merger agreement will fix the City’s financial obligations to the Medical Center and to certain services of the Public Health Commission in term and amount for both operational and capital e.xpenses. Over the three years from fiscal 1992 through fiscal 1994, the City’s assistance to DH&H averaged $34.2 million. The bulk of that assistance was for public health services with the balance allocated to BCH, BSRH, EMS and Long Island Shelter. The City will continue to be responsible for funding public health services and Long Island Shelter but its assistance to the other services will be defined in the merger agreement. With the approval of the home rule petition, the City’s debt service obligations for the new BCH facility will transfer to the Public Health Commission and over 2,500 employees will transfer to either the Commission or the Medical Center.
The New Boston Public Health Network Should Be Approved, Boston Municipal Research Bureau (June 29 1995).
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Boston City Hospital
Brass Tacks
By Paul J. Corkery
May 21, 1968
BOSTON CITY HOSPITAL, an amazing complex of buildings in a dreary corner of the South End, was never really planned. Like the city it serves, "City" grew haphazardly and in quirks through the last years of the 19th century and through the first third of this century. The jumble of buildings, none of them new, each seemingly done in a different architectural mode without concern for the total environment, and all of them connected by a weird system of tunnels, reflects the different plans that different generations have proposed to fulfill the hospital's prime purpose: the service of the indigent sick. Today City does seem to be filling that need. Its only patients are Boston's poor--Negroes, Puerto Ricans, derelicts, and the whites who have been left behind in the South End. The quality of service is the best the government of Boston can provide. In return for medical care, Boston's medical schools are allowed to use the patients at City as teaching cases. It is a system which was set up at the turn of the century and for most of these years has been the most effective means of providing Boston with charity medicine. From the Civil War through the Depression of the 30's, City thrived. It was the only place where the poor in Boston could go. The resulting variety of cases was immense, and medical students even scrambled to obtain residencies and research posts there. Rseearch performed at City and social legislation enacted in Washington, however, were by the end of World War II spelling the end of the need for a hospital of City's scope and purpose. The huge, 500-plus-bed South Department gradually became obsolete. Created as a hospital-within-a-hospital, South Department was designed for victims of "contagious diseases." It is physically isolated from the rest of City. Brick walls and iron fences set it off from the neighborhood; entrance to South Department can be gained only through a few central gates. Vaccines and preventive medicine have eliminated most of the "contagious diseases." Today, South Department for the most part stands empty and closed. Some of its buildings have been put to use as psychiatric and day-care centers, but South Department's basic function is gone. MUCH of City is that way today: empty and unneeded. But medical research is only partially and indirectly responsible. There are just not enough people left who are unable to go to a private hospital or to choose their own doctors. "Medicare and medicaid have made obsolete the concept of charity medicine," says Dr. Andrew P. Sackett, Boston's Health and Hospitals Commissioner. The fact that City lies in Boston's oldest and most horrible slum somewhat obscures the meaning of this fact. There are people who do need a charity hospital; the small waiting room at City's admitting office is full of confused, bewildered, weary people who are hardly--if at all--aware of medicare. But to devote the massive plant of City Hospital to the few who still need a charity hospital is to provide them and Boston with a disservice. The care given the poor today at City, while decent, is not adequate. There is no need for a full staff at City anymore, and the result has been that some parts of it are hardly staffed at all. The few patients who must go there suffer. One obvious suggestion is to close down City completely and replace it with a smaller general hospital for the South End. But a hospital of this scope would not be adequate enough for the clinical training needs of the medical schools that currently service City--Harvard, Boston University, and Tufts. Solution of these two problems--medical care for the poor, and clinical training for medical students--will not be gained by metaphysical and physical re-construction of the old City Hospital or by construction of a small South End Hospital. The entirely new nature of medical care calls for an abandoning of stop-gap proposals and anachronistic wishes. Boston's citizens and Boston's medical students deserve more than sloppy attempts to avoid some very basic problems.
https://www.thecrimson.com/article/1968/5/21/boston-city-hospital-pbbboston-city-hospital/
Brass Tacks
By Paul J. Corkery
May 21, 1968
BOSTON CITY HOSPITAL, an amazing complex of buildings in a dreary corner of the South End, was never really planned. Like the city it serves, "City" grew haphazardly and in quirks through the last years of the 19th century and through the first third of this century. The jumble of buildings, none of them new, each seemingly done in a different architectural mode without concern for the total environment, and all of them connected by a weird system of tunnels, reflects the different plans that different generations have proposed to fulfill the hospital's prime purpose: the service of the indigent sick. Today City does seem to be filling that need. Its only patients are Boston's poor--Negroes, Puerto Ricans, derelicts, and the whites who have been left behind in the South End. The quality of service is the best the government of Boston can provide. In return for medical care, Boston's medical schools are allowed to use the patients at City as teaching cases. It is a system which was set up at the turn of the century and for most of these years has been the most effective means of providing Boston with charity medicine. From the Civil War through the Depression of the 30's, City thrived. It was the only place where the poor in Boston could go. The resulting variety of cases was immense, and medical students even scrambled to obtain residencies and research posts there. Rseearch performed at City and social legislation enacted in Washington, however, were by the end of World War II spelling the end of the need for a hospital of City's scope and purpose. The huge, 500-plus-bed South Department gradually became obsolete. Created as a hospital-within-a-hospital, South Department was designed for victims of "contagious diseases." It is physically isolated from the rest of City. Brick walls and iron fences set it off from the neighborhood; entrance to South Department can be gained only through a few central gates. Vaccines and preventive medicine have eliminated most of the "contagious diseases." Today, South Department for the most part stands empty and closed. Some of its buildings have been put to use as psychiatric and day-care centers, but South Department's basic function is gone. MUCH of City is that way today: empty and unneeded. But medical research is only partially and indirectly responsible. There are just not enough people left who are unable to go to a private hospital or to choose their own doctors. "Medicare and medicaid have made obsolete the concept of charity medicine," says Dr. Andrew P. Sackett, Boston's Health and Hospitals Commissioner. The fact that City lies in Boston's oldest and most horrible slum somewhat obscures the meaning of this fact. There are people who do need a charity hospital; the small waiting room at City's admitting office is full of confused, bewildered, weary people who are hardly--if at all--aware of medicare. But to devote the massive plant of City Hospital to the few who still need a charity hospital is to provide them and Boston with a disservice. The care given the poor today at City, while decent, is not adequate. There is no need for a full staff at City anymore, and the result has been that some parts of it are hardly staffed at all. The few patients who must go there suffer. One obvious suggestion is to close down City completely and replace it with a smaller general hospital for the South End. But a hospital of this scope would not be adequate enough for the clinical training needs of the medical schools that currently service City--Harvard, Boston University, and Tufts. Solution of these two problems--medical care for the poor, and clinical training for medical students--will not be gained by metaphysical and physical re-construction of the old City Hospital or by construction of a small South End Hospital. The entirely new nature of medical care calls for an abandoning of stop-gap proposals and anachronistic wishes. Boston's citizens and Boston's medical students deserve more than sloppy attempts to avoid some very basic problems.
https://www.thecrimson.com/article/1968/5/21/boston-city-hospital-pbbboston-city-hospital/
Med Services Unaffected By Hospital Rating Loss, January 9, 1970
Boston City Hospital's (BCH) loss of accreditation will not affect the services or medical student training programs which Harvard operates at the hospital. The Joint Commission on Accreditation of Hospitals, a national medical rating organization, stripped BCH of its accreditation Wednesday for the first time in the hospital's 106-year history. BCH officials immediately asked the commission to inspect the hospital again in June. "The chiefs of all the Harvard services are anxious to work in every possible way to correct the deficiencies cited by the accreditation commission," Dr. Robert H. Ebert, dean of Harvard Medical School, said yesterday.
Harvard operates four medical services at BCH - one each in medicine, surgery, neurology, and neurosurgery - which altogether provide care for up to 300 patients. These services are staffed by 150 faculty members, and 100 interns and residents from the Harvard Medical School. Each year 250 Harvard Medical students receive their clinical training by working in the services.
Harvard also runs three research laboratories at the hospital. The loss of accreditation will cause no change in their operation cither, Ebert said. Dr. Andrew P. Sackcu, the city's health and hospitals commissioner, said he was "shocked" and called the accreditation removal "a harsh and unjustified action." The commission charged the hospital with 52 separate deficiencies-including sloppy housekeeping, failure to maintain sprinkling systems, neglect of fire and disaster planning, failure to recruit enough registered nurses and dieticians, inadequate record systems, and operating in antiquated facilities.
https://www.thecrimson.com/article/1970/1/9/med-services-unaffected-by-hospital-rating/
Boston Mayor Endorses Harvard Plan for BCH, May 5, 1965
Boston Mayor John F. Collins presented a bill to the Massachusetts Legislature yesterday that would merge the Boston City Hospital with the Boston Health Department to form a single Department of Health and Hospitals. Collins was acting on a report submitted to him by three faculty members of the School of Public Health. The BCH presently faces a loss of accreditation because of its substandard physical plant and inadequate administrative staff. The Joint Commission of Hospitals (JCAH), a national association, put the BCH on probation two years ago. The probation period ends Jan. 1, 1966 and the hospital is up for review this September.
Dr. Robert H. Hamlin, professor of Public Health and an author of the report, commented yesterday, "By establishing a high level decision-making apparatus under a new Commissioner of Health and Hospitals, we could start to remedy BCH's unfortunate legacy, compiled through lack of planning in the 1940's and 1950's." John, H. Knowles '47, lecturer in Medicine at the Medical School and director of the Massachusetts General Hospital, said yesterday that he did not think the new plans alone would solve BCH's problems. Although he called the merger "abundantly sound," Knowles said he doubted that the legislature would appropriate the needed money "unless all with an interest in BCH--especially the medical schools (Harvard, Tufts, B.U.) with teaching facilities there-take off their coats and jump into the fight." organizational charts you draw, you still He added that "no matter how many have to get money to finance your plans."
https://www.thecrimson.com/article/1965/5/5/boston-mayor-endorses-harvard-plan-for/
Plaintiff Boston Medical Center Corporation (BMC) is the non-profit corporation that operates Boston Medical Center. Boston Medical Center was established by the City of Boston, pursuant to statutory authorization granted in the Boston Public Health Act of 1995, St. 1995, c. 146 (the BPH Act), as a result of the merger of the former Boston City Hospital and the former Boston University Medical Center. Section 1(a) of he BPH Act declared "that the city should be empowered to provide for the establishment of a new medical center," which would have as its "mission . . . to consistently provide excellent and accessible health care services to all in need of care, regardless of status or ability to pay; . . . play an important role as a referral, tertiary level hospital serving the region in a financially responsible manner and continue to serve the most acutely ill patient populations." Section 1(b) proceeded to set forth "six equally important guiding principles" to which "the new medical center shall commit itself." Among these was "ensuring the availability of a full range of primary through tertiary medical programs," "serving both urban and suburban communities in a culturally and linguistically competent manner," "enhancing its role as a major academic medical center," and "participating effectively and competitively in managed care plans serving the patient population."
Section 5 of the BPH Act empowered the city to execute an agreement providing for the merger of the former Boston City Hospital with the former Boston University Medical Center, "providing that the corporation resulting from such merger . . . accepts as its mission the statement of policy set forth in paragraph (b) of section one, and agrees with the city to utilize the acute-care hospitals and other health care facilities under its custody and control . . . to provide a single standard of health care to all in need of care, including vulnerable populations within the city, with equal access regardless of status or ability to pay." Section 5(f) of the BPH Act provided that "the hospital resulting from such merger . . .shall be deemed to retain the status which Boston City Hospital had . . . as a public service hospital" for purposes of specified regulations then in effect, and of eligibility for payments pursuant to specified statutes and regulations then in effect, including "payments to high public payer hospitals," "disproportionate share adjustments for safety net providers," payments "from the uncompensated care pool," and "payment from and participation in medical assistance programs . . . on a basis which recognizes such resulting hospital as the successor to Boston City Hospital," all pursuant to specified statutes and regulations then in effect.
Boston Medical Center Corporation and Boston Medical Center Health Plan, Inc. v. Secretary of the Executive, 09-2959-BLS2, No. 09-2959BLS2, Commonwealth of Massachusetts Superior Court. Suffolk, SS., Dec 21, 2010
Section 5 of the BPH Act empowered the city to execute an agreement providing for the merger of the former Boston City Hospital with the former Boston University Medical Center, "providing that the corporation resulting from such merger . . . accepts as its mission the statement of policy set forth in paragraph (b) of section one, and agrees with the city to utilize the acute-care hospitals and other health care facilities under its custody and control . . . to provide a single standard of health care to all in need of care, including vulnerable populations within the city, with equal access regardless of status or ability to pay." Section 5(f) of the BPH Act provided that "the hospital resulting from such merger . . .shall be deemed to retain the status which Boston City Hospital had . . . as a public service hospital" for purposes of specified regulations then in effect, and of eligibility for payments pursuant to specified statutes and regulations then in effect, including "payments to high public payer hospitals," "disproportionate share adjustments for safety net providers," payments "from the uncompensated care pool," and "payment from and participation in medical assistance programs . . . on a basis which recognizes such resulting hospital as the successor to Boston City Hospital," all pursuant to specified statutes and regulations then in effect.
Boston Medical Center Corporation and Boston Medical Center Health Plan, Inc. v. Secretary of the Executive, 09-2959-BLS2, No. 09-2959BLS2, Commonwealth of Massachusetts Superior Court. Suffolk, SS., Dec 21, 2010
Public Health: The Boston Public Health Commission (“BPHC”), successor to the City’s Department of Health and Hospitals, is a body politic and corporate separate from the City created in 1996 when the operations of the City’s former acute-care hospital, Boston City Hospital, were consolidated with the operations of Boston University Medical Center Hospital under the control of the Boston Medical Center Corporation (“BMCC”), a private, Massachusetts non-profit corporation. The BPHC is governed by a seven-member board, six of whom are appointed by the Mayor, subject to confirmation by the City Council, and one of whom, as the chief executive officer of BMCC, serves ex-officio. The BPHC functions as the City’s board of health and operates a wide range of public health programs throughout the City funded from public and private grants and City appropriations. The BPHC is a discretely presented component unit for GAAP reporting purposes in the City’s annual audited financial statements.
Boston Public Health Commission: The Boston Public Health Commission is a body politic and corporate and a political subdivision of the Commonwealth created in June 1996 as the successor to the City’s Department of Health and Hospitals. See “The City—Principal Government Services—Public Health.” The BPHC is responsible for the implementation of public health programs in the City and serves as the board of health of the City. In addition to its other powers, the BPHC is authorized by its enabling act, with the approval of the City Council and the Mayor, to borrow money for any of its corporate purposes from the City or from the Massachusetts Health and Educational Facilities Authority. Debt of the BPHC is not a debt or other obligation of the City. The BPHC has no debt currently outstanding. The BPHC has required, and can be expected to continue to require, substantial financial support from the City to maintain its public health mission and programs.
CITY OF BOSTON, MASSACHUSETTS, INFORMATION STATEMENT, Dated March 25, 2024
Boston Public Health Commission: The Boston Public Health Commission is a body politic and corporate and a political subdivision of the Commonwealth created in June 1996 as the successor to the City’s Department of Health and Hospitals. See “The City—Principal Government Services—Public Health.” The BPHC is responsible for the implementation of public health programs in the City and serves as the board of health of the City. In addition to its other powers, the BPHC is authorized by its enabling act, with the approval of the City Council and the Mayor, to borrow money for any of its corporate purposes from the City or from the Massachusetts Health and Educational Facilities Authority. Debt of the BPHC is not a debt or other obligation of the City. The BPHC has no debt currently outstanding. The BPHC has required, and can be expected to continue to require, substantial financial support from the City to maintain its public health mission and programs.
CITY OF BOSTON, MASSACHUSETTS, INFORMATION STATEMENT, Dated March 25, 2024
April 14, 2005 (CIDRAP News) – Despite 4 months of investigation, the source of bacteria that caused tularemia in three laboratory workers at Boston University remains a mystery, the Boston Public Health Commission (BPHC) has reported. The investigation into the three cases has led to some new safety precautions for microbiology researchers in the Boston area, however, according to the report by M. Anita Barry, MD, MPH, director of communicable disease control for the BPHC. In the coming months, the BPHC will take a number of steps to bolster monitoring and reporting of infectious diseases acquired on the job, noted John Auerbach, BPHC executive director, in the forward to the report. Steps include mandatory training, close monitoring of Boston University's improvement efforts, and training for research laboratory personnel. Most of the changes affect microbiology lab researchers throughout the Boston area, not just at Boston University. The following account of the event and conclusions of investigators are taken from the 15-page report: While studying a relatively benign strain of Francisella tularensis last year, three lab workers at the university fell ill. Two got sick in May, the third in September. Their symptoms were consistent with tularemia, which can cause fever, chills, malaise, low back pain, and chest pain. F tularensis is also considered one of a handful of pathogens with potential to be used as a biological weapon. The illnesses weren't reported until Nov 10. Authorities immediately launched an investigation that included the BPHC, the state health department, the Centers for Disease Control and Prevention (CDC), and the FBI. The investigation yielded some information on how the workers came to be infected through working with an attenuated laboratory strain not previously linked with human infection: they may have also been exposed to a wild strain of F tularensis found in some samples of their laboratory strain obtained from the University of Nebraska. But how the virulent bacteria found its way into the attenuated samples remains a mystery. The report said, "Testing at CDC continues in the effort to determine the time and place of contamination of the original vial. CDC is currently focusing its investigation on potential sources of the Type A tularemia outside Boston."
There is no evidence to suggest an intentional infection or contamination, Barry reported. However, she repeatedly noted concerns over a "routine failure to comply with safety protocols." The report's conclusions also include the following:
The outbreak was limited to three people and never posed a risk to the public
Failure to spot and quickly report work-related illness in lab staff is a major concern for health officials
Laboratory infection control practices must be clearly documented and enforced
In addition, the health commission is requiring that Boston University take several steps before it resumes tularemia research, including retraining workers on safety and modifying and strengthening standard operating procedures.
Inquiry leaves Boston tularemia mystery unsolved, April 14, 2005
There is no evidence to suggest an intentional infection or contamination, Barry reported. However, she repeatedly noted concerns over a "routine failure to comply with safety protocols." The report's conclusions also include the following:
The outbreak was limited to three people and never posed a risk to the public
Failure to spot and quickly report work-related illness in lab staff is a major concern for health officials
Laboratory infection control practices must be clearly documented and enforced
In addition, the health commission is requiring that Boston University take several steps before it resumes tularemia research, including retraining workers on safety and modifying and strengthening standard operating procedures.
Inquiry leaves Boston tularemia mystery unsolved, April 14, 2005
Massachusetts Homeopathic Medical Society records, 1840-1964 (inclusive). B MS c26
The Massachusetts Homeopathic Medical Society was incorporated in 1856; it developed from the Massachusetts Homeopathic Fraternity, organized by six physicians meeting in Dorchester, Mass. on December 25, 1840. The Society was the official homeopathic agent in the state; it sponsored a medical dispensary in Boston (incorporated in 1856 and opened in 1857), established the Boston University School of Medicine (opened in 1873) and appointed its faculty by nomination, founded a hospital (1871), and opened a nursing school (1885) near the medical school. The Society began publication of its annual transactions in 1867. Includes membership applications and lists of members; minutes of meetings; agendas and programs; treasurers' reports and reports of the necrologist and secretary; constitutions and bylaws; transcript of 1910 hearing before the Massachusetts State Sanatoria; and clippings containing notices of meetings.
https://collections.countway.harvard.edu/onview/index.php/collections/show/66
With the opening of the Boston University School of Medicine in 1873 and the adjacent Massachusetts Homeopathic Hospital in 1876, homeopathic medicine had an academic campus in the shadow of the Boston City Hospital. The homeopathic faculty that built up and nurtured BUSM, which included education in standard medical subjects as well as homeopathic theories, did a fine job.
https://blogs.bu.edu/busmhs/files/2019/09/ACESO-2018-2019-Final.pdf
The Massachusetts Homeopathic Medical Society was incorporated in 1856; it developed from the Massachusetts Homeopathic Fraternity, organized by six physicians meeting in Dorchester, Mass. on December 25, 1840. The Society was the official homeopathic agent in the state; it sponsored a medical dispensary in Boston (incorporated in 1856 and opened in 1857), established the Boston University School of Medicine (opened in 1873) and appointed its faculty by nomination, founded a hospital (1871), and opened a nursing school (1885) near the medical school. The Society began publication of its annual transactions in 1867. Includes membership applications and lists of members; minutes of meetings; agendas and programs; treasurers' reports and reports of the necrologist and secretary; constitutions and bylaws; transcript of 1910 hearing before the Massachusetts State Sanatoria; and clippings containing notices of meetings.
https://collections.countway.harvard.edu/onview/index.php/collections/show/66
With the opening of the Boston University School of Medicine in 1873 and the adjacent Massachusetts Homeopathic Hospital in 1876, homeopathic medicine had an academic campus in the shadow of the Boston City Hospital. The homeopathic faculty that built up and nurtured BUSM, which included education in standard medical subjects as well as homeopathic theories, did a fine job.
https://blogs.bu.edu/busmhs/files/2019/09/ACESO-2018-2019-Final.pdf
HARVARD UNIVERSITY MEDICAL SCHOOL
HMS had served Boston City since the hospital’s founding in the South End in 1864, but the School’s role expanded in the 1920s with the appointment of Francis Weld Peabody, Class of 1907, to lead its efforts there and to spearhead the construction of the Thorndike Lab, the first clinical research center in a U.S. municipal hospital. Named for surgeon William Thorndike, Class of 1848, the center housed a 17-bed ward for clinical research and two floors for laboratory investigations. For years, Boston City was affiliated with Harvard, Boston University, and Tufts Medical Schools and was widely acknowledged as a stimulating environment for clinical research, patient care, and medical education. During the pre-Medicare era, the hospital attracted “some of the sickest, poorest, saddest, and often drunkest people you can imagine,” notes Daniel Federman ’53, HMS Carl W. Walter Distinguished Professor of Medicine. Patients didn’t know how long they’d wait, but once seen, “they knew they would receive some of the kindest, most loving, most dedicated care on Earth.”
At Their Service: The Harvard Medical Unit created leaders in medicine, leaving a legacy of world-class teaching, research, and patient care, Harvard Medical School, (Winter 2014), https://magazine.hms.harvard.edu/articles/their-service
Finland and his infectious diseases group conducted seminal work on pneumonia, antibiotics, and hospital-acquired infections. This included rigorous studies of the efficacy and side effects of almost every antibiotic developed between the late 1930s and the 1970s, among them sulfonamides and penicillin. Finland’s team also documented the emergence of antibiotic-resistant bacterial organisms—in particular, gram-negative bacilli and Staphylococcus aureus—and their role in causing serious infections in patients at Boston City.
The School’s research enterprise at Boston City expanded in the early 1960s with the construction of the Channing Laboratory. Led for years by Kass and now part of Brigham and Women’s Hospital, Channing is a locus for research on infectious diseases and epidemiology. The Nurses’ Health Study was begun in 1976 by longtime lab member Frank Speizer, now the HMS Edward H. Kass Distinguished Professor of Medicine, when he headed Channing’s clinical epidemiology division.
Among other accomplishments of Channing investigators are studies that advanced the diagnosis and treatment of urinary tract infections. A team led by Kass in the mid-1980s found that toxic shock syndrome, a rare but debilitating, and sometimes fatal, bacterial infection, was triggered by magnesium deficiency, an imbalance that occurred when the mineral was absorbed from the body by fibers in certain tampons. Channing scientists also helped launch the East Boston Neighborhood Health Center, which was directed for more than 40 years by chronic disease epidemiologist James Taylor, and which remains one of the nation’s most successful community health centers.
At Their Service: The Harvard Medical Unit created leaders in medicine, leaving a legacy of world-class teaching, research, and patient care, Harvard Medical School, (Winter 2014), https://magazine.hms.harvard.edu/articles/their-service
HMS had served Boston City since the hospital’s founding in the South End in 1864, but the School’s role expanded in the 1920s with the appointment of Francis Weld Peabody, Class of 1907, to lead its efforts there and to spearhead the construction of the Thorndike Lab, the first clinical research center in a U.S. municipal hospital. Named for surgeon William Thorndike, Class of 1848, the center housed a 17-bed ward for clinical research and two floors for laboratory investigations. For years, Boston City was affiliated with Harvard, Boston University, and Tufts Medical Schools and was widely acknowledged as a stimulating environment for clinical research, patient care, and medical education. During the pre-Medicare era, the hospital attracted “some of the sickest, poorest, saddest, and often drunkest people you can imagine,” notes Daniel Federman ’53, HMS Carl W. Walter Distinguished Professor of Medicine. Patients didn’t know how long they’d wait, but once seen, “they knew they would receive some of the kindest, most loving, most dedicated care on Earth.”
At Their Service: The Harvard Medical Unit created leaders in medicine, leaving a legacy of world-class teaching, research, and patient care, Harvard Medical School, (Winter 2014), https://magazine.hms.harvard.edu/articles/their-service
Finland and his infectious diseases group conducted seminal work on pneumonia, antibiotics, and hospital-acquired infections. This included rigorous studies of the efficacy and side effects of almost every antibiotic developed between the late 1930s and the 1970s, among them sulfonamides and penicillin. Finland’s team also documented the emergence of antibiotic-resistant bacterial organisms—in particular, gram-negative bacilli and Staphylococcus aureus—and their role in causing serious infections in patients at Boston City.
The School’s research enterprise at Boston City expanded in the early 1960s with the construction of the Channing Laboratory. Led for years by Kass and now part of Brigham and Women’s Hospital, Channing is a locus for research on infectious diseases and epidemiology. The Nurses’ Health Study was begun in 1976 by longtime lab member Frank Speizer, now the HMS Edward H. Kass Distinguished Professor of Medicine, when he headed Channing’s clinical epidemiology division.
Among other accomplishments of Channing investigators are studies that advanced the diagnosis and treatment of urinary tract infections. A team led by Kass in the mid-1980s found that toxic shock syndrome, a rare but debilitating, and sometimes fatal, bacterial infection, was triggered by magnesium deficiency, an imbalance that occurred when the mineral was absorbed from the body by fibers in certain tampons. Channing scientists also helped launch the East Boston Neighborhood Health Center, which was directed for more than 40 years by chronic disease epidemiologist James Taylor, and which remains one of the nation’s most successful community health centers.
At Their Service: The Harvard Medical Unit created leaders in medicine, leaving a legacy of world-class teaching, research, and patient care, Harvard Medical School, (Winter 2014), https://magazine.hms.harvard.edu/articles/their-service
On July 1, 1996, Boston City Hospital (BCH), the city of Boston’s public acute care hospital, Boston Specialty and Rehabilitation Hospital (BSRH), a public long-term care hospital, and Boston University Medical Center Hospital (BUMCH), a private, non-profit hospital, consolidated their operations to form a new entity, Boston Medical Center (BMC), a private, non-profit 501(c)(3) corporation. Legislation authorizing the consolidation between the formerly public and private hospitals was introduced in the Massachusetts state legislature in July 1995. The legislation included a one-year sunset provision, according to which the city of Boston had to consolidate the operations of BCH and BSRH with BUMCH within one year or would lose its authority to do so. After a year of public debate and approval by the Boston City Council, the hospitals consolidated. According to the consolidation agreement, BSRH closed 90 days after the affiliation, and its services were consolidated with those of BCH. Located in Boston’s South End, BMC operates 432 licensed beds on its two contiguous campuses. The former BCH site is referred to as the Harrison Avenue campus and the former BUMCH site is referred to as the East Newton campus.
BCH had its own incentives to affiliate apart from the general trends in health and hospital care. City officials were concerned that BCH’s future revenue streams were in jeopardy, and that the city would not be able to support hospital operations with public funds indefinitely. For example, the federal government had been threatening throughout the early to mid-1990s to make cuts in Medicaid payments to disproportionate share hospitals (DSH), which provide care to large numbers of Medicaid and charity care patients. These threats eventually materialized under the Balanced Budget Act of 1997. Prior to the affiliation, BCH provided over one-third of the charity care in Massachusetts and, by far, the most charity care in the city of Boston. As a result, the hospital received substantial DSH payments. In addition, there had been talk of future plans to capitate reimbursement from the free care pool, of which BCH received the largest share in the state. Hospital administrators feared this might have further limited BCH’s public funding sources. With Medicaid eligibility expansions, and more individuals carrying insurance cards, officials also feared that new Medicaid enrollees might not continue to choose BCH as their hospital, particularly because it is considered Boston’s safety net hospital or hospital of last resort. Some respondents asserted that BCH wanted to disassociate itself from this image and attract a broader range of patients. Medicaid managed care expansions might further erode BCH’s patient base, as more and more patients would be able to obtain primary care in an office setting, rather than the hospital’s emergency department.
Because BCH was literally a department of the city government, many respondents claimed that BCH was not operated as efficiently as it could have been, particularly in the areas of purchasing, personnel, budget outlays, and long-term planning. According to one respondent, the city employees responsible for purchasing were not clinically trained or medically informed and did not know one piece of medical equipment from another. The individual felt this caused inefficiencies and delays in purchasing. In terms of budget outlays, one critic of the hospital’s public governance remarked that the city would never have understood the necessity of spending money for the services of a high-priced, specialty surgeon who would attract a broad range of patients and generate millions of dollars in revenues for the hospital. Respondents felt that BCH could not rapidly respond to changes in the health care industry, which were necessary to compete effectively for dollars and patients with larger hospitals or private hospital systems. City controllers knew that public hospitals around the country that remained under public governance were being forced to drastically reduce costs to survive or face closure.
In October 1995, the Massachusetts State Legislature approved legislation (HB 5336–1995 First Annual Session) authorizing the consolidation of BCH, BSRH, and BUMCH and creating the Boston Medical Center (BMC). The legislation also created the Boston Public Health Commission, a seven-member board created to continue the city’s public health responsibilities. As noted earlier, BSRH was closed and its services transferred to the BCH site 90 days after the consolidation State and city approval for the consolidation was necessary, as BCH was a public entity and controlled public assets. This fact guided the complex structure of the affiliation. On the BCH side, certain assets were transferred directly to BMC. These assets, deemed “a contribution of net assets” in the consolidation agreement, included cash, accounts receivable, inventory, and moveable equipment totaling $58.7 million. Other public assets, however, required judicial approval for transfer. For example, trust fund assets pledged to BCH from private trusts, totaling $24 million, had to be transferred to BMC under cy pres proceedings, in which a court determines that the literal and intended use of the trust funds is no longer practical or possible and that the assets will be used for similar charitable purposes by the new private entity. Massachusetts’ attorney general supervised this redirection of public funds.
The physical plant of BCH was transferred under a different structure. In 1987, the city decided to rebuild BCH’s inpatient facility (the building opened in January 1994). The rebuilding was financed through a Housing and Urban Development-guaranteed/Health and Human Services-approved loan. Pursuant to the consolidation negotiations and agreement, the obligation for this debt remained with the city. Consequently, when Boston’s Department of Health and Hospitals (DHH) was dissolved at the time of the consolidation, the lease of the BCH facility was transferred from DHH to the Boston Public Health Commission, and BMC leases the facility from the commission. The lease payments are used to repay the city’s HUD loan. BMC now has a 50-year lease of the BCH facilities and premises with four 10-year renewal options. Hence, the lease is considered a 90-year lease. The transfer of BUMCH assets was simpler because it was a private institution. All of the assets and liabilities of BUMCH and its subsidiaries merged into BMC through a statutory merger, which is a merger defined and guided by state corporate law.
BCH and BUMCH were separately-owned hospitals prior to the affiliation. BCH was a cityowned and operated acute care hospital since it opened in 1864. As a public hospital mandated to care for all patients regardless of their ability to pay, BCH served mostly indigent and Medicaid patients. BCH was essentially a department of the city government, as it was operated under the Department of Health and Hospitals (DHH) and had no separate legal existence from the city. The board of trustees of DHH, which had nine community-based members appointed by the mayor, had authority over the city’s two public hospitals—Boston City Hospital and Boston Specialty and Rehabilitation Hospital. DHH also had responsibility for the city’s public health activities. BUMCH opened its doors in 1855 and had various names throughout the past century. Today, it is alternately referred to as University Hospital or BUMCH. BUMCH was a private, non-profit hospital located on the campus of, but not owned by, Boston University’s School of Medicine. BUMCH was a tertiary care medical center, with a patient base primarily comprised of suburban referrals. BUMCH had a board of trustees separate from the University
Boston Medical Center, the new entity formed by the consolidation of BCH and BUMCH, is a private, non-profit corporation. BMC is governed by a 30-member board of trustees, who are appointed according to their class designation. Class A board members are the 10 members. appointed by the mayor of Boston. Class B board members are the 10 individuals appointed by BUMCH’s board of trustees. There are six Class C members, which all serve in an ex officio capacity. Class C members are the executive director of the Public Health Commission, the dean of BU’s School of Medicine; the CEO of BMC; the president of the medical staff of BMC; the physician in chief of BMC; and the surgeon in chief of BMC. There are four Class D Board members, who are nominated by the neighborhood health centers in Boston HealthNet (the city’s network of community health centers), and must be a senior official or physician of one of the health centers in the network.
The two biggest issues facing BMC in the future are the physical consolidation of the two facilities and the cultural consolidation of the patient population and physician staff of the two hospitals. These issues have been the biggest barriers to complete consolidation of BCH and BUMCH and full realization of potential economies of scale.
Privatization of Public Hospitals, Prepared for The Henry J.Kaiser Family Foundation by: The Economic and Social Research Institute (Jan. 1999).
BCH had its own incentives to affiliate apart from the general trends in health and hospital care. City officials were concerned that BCH’s future revenue streams were in jeopardy, and that the city would not be able to support hospital operations with public funds indefinitely. For example, the federal government had been threatening throughout the early to mid-1990s to make cuts in Medicaid payments to disproportionate share hospitals (DSH), which provide care to large numbers of Medicaid and charity care patients. These threats eventually materialized under the Balanced Budget Act of 1997. Prior to the affiliation, BCH provided over one-third of the charity care in Massachusetts and, by far, the most charity care in the city of Boston. As a result, the hospital received substantial DSH payments. In addition, there had been talk of future plans to capitate reimbursement from the free care pool, of which BCH received the largest share in the state. Hospital administrators feared this might have further limited BCH’s public funding sources. With Medicaid eligibility expansions, and more individuals carrying insurance cards, officials also feared that new Medicaid enrollees might not continue to choose BCH as their hospital, particularly because it is considered Boston’s safety net hospital or hospital of last resort. Some respondents asserted that BCH wanted to disassociate itself from this image and attract a broader range of patients. Medicaid managed care expansions might further erode BCH’s patient base, as more and more patients would be able to obtain primary care in an office setting, rather than the hospital’s emergency department.
Because BCH was literally a department of the city government, many respondents claimed that BCH was not operated as efficiently as it could have been, particularly in the areas of purchasing, personnel, budget outlays, and long-term planning. According to one respondent, the city employees responsible for purchasing were not clinically trained or medically informed and did not know one piece of medical equipment from another. The individual felt this caused inefficiencies and delays in purchasing. In terms of budget outlays, one critic of the hospital’s public governance remarked that the city would never have understood the necessity of spending money for the services of a high-priced, specialty surgeon who would attract a broad range of patients and generate millions of dollars in revenues for the hospital. Respondents felt that BCH could not rapidly respond to changes in the health care industry, which were necessary to compete effectively for dollars and patients with larger hospitals or private hospital systems. City controllers knew that public hospitals around the country that remained under public governance were being forced to drastically reduce costs to survive or face closure.
In October 1995, the Massachusetts State Legislature approved legislation (HB 5336–1995 First Annual Session) authorizing the consolidation of BCH, BSRH, and BUMCH and creating the Boston Medical Center (BMC). The legislation also created the Boston Public Health Commission, a seven-member board created to continue the city’s public health responsibilities. As noted earlier, BSRH was closed and its services transferred to the BCH site 90 days after the consolidation State and city approval for the consolidation was necessary, as BCH was a public entity and controlled public assets. This fact guided the complex structure of the affiliation. On the BCH side, certain assets were transferred directly to BMC. These assets, deemed “a contribution of net assets” in the consolidation agreement, included cash, accounts receivable, inventory, and moveable equipment totaling $58.7 million. Other public assets, however, required judicial approval for transfer. For example, trust fund assets pledged to BCH from private trusts, totaling $24 million, had to be transferred to BMC under cy pres proceedings, in which a court determines that the literal and intended use of the trust funds is no longer practical or possible and that the assets will be used for similar charitable purposes by the new private entity. Massachusetts’ attorney general supervised this redirection of public funds.
The physical plant of BCH was transferred under a different structure. In 1987, the city decided to rebuild BCH’s inpatient facility (the building opened in January 1994). The rebuilding was financed through a Housing and Urban Development-guaranteed/Health and Human Services-approved loan. Pursuant to the consolidation negotiations and agreement, the obligation for this debt remained with the city. Consequently, when Boston’s Department of Health and Hospitals (DHH) was dissolved at the time of the consolidation, the lease of the BCH facility was transferred from DHH to the Boston Public Health Commission, and BMC leases the facility from the commission. The lease payments are used to repay the city’s HUD loan. BMC now has a 50-year lease of the BCH facilities and premises with four 10-year renewal options. Hence, the lease is considered a 90-year lease. The transfer of BUMCH assets was simpler because it was a private institution. All of the assets and liabilities of BUMCH and its subsidiaries merged into BMC through a statutory merger, which is a merger defined and guided by state corporate law.
BCH and BUMCH were separately-owned hospitals prior to the affiliation. BCH was a cityowned and operated acute care hospital since it opened in 1864. As a public hospital mandated to care for all patients regardless of their ability to pay, BCH served mostly indigent and Medicaid patients. BCH was essentially a department of the city government, as it was operated under the Department of Health and Hospitals (DHH) and had no separate legal existence from the city. The board of trustees of DHH, which had nine community-based members appointed by the mayor, had authority over the city’s two public hospitals—Boston City Hospital and Boston Specialty and Rehabilitation Hospital. DHH also had responsibility for the city’s public health activities. BUMCH opened its doors in 1855 and had various names throughout the past century. Today, it is alternately referred to as University Hospital or BUMCH. BUMCH was a private, non-profit hospital located on the campus of, but not owned by, Boston University’s School of Medicine. BUMCH was a tertiary care medical center, with a patient base primarily comprised of suburban referrals. BUMCH had a board of trustees separate from the University
Boston Medical Center, the new entity formed by the consolidation of BCH and BUMCH, is a private, non-profit corporation. BMC is governed by a 30-member board of trustees, who are appointed according to their class designation. Class A board members are the 10 members. appointed by the mayor of Boston. Class B board members are the 10 individuals appointed by BUMCH’s board of trustees. There are six Class C members, which all serve in an ex officio capacity. Class C members are the executive director of the Public Health Commission, the dean of BU’s School of Medicine; the CEO of BMC; the president of the medical staff of BMC; the physician in chief of BMC; and the surgeon in chief of BMC. There are four Class D Board members, who are nominated by the neighborhood health centers in Boston HealthNet (the city’s network of community health centers), and must be a senior official or physician of one of the health centers in the network.
The two biggest issues facing BMC in the future are the physical consolidation of the two facilities and the cultural consolidation of the patient population and physician staff of the two hospitals. These issues have been the biggest barriers to complete consolidation of BCH and BUMCH and full realization of potential economies of scale.
Privatization of Public Hospitals, Prepared for The Henry J.Kaiser Family Foundation by: The Economic and Social Research Institute (Jan. 1999).