The University of Michigan, an encyclopedic survey ... Wilfred B. Shaw, editor.

THE UNIVERSITY HOSPITAL

IN 1869, almost two decades after the establishment of the Department of Medicine and Surgery in the University, the first little hospital on the campus was authorized. The idea of utilizing hospitals as centers of clinical training had developed slowly in this country, although bedside hospital teaching was highly advanced in Europe, especially in Germany and in France.

A few medical schools, notably Yale, Harvard, and Virginia, arranged to have their students use the local hospitals for clinical study, but a report by Professor Cabell, of the University of Virginia, reprinted in the Peninsular Journal of Medicine, maintained that "the plan of making clinical instruction follow, instead of accompany, elementary teaching is so obviously the natural and effective plan, that all our better students adopt it in spite of the absurd attempts of the schools to impose upon them a different system" (R.P., 1837-64, p. 776).

The number of adequately equipped hospitals was small, and the difficulties of maintaining them in connection with medical schools seemed at that time insuperable. The schools themselves, for the most part small proprietary institutions scattered over the country, were very weak and depended almost entirely upon student fees for their support. Instruction was, therefore, almost entirely by lectures.

In the early years of the University of Michigan Medical School, then called the Department of Medicine and Surgery, the few patients who came for treatment to members of the medical faculty gave some semblance of the clinical instruction advertised in the Announcement. The main emphasis, however, was on didactic instruction; clinical instruction was in practice a negligible part of the program. The prevailing lecture system was considered the only acceptable method as far as work in the University was concerned. Although the desirability of actual bedside experience for the young physician was recognized, it was difficult to obtain such instruction except under the supervision of a preceptor — an established practitioner with whom the young doctor served an apprenticeship as assistant.

The Regents, not unmindful of the increasing public demand for a hospital, in March, 1861, asked the medical faculty to submit a plan for the conversion of one of the faculty residences on the campus into a hospital. The faculty, however, took no action, and the committee was discharged the following June. During the Civil War, because of the large number of wounded treated in Army hospitals, the public became more aware of the need for hospitals. The Regents in 1864 considered the establishment of a military hospital in Ann Arbor, but no action was taken in the matter, probably because the end of the war was in sight.

After 1865 a great increase in medical school enrollment in this country resulted in further agitation both for bedside hospital instruction and for expert care. In 1868 the medical faculty reported that even though there were no hospital facilities available, over three hundred patients, more than six times the number cared for in any previous year, had come to the University for consultation and help.

In 1868 Dr. A. B. Palmer, Professor of the Theory and Practice of Internal Medicine, headed a movement in the

American Medical Association to obtain more clinical instruction in American medical schools. As a result of his efforts, as well as of the increasing community demand in Ann Arbor for a hospital, the faculty finally asked to be allowed to establish a hospital. The Regents authorized, in 1869, the use of the northeast professorial residence on the campus for that purpose, at a total expense of $582.18 for necessary changes. This building, which afforded room for about twenty beds, was a small two-story, stucco structure, with two rooms on each floor opening from either side of a central hall.

In the words of Dr. Victor C. Vaughan, this little hospital was "nothing more than a receiving home, in which patients brought in for the clinics could be kept before and after presentation to the class. There were no wards and no operating or dressing rooms, no place where students might receive bedside instruction" (Vaughan, A Doctor's Memories, pp. 197-98). While such a makeshift was not well adapted for hospital purposes, it was a significant beginning because it represented a most important landmark in the history of American medicine — the first instance of a university owning and controlling a hospital in connection with its own medical school. The University Hospital has remained entirely under the control of the Regents and of the Medical School and has provided teaching facilities under the most favorable conditions.

Before the opening of the University in the fall of 1869, Dr. Abram Sager, Dean of the Medical School, submitted a plan for the management of the new Hospital which indicated that the faculty proposed to utilize all of the patients who applied, rich and poor alike, as material for clinical study. This rule was changed later at the insistence of the medical profession of the state, so as to exclude as far as possible those able to pay a minimum fee for professional services. Nevertheless, until about 1920, all who entered the Hospital did so with the understanding that they were to be used, if necessary, for teaching purposes. The charge for maintenance was to be placed at the lowest rate consistent with the avoidance of actual loss. This was the basis of a long-standing argument among the Regents, who insisted that the Hospital be self-supporting, and the clinical faculty, who maintained that low hospital charges were necessary to furnish the maximum amount of teaching material.

The Campus Pavilion Hospital, 1876-91. — The original little campus residence Hospital, although inadequate, served its purpose by demonstrating that such an addition to the facilities of the school was both desirable and practicable. Efforts to secure a legislative appropriation for a larger hospital resulted in 1875 in a grant of $8,000 for an enlarged University Hospital, contingent upon a contribution of $4,000 from the city of Ann Arbor. Within a year the new Hospital was opened. It provided sixty beds and was widely heralded, although actually rather a sorry affair, judged by modern standards, consisting of two frame pavilions 114 feet long and 30 feet wide, which extended from the rear of the original little Hospital. Without a basement, poorly ventilated, originally without an operating room, it was typical of the era and was, in fact, designed to last only five years.

At first the Hospital had been kept open only six months of the year, but eventually special support from the legislature, first granted in 1877, permitted full-time operation. It was, however, closed for many summer periods during the succeeding two decades. In 1897 summer operation was made the condition of continuing legislative support for the Hospital.

The Regents directed in 1878 that one-fifth of the beds available be assigned to patients of the newly created Homeopathic faculty. This resulted in an increase in the total number of beds to about seventy. In 1879 an appropriation was made for converting another residence on the north side of the campus into a Homeopathic hospital. The University Hospital thus recovered all the ward space in the original pavilion building. At this time funds were granted for further expansion and for the building of an operating amphitheater and of a dining room and kitchen in connection with the matron's home. In 1881 an eye and ear ward was added — the first special ward to be erected as a separate building. The "older [or residence] portion of the Hospital [was] occupied by the Resident Physician, Matrons, and private rooms for very sick patients" (R.P., 1881-86, pp. 223-24).

This enlarged Hospital remained the center of clinical instruction of the Department of Medicine and Surgery until 1891, a period of fifteen years. It provided for the clinics which were gradually developing — in medicine under Dr. A. B. Palmer, in surgery under Dr. Donald Maclean, in obstetrics under Dr. Edward S. Dunster, and in the new field of eye and ear service under Dr. George E. Frothingham. After 1891 this old campus building was utilized for many years by the College of Dental Surgery before it was torn down to make room for the present Chemistry Building.

The Catherine Street Hospital, 1891-1925. — Throughout almost the entire life of the campus Pavilion Hospital, agitation continued for better hospital facilities. It was not until 1889, however, when the city of Ann Arbor once more came forward with a contribution of $25,000 to augment an appropriation of $50,000 by the legislature, that the construction of an entirely new hospital on Catherine Street was made possible. This building, completed in 1891, although a great improvement over the old Hospital, was designed before hospital architecture had become a specialty, and there were many architectural faults, corrected to a certain extent as additional buildings were added.

Eventually, the old Hospital group, as it is still called, comprised a congeries of some twenty buildings, large and small. Originally, two main structures were erected on the site, one on the east for the Medical Department and one on the west for the more recently established and smaller Homeopathic Medical College, which demanded facilities equal to those of the Department of Medicine and Surgery. The small heating plant built between these two buildings proved inadequate to the growing needs of the Hospital, and a larger heating plant (the present Wood Utilization Laboratory) was erected at the rear of the group in 1897. The new heating plant permitted the alteration and extension of the old building which was remodeled and used continuously as a home for nurses from 1898 until Couzens Hall was opened in 1925.

When the new Homeopathic Hospital on North University Avenue was occupied in 1900, the west building of the Catherine Street group, which had been the Homeopathic Hospital, became the Medical Ward of the University Hospital, and the Department of Surgery took over practically the entire east building, which for the past nine years had been the University Hospital. The Surgical Ward, the Nurses' Residence, and the Medical Ward were then connected by corridors. The westernmost of these three buildings, the first Medical Ward, was destroyed by fire in 1927. Some of the congestion in the Hospital was relieved in 1896 by the erection of a small office building, the capacity of which was

more than doubled by an addition made in 1918.

In 1901 Mrs. Love Maria Palmer, widow of Dr. Alonzo B. Palmer, bequeathed $20,000 to establish a special ward as a memorial to her husband, and an additional $15,000 as an endowment for its support and for the maintenance of free beds. This building, which was opened in 1904 and formally dedicated in 1907, was placed directly in front of the nurses' home and made a part of that building. It was known as the Palmer Ward and was assigned to the surgical and medical care of children. Originally, it provided sixty-four beds. As few children were referred to the Hospital at first, much of the new wing was used to house nurses and to accommodate maternity cases. An X-ray laboratory was set up in the basement.

Upon the urgent representations of the heads of the clinics in ophthalmology and otolaryngology, a new building to serve as an eye and ear ward was recommended by the Hospital Committee in 1904. It was not until 1909, however, that $25,000 was voted by the Regents for this purpose. In addition, equipment was later purchased for $9,000. This ward was completed in 1910 and was connected with the main building by a covered passageway.

In the early days of the Hospital, the question of contagious diseases was always serious, and pressure from the community for a contagious disease hospital speedily developed. Nevertheless, this need was not met until 1897, when a small building north of the new Homeopathic Hospital, formerly a laundry, was converted into the University's first separate contagious disease hospital. This primitive structure could accommodate only the few patients who contracted contagious diseases while in the various hospital wards, and when an epidemic of smallpox developed in the city of Ann Arbor in 1908 patients perforce were isolated in another hastily prepared building.

The situation did not improve until 1914, when, following an appropriation of $25,000 for this purpose by the city, a contagious disease hospital was built northeast of the hospital group. Two houses which had been moved near the Hospital and designed originally for patients with contagious diseases were never used for that purpose, but were soon taken over as housing for maternity patients.

A separate building for each contagious disease was out of the question because the expense of separate units would have been about four times the amount voted by the city. A hospital in Providence, Rhode Island, had undertaken the treatment of a variety of contagious diseases under one roof, however, and such a hospital, 40 by 100 feet, was designed by J. H. Marks, then Superintendent of the University Buildings and Grounds Department. A nurse was sent to Providence to learn the technique of directing such a hospital, and the system was inaugurated and carried out by Dr. D. M. Cowie. Under his skillful administration there were few cross-infections.

A very substantial increase in the actual facilities of the Hospital came through the authorization of a Psychopathic Hospital by the state in 1901. It was completed in February, 1906. This building, maintained by the state and not by the University, was erected east of the Hospital group of buildings and accommodated forty patients. It was described as follows:

The Legislature of Michigan at its last session … made provision for an addition to the University Hospital of a ward especially equipped for the care of a limited number of acute cases of insanity. This was done with the view of furnishing an opportunity

for the more thorough study of the conditions attending insanity in its incipient stages, and with the hope that, by the aid of specialists in all branches of medicine and surgery, and the laboratory facilities available at the University Hospital, there might result the discovery of causes of these diseases at present unknown, and the development of methods of treatment that might increase the number of cures. The advantages to the medical student of such an addition to our hospital are apparent to all.

Announcement of the Department of Medicine and Surgery

With a laboratory and an addition for violent patients, this was the State Psychopathic Hospital until the legislature in 1937 turned it over to the University.

Facilities for the clinic in obstetrics and diseases of women and children were at first practically nonexistent, but by the time the first campus Hospital was built, an increasing number of cases was reported every year. In 1903 provision had been made for temporary housing of maternity cases in Palmer Ward, but this was a makeshift arrangement, and in 1906 a building originally moved from North University Avenue was utilized by the Department of Obstetrics. A second building was moved to an adjacent site in 1908. These two frame houses were in use until the old Eye and Ear ward of 1910 was rearranged for the care of obstetrical patients in 1925.

A small frame dermatology ward, providing space for twenty-five beds, erected in 1918 at the rear of Palmer Ward, was the last addition to the old Hospital group. Of temporary construction, it was torn down in 1932.

Despite its many drawbacks, scattered buildings, long passageways, crowded wards, and unsanitary corners, the old Catherine Street Hospital group, during a period of nearly thirty-five years, had become one of the great teaching hospitals of the country. As in the case of the earlier hospitals, however, the obvious deficiencies of the Hospital and the ever-increasing demands upon it, once more led to agitation for new and better facilities.

The present University Hospital. — In 1915 the Regents appropriated the sum of $1,500 to cover the expense of plans for a new hospital. The legislature, in December, 1916, was asked for an appropriation of $1,050,000, to be distributed in equal payments over a period of six years, for construction of the hospital. The request was granted in the spring of 1917. Albert Kahn, of Detroit, was designated as the architect for the building.

In the meantime Dr. Peterson, then engaged in war duties, resigned as Medical Director, so that a medical superintendent and director could be secured who would give his whole time to the Hospital and superintend the plans and specifications for the new building. Dr. Christopher G. Parnall ('02, '04m) was appointed Medical Superintendent in April, 1918, and with his coming the whole scheme of management of the Hospital was changed. At that time yearly admissions numbered approximately nine thousand patients.

Early in 1919 the University acquired a site for the Hospital on Ann Street, a block south and east of the old Hospital on the hills overlooking the Huron Valley, and early in 1920 the construction of the new building was under way. The original plan to erect the building by units as the successive appropriations of $350,000 for each biennium were made available was found impracticable, and it was constructed as one unit, designed for six hundred beds. The shell of the Hospital was completed in 1921, but, unfortunately, no more funds were available, and for two years the building remained with the windows boarded up, until a further appropriation of $2,300,000 in 1923 permitted its completion. When the Hospital was actually ready

and equipped in 1925, it represented an expenditure of $4,440,000.

On August 12, 1925, 597 patients were moved from the old buildings on Catherine Street, and a new era began in the history of University Hospital. In his report for the year 1924-25, Harley Haynes ('02m), who in September, 1924, had succeeded Dr. Parnall as Director of the Hospital, stated that 23,010 patients had been registered in the Hospital, about half of them inpatients and half of them outpatients. Couzens Hall, the nurses' residence, was also completed in 1925.

The opening of the present Hospital inaugurated an expanding program. The clinics in the old Hospital were all given new quarters carefully designed for their special requirements, and new clinics were gradually organized.

When the older Hospital was built in 1891, it was one of the few large hospitals of the country and one of the very few maintained under university auspices, but hospital design and methods of hospital administration had made such great advances that it had become very unsatisfactory. The new University Hospital was at once recognized as one of the most up-to-date institutions in the country, skillfully designed both for the care of the sick and for medical instruction. Its facilities were utilized almost from the first days of occupancy, and usually there has been a waiting list of patients.

The building is 460 feet long and is constructed of light sand-colored brick with stone trimmings. It has branching wings at either end, which give it the general form of a double Y (> — <) connected at the stems. Its thirteen stories are carried on regularly spaced piers which form the units for the separation of wards, classrooms, laboratories, and offices. The main structure comprises nine stories with an additional sub-subbasement devoted to shops and storage, two floors over the central section forming a one-hundred-bed tuberculosis unit, with a smaller unit on the roof forming a thirteenth story, designed as a recreation center and school for crippled children.

A three-story administration wing rises directly before the main building. At the rear are a large ten-story surgical wing, a five-story Neuropsychiatric Institute, and an interns' home, built since the original construction of the Hospital. All are connected with the main building by a long corridor so that they form, in effect, integral parts of the Hospital. The two additional floors devoted to the care and treatment of tuberculosis were added in 1931, the Neuropsychiatric Institute in 1937, and the interns' home in 1939. Other minor additions have been a small animal house built in 1925, a root-cellar addition in 1927, and a building for storage of inflammable X-ray film in 1929. Additional storage space, a machine room, and a penthouse for the elevator machinery were added in 1939.

The building stands at the crest of the line of hills which define the Huron Valley, so that the rear is actually several stories higher above the ground than is the front of the building, thus giving added light and ventilation to the lower floors. The first floor of the main building and the ground floor and the first floor of the surgical wing constitute a diagnostic clinic in which every department of the Hospital is represented. Here all patients are examined and referred to the proper department for treatment. The main entrance to the Hospital is through the administration section, to the second floor, on which are the general offices and nurses' headquarters. On the floor below are the general administration, finance, and social service offices. There is space in the basement for the storage of records.

The Hospital has 823 beds, some of

which are in private rooms. The ten acres of floor space include wards, laboratories, operating and diagnostic rooms, and offices. With land and equipment the Hospital cost about $5,350,000. The value of the old hospital group on Catherine Street is given in the University inventory at about $400,000. These old buildings have since been used as convalescent wards and special research laboratories.

The number of patients admitted to the Hospital clinics in 1938-39 was approximately 24,000. An additional 30,000 were treated in the outpatient department. This number dropped sharply in 1939-40 because of a change in the state law which effected a reduction in the amount paid for the care of patients referred by the counties and state, so that more patients were sent to local hospitals and infirmaries. In that year admissions dropped to 16,500, with nearly 27,000 outpatients.

Clinical services. — From the opening of the Department of Medicine and Surgery in 1850, persons suffering from various ailments either applied for diagnosis and treatment or were brought to Ann Arbor by their doctors. These patients, at first not more than fifty or sixty a year, consulted the medical faculty on Saturday mornings, when they were demonstrated "before the class." As previously mentioned, this was a negligible part of the instruction.

There was no hospital, however, for nearly twenty years, and such operations as were necessary were performed in the anatomical lecture room, and patients were cared for by relatives, medical students, or untrained nurses. Since this was before the days of antisepsis, there seemed no incongruity in operating in an anatomical lecture room. Even when the first little Hospital on the campus was enlarged and became the Pavilion Hospital in 1876, no operating room was included, and the old arrangements prevailed until the Homeopathic Medical College, in 1879, equipped its new hospital with an operating amphitheater, whereupon the "regulars" were given a similar addition to their hospital.

For a few years after the Department of Medicine and Surgery was established in 1850, it was stated in the medical Announcement: "Clinical instruction, it is believed, is far better imparted in … private practice … The hasty walk through the wards of a hospital … furnishes but a sorry substitute for the close and accurate study of cases …" The statement was dropped in 1857, which can be taken as indirect evidence of a growing realization of the importance of clinical instruction. Another evidence is the establishment of a summer clinical course in Detroit in 1857 by Dr. Zina Pitcher. This was discontinued after two years, despite the appeal of forty students for a continuation of the course in Detroit.

General recognition of the necessity for clinical instruction was growing, although the faculty for the most part clung to the old didactic methods of teaching. The American Medical Association held a convention in 1867 to consider suggested reforms in medical education. Dr. Alonzo Palmer was a delegate to it. A graded medical course of three years was recommended, each year to have a minimum duration of six months, and the third year to be devoted to clinical instruction in a hospital. These recommendations were laid before the Regents.

In 1868 Palmer, as chairman of the Committee on Medical Education, in a report to the American Medical Association, stated:

[The importance of clinical instruction can] scarcely be exaggerated [but] clinical medicine cannot be properly pursued while the student is listening to from five to seven

didactic lectures a day … If the present system of short courses of lectures be continued, the most imperative need … is the establishment of distinct schools of clinical instruction … where students shall be required to attend before presenting themselves for graduation.

Trans. Amer. Med. Assn.

These progressive steps were not realized immediately. It was not until 1880 that the three-year course was required at Michigan, though the third year was suggested in 1875 and offered as an option in 1877. But in these measures can be seen the germ of the present medical curriculum in which the third and the fourth years are given increasingly to clinical instruction in the Hospital.

The question of financing a hospital was a major problem. After their unsuccessful attempt to have an Army hospital established in Ann Arbor, the Regents became interested in the possibility of a state hospital for indigent patients in connection with the University, but nothing came of these plans.

Though a few patients came to the University even before the first Hospital was opened, little in the way of clinics in the modern sense existed. The clinics originally associated with the Hospital were indicated by the titles of the first professorships, but it was probably not until 1880, when the amphitheater of the campus Hospital was completed and the additional title of clinical professor was given to the professors of internal medicine, surgery, obstetrics, and ophthalmology, that the first real steps toward systematic clinical instruction were taken. As new members of the faculty specializing in different fields were appointed other clinics came to be established.

Internal Medicine and Pediatrics. — By 1860, when Alonzo B. Palmer took charge of the didactic and clinical instruction in internal medicine, students were given some opportunity to study cases, and up to the time of his death in 1887 many improvements were made in conditions affecting the efficiency of all the clinical departments. Several of these took place within the twelve years when he was Dean — the building of the amphitheater, the recognition and fostering of the departmental clinics, the passage of a law authorizing the treatment of dependent children in the University Hospital at state expense, and the extension of the medical course from two six-month terms to three full college years, partly with a view to providing throughout the senior year frequent bedside instruction accompanied by clinical lectures.

George Dock, who became head of the Department of Theory and Practice in 1891, built up a laboratory of clinical medicine for the dual purpose of carrying out instrumental investigations of disease and for teaching techniques of diagnosis, and his success in making laboratory work an important part of the study of clinical medicine led to the adoption of similar teaching devices in the other clinical departments.

The erection of Palmer Ward made possible the organization of a special children's clinic in 1906 within the Department of Internal Medicine. The work in both pediatrics and contagious diseases was separated from that in general medical practice by the formation of a new department under Cowie in 1921.

Dock was followed in 1908 by Albion W. Hewlett, who before his resignation in 1916, added new equipment, particularly for the study of the cardiovascular system. In 1916-17 the medical clinic was headed by Nellis D. Foster. He in turn was succeeded by Louis H. Newburgh, acting head of the Department of Internal Medicine. Imbued with the idea that investigation and research are essential to a growing clinic, Newburgh

carried on studies in diabetes which led the Rockefeller Foundation to give funds for a diet kitchen, a dining-room for diabetic patients, and a small laboratory. This simple clinic was the forerunner of the present diet therapy clinic. Studies in metabolism and heart diseases were inaugurated with the purchase of an electrocardiograph and the establishment of a heart station. Newburgh was succeeded in 1922 by Louis M. Warfield, who resigned, however, in 1925 to return to private practice.

With the opening of the Palmer Ward for children, the demands of pediatrics developed so rapidly that the number of patients grew from fewer than fifty in 1905 to more than 2,300 in 1920. This necessitated the removal of the maternity cases to two dwelling houses near the Hospital, which had been fitted up for that purpose, so that the first floor of Palmer Ward in 1911 was finally given over entirely to pediatrics. A new food laboratory, diet kitchen, and pediatrics laboratory in the basement were added. By 1913 the nurses on the two upper floors of Palmer Ward were also compelled to find quarters elsewhere, and the space thus gained, together with the passageways leading to the building on each side, was used for children. In 1907 an orthopedic ward had also been opened in the building.

Upon the completion of the new Hospital in 1925, the children's ward was removed to the sixth floor of the new building, where a tablet marked it as the Palmer Ward, in memory of Dr. Palmer and in recognition of Mrs. Palmer's generous gift a quarter of a century earlier.

The first professorship in obstetrics and gynecology included the diseases of children. A separate clinic in pediatrics was not established until some years after the completion of the Palmer Ward in 1905. Dr. D. M. Cowie became Clinical Professor of Pediatrics and Internal Medicine in 1907 and continued in charge of this clinic until his death in 1940. Cowie was also in charge of the program in infectious diseases after the erection of the Contagious Disease Hospital, for which funds were given by the city of Ann Arbor in 1913. He was made Professor of Pediatrics and Infectious Diseases in 1921.

Children had been treated in the University Hospital before 1908, but it was not until Dr. Cowie's appointment that they were reported separately by the Department of Internal Medicine. The clinic grew with the large number of patients referred to it under the state laws, particularly those of 1927 authorizing care of crippled children in the state. When the laws were changed in 1939 under Act No. 283, and the appropriations for the care of children were reduced, the number of children referred to the University Hospital substantially decreased.

Dr. Cowie was succeeded by Dr. Charles Fremont McKhann as Professor of Pediatrics and Communicable Diseases and chairman of the department.

To expand further the service of the University Hospital for sick and crippled children, the Northern Michigan Children's Clinic at Marquette (a unit supported by the Children's Fund of Michigan), was designated by the Regents in 1931 as a part of the University Hospital, and the acceptance of children for state care by the clinic was authorized. A similar action for the Central Michigan Children's Clinic at Traverse City was taken in 1936. Each of these clinics in 1940 represented the expenditure of some $5,000 annually.

The appointment of Dr. James D. Bruce as Director of Internal Medicine and Chief of the Medical Service almost exactly coincided with the opening of the new Hospital. He came shortly after the receipt of the endowment of the Thomas

Henry Simpson Memorial Institute for Medical Research, which enlarged the already extensive fields of research carried on in internal medicine. When the Regents approved the establishment of the Department of Postgraduate Medicine, Dr. Bruce was named its head, to begin the organization of the department during the year 1927-28. Dr. C. C. Sturgis, who in 1927 had been named Director of the Simpson Memorial Institute, in 1928 became Director of the Department of Internal Medicine.

The second floor of the Hospital is occupied for the most part by the internal medicine service. An important offshoot of this clinic, the Heart Station, was set up in a part of the basement of the surgical wing. This clinic was inaugurated in 1921 on Dr. Newburgh's initiative, and Dr. Frank N. Wilson, a recognized authority on diseases of circulation, was appointed Associate Professor of Internal Medicine and made responsible for further research and use of the electrocardiograph. In a comparatively short time the equipment was increased, and in the new Hospital the Heart Station has become an important aid to diagnosis.

The clinic for the study of tuberculosis was also first developed under the Department of Internal Medicine. Two floors were added to the Hospital in 1931 to care for this program.

Surgery. — After the resignation of Moses Gunn, the first Professor of Surgery, in 1867 and a series of short incumbencies, Donald Maclean was obtained as Lecturer in Surgery in 1872 and in the following year was appointed Professor of Surgery. In 1880 as head of the "surgical clinique" (R.P., 1876-80, pp. 531-37), he reported to the Regents that clinics were held daily, that almost every form of "surgical affection" was presented, and that treatment was "practically illustrated." Maclean was succeeded in 1889 by Charles De Nancrède, whose skill as a surgeon gave the clinic an outstanding reputation for more than a quarter of a century. When the former University Hospital Building became the Surgical Ward in 1900, an amphitheater and three smaller operating rooms were made available. As early as 1897 emphasis had been placed upon improved methods of sterilization, and the use of X-ray apparatus, loaned to the University, proved invaluable in surgical diagnosis. Under De Nancrède, a surgical laboratory was established which increased facilities and stimulated original investigations.

Specialization within the Department of Surgery was placed upon a substantial foundation by the appointment of Ira D. Loree as Clinical Professor of Genitourinary Surgery in 1908 and by the establishment of a weekly clinic in that subject. Cyrenus G. Darling, previously Lecturer on Genitourinary and Minor Surgery, and at that time Clinical Professor of Surgery, and of Oral Surgery in the College of Dental Surgery, had charge of the cleft-lip and cleft-palate cases. A large number of cases of bone fracture in the surgical clinics led to the establishment of a clinic in orthopedics in 1911, with Charles L. Washburne as demonstrator, and a few years later Max Minor Peet took charge of a new clinic in neurological surgery.

Failing health led De Nancrède to turn more of his work over to Darling, who succeeded him and became head of the surgical clinic in 1917. Darling resigned in 1919 and was replaced by Hugh Cabot, who was shortly to become Dean of the Medical School and who remained in charge until 1930. Cabot's particular interest was genitourinary surgery, and upon Loree's resignation in 1920, he concentrated primarily in this field.

The surgical clinic, one of the oldest and most important teaching divisions

of the Hospital, had occupied a separate building in the days of the Catherine Street Hospital. In the new building it was assigned, with its subdivisions, to parts of the third, fourth, and fifth floors of the Hospital. Under Cabot, who was Professor of Surgery at the time the new Hospital was occupied, the question of full-time service for the members of the Hospital staff was under serious consideration, and for a time the different surgical clinics were maintained on a full-time basis. When Cabot resigned in 1930, Reed M. Nesbit was placed in charge of the clinic in genitourinary surgery.

In orthopedic surgery LeRoy C. Abbott succeeded Dr. Washburne in 1918 and he, in turn, was followed in 1924 by Carl E. Badgley, who inaugurated the clinic in the new University Hospital. He has remained in charge, except for the three years when he was at the Ford Hospital in Detroit. During this time his place was taken by Vernon L. Hart. Perhaps no one clinic in the Hospital has experienced such fluctuations in numbers seeking diagnosis or treatment as has the bone and joint clinic, largely because of radical changes in legislation offering medical care for children, such as the withdrawal and drastic curtailment of funds.

Although the oral surgical unit is in the Hospital, it is not under the immediate direction of the Department of Surgery. Chalmers J. Lyons, who was made Instructor in Oral Surgery and Consulting Dentist to the Hospital in 1919, succeeded Darling in this field and was largely responsible for the establishment of this important clinic. After his death in 1935 he was succeeded by John W. Kemper, Professor of Dentistry and Consulting Dental Surgeon to the Hospital, who is now in charge of oral surgery. In this ward hundreds of children have had opportunity for the surgical correction of mouth malformations.

Dr. Cabot was succeeded as head of the surgical clinic in 1930 by Frederick Amasa Coller, who had come to the University as Assistant Professor of Surgery in 1920. As chairman of the department, he is responsible for all subdivisions of surgery, and under his administration standards in surgery, as well as teaching methods and content of instruction and research, have been continually improved.

Obstetrics and gynecology. — The third of what may be called the original clinics was that of obstetrics and diseases of women and children, which was at first established under Abram Sager, one of the founders of the Medical School. He was succeeded in 1873 by Edward S. Dunster, who was followed by his assistant, James N. Martin, as Acting Professor in 1888. "Children's diseases" was dropped from his title when Martin was made Professor in 1891, but was nominally included in his duties when, in 1899, he became Bates Professor of Diseases of Women and Children.

Reuben Peterson became head of the department in 1901 and remained in charge until his retirement in 1931. During the first five years of his administration, the clinical material nearly doubled. Peterson was succeeded in 1931 by Norman Fritz Miller as Professor of Obstetrics and Gynecology and Bates Professor of Diseases of Women and Children. He became chairman of the department in April, 1938.

Although obstetrical clinical material had been plentiful for some time, radical changes in legislation (1933) shifted the assignment of cases from the University Hospital to local units. This and other causes contributed to a decline in the number of cases received at the Hospital and created a problem in supplying adequate clinical material for student instruction.

Ophthalmology and otolaryngology. — With the coming of George E. Frothingham to the University in 1867, a special interest arose in ophthalmology and aural surgery. When Frothingham became Lecturer in Ophthalmology in 1870, a clinic in these branches was developed under his direction. The unusual importance attached to this branch of surgery was indicated by the fact that the first University building designed for a special clinic was a small Eye and Ear Ward, added to the campus Hospital in 1881.

Apparently, no special provision was made for this clinic in the Hospital on Catherine Street until Walter R. Parker and Roy Bishop Canfield were appointed, respectively, to the professorships of ophthalmology and otolaryngology in 1904. They realized at once that efficient work in their specialties was not possible while patients were treated in a general ward where they were in contact with septic cases. They began a campaign for a new building, which was eventually built in 1910. From that time the clinics in both of these subjects expanded rapidly.

The removal of the ophthalmology clinic to the new Hospital took place under Parker, who continued as Clinical Professor of Diseases of the Eye, until his resignation in July, 1932. He was succeeded by his associate, George Slocum, upon whose death in 1933 F. Bruce Fralick became Acting Chairman of the Department of Ophthalmology and in 1938 Professor of Ophthalmology and chairman of the department.

Originally, the clinic treated diseases of the ear, nose, and throat, as well as those of the eye, but in 1904 Canfield became Professor of Otolaryngology and head of the otolaryngology clinic. Under his energetic direction and because of his extraordinary skill as a surgeon, the clinic grew rapidly. Canfield, who was killed in an automobile accident in 1932, was succeeded by Albert C. Furstenberg, who had been for many years his able assistant.

Psychiatry and neurology. — The history of the development of the Hospital clinic in neuropathology goes back to the time of William J. Herdman, who had assumed charge of the work in nervous and mental disorders in 1888. Just before his sudden death in December, 1906, he had recommended the appointment of Dr. Albert M. Barrett who in September, 1905, had taken charge of the instruction in psychiatry and diseases of the nervous system. A clinical professorship of the diseases of the nervous system was also created. In June, 1907, this was filled, on Barrett's recommendation, by Dr. Carl D. Camp.

At the time of his appointment Dr. Barrett, who thus had the distinction of carrying out and organizing the first University Hospital clinic for the treatment of mental diseases in the United States, issued a statement about the work in the two divisions, psychiatry and neurology, as follows:

The Psychopathic Ward is a hospital intended for the so-called psychopathic conditions or for mild forms of mental diseases. This means that there will always be present in this Ward, patients which might properly belong either to the neurologists or the psychiatrists… The Director of the Psychopathic Ward in his capacity of Pathologist of the State Asylums, visits these institutions from time to time and has become familiar with much of their more interesting clinical material …

"Medical Faculty Minutes,"

Under Barrett, the clinic grew rapidly. It was centered in the State Psychopathic Hospital, which was connected with the old Catherine Street Hospital. An additional clinic was established in the new Hospital in 1925. Upon Dr. Barrett's death in 1936, he was succeeded

by Raymond Walter Waggoner, who, as Medical Director of the State Psychopathic Hospital, was placed in charge of the neuropsychiatric unit in the University Hospital. The Neuropsychiatric Institute was built in 1939 as a separate building just to the rear of the Hospital proper. The old State Psychopathic Hospital eventually was fitted over as a nurses' home. The clinic in neurology, which was separated from that of pyschiatry in 1920 when the separate Department of Neurology was created, remained under the charge of Dr. Camp.

Roentgenology. — Although interest in X ray as an agent in diagnosis developed in the Medical School soon after Roentgen's discovery in 1895, the clinic in roentgenology was not inaugurated until December, 1903. It was first installed in a five-room laboratory in the basement of the Palmer Ward and was furnished with X-ray equipment purchased the year before. From the first the work of the laboratory, devoted to X-ray diagnosis, therapy, and photography, increased enormously.

Work in this field was at first under the charge of Vernon J. Willey, who became Director of the laboratory in 1906. X-ray therapy was conservatively practiced at first as a joint undertaking with the Department of Dermatology; little deep therapy was attempted. In 1909, Lyle Steen Hill became Director of the laboratory, which by this time had become of great value in the diagnosis of fractures, dislocations, and bone diseases, as well as in the localization of foreign bodies.

In 1913 James G. Van Zwaluwenburg became Clinical Professor and later Professor of Roentgenology. The clinic had become more than self-supporting so that the appointment of a technical assistant was authorized, and the clinic became a full-time service of the Hospital. Dr. Van Zwaluwenburg died January 5, 1922, and was succeeded by Samuel Wright Donaldson, who was acting head until the appointment of Preston Manasseh Hickey a few months later.

The design for the roentgenology clinic, in the present hospital, with its special examining rooms and photographic equipment, was the work of Dr. Hickey, who was in charge at the time of removal to the new building. The facilities of the clinic were also increased in 1928 by a purchase of 100 milligrams of radium for $7,000 under a general appropriation of $35,000 for a radium and emanation plant. Dr. Hickey died in 1930, and his place was taken temporarily by Carleton Barnhart Peirce, who was, in turn, succeeded in 1931 by Fred Jenner Hodges as Professor of Roentgenology and later chairman of the department.

Under Hodges' direction many changes have been made in the arrangement and equipment of the clinic, which is now situated on the east side of the surgical wing. In May, 1940, the W. K. Kellogg Foundation provided funds for the installation of equipment for chest X-ray examinations of patients admitted to the Hospital, for clinical investigation, for the study and prevention of tuberculosis, and for research toward the more efficient uses of X ray for diagnosis.

Dermatology and syphilology. — The dermatology clinic was the last of the major clinics to be developed in the Catherine Street Hospital. When William F. Breakey, Professor of Dermatology and Syphilology, resigned in 1912, he was succeeded by Udo J. Wile, who remained in charge of the department and of the clinic. A laboratory for dermatology was set up in the basement of the medical building of the old Hospital in 1912, but it proved inadequate. Wile almost immediately called attention to the fact that although the bed

capacity for the treatment of syphilis cases was far larger than that found in any other institution of like character, there was urgent need for additional bed space. Accordingly, the construction of a special ward was authorized in 1917. It was of temporary character, however, and was used only until the new Hospital was completed, when more satisfactory quarters for the clinic became available.

Special clinics and research programs. — From time to time there have been additions to the facilities of the Hospital in the way of special clinics and research programs developed in co-operation with different members of the medical faculty. Among these are to be noted new clinics in allergy, arthritis, cancer, and the Clara Ward Seabury clinic in infantile paralysis.

A sensitization clinic organized in the basement of the old Contagious Hospital grew into a much larger clinic after it was moved to the new Hospital. General interest in allergy, at first a subject of doubt and ridicule, was increasing, and an allergy clinic was developed within the Department of Internal Medicine under the direction of Dr. John Sheldon.

In 1936 a teaching clinic for the study of malignant growths was created through the combined efforts of all the professional departments of the Medical School. The work has been correlated with nuclear research carried on with the physics and the roentgenology departments, with financial support from the Rackham Fund.

The arthritis clinic was organized in 1935 at the suggestion of Dr. Sturgis and Dr. Badgley to co-ordinate various methods used in the Hospital for treatment of arthritis. Three years later a trust fund of $1,000,000 was established by the Rackham Fund for the furtherance of research in this field. This support resulted in the development of an arthritis unit in the basement of the Hospital, with Richard Freyberg in charge.

A gift of $8,000 from anonymous donors in 1937 made possible the establishment of a memorial clinic to Mrs. Clara Ward Seabury for the study of infantile paralysis. This research clinic was placed under charge of Malcolm H. Soule, Professor of Bacteriology and Chairman of the Hygienic Laboratory.

Several services directly related to the clinics, and functioning in co-ordination with them, are the pathological diagnostic service, the clinical laboratories, the Department of Anesthesia, the Hospital Pharmacy, and the dietetic, physical therapy, and blood bank services.

Pathology. — The pathological service was first organized in 1900 under Aldred Scott Warthin, at that time Chairman of the Department of Pathology. Under his administrative direction it was enlarged, and offices and laboratories were provided for it in the basement of the new Hospital. This service gave ample proof of Dr. Warthin's assertion that in a single year the Hospital's clinical material covers almost the entire range of practical diagnostic pathology and gives the Hospital a unique teaching and research value quite different from that of the ordinary city hospital. When Warthin died in 1931, he was succeeded by Carl Vernon Weller.

The growth of the clinical laboratory and of the consultation services coincided with the emergence of the Hospital as one of the outstanding medical centers of the country. In March, 1928, Dr. R. L. Kahn was made Director of Laboratories and Assistant Professor of Clinical Bacteriology and Serology. His researches and clinical tests have been internationally recognized.

Anesthesia. — In 1919 Miss Laura M. Davis, the anesthetist of the Hospital, organized a course for graduate training in anesthesia. She continued as director

of the course until 1938, when Fenimore E. Davis was placed in charge of a newly organized Department of Anesthesia established in the Department of Surgery.

The first appointment of a Hospital dietitian was apparently made in 1901, and from that time increasing emphasis was placed on adequate and proper diet for patients. A more scientific approach to the subject, however, was not undertaken until the establishment of the diet therapy clinic under S. Margaret Gillam, who, as Director of Dietetics, worked closely with Dr. Newburgh and others in the study of diet and metabolism. Miss Gillam resigned in 1932 to be succeeded by Mrs. Dorothy Stewart Waller, who was also Instructor in Internal Medicine. Upon her death in 1934, Miss Mable M. MacLachlan was appointed Director of Dietetics and Housekeeping.

A metabolism unit with twelve beds was opened in 1922 under the direction of Phil Lewis Marsh. This included a well-equipped kitchen and a small laboratory for the treatment of diabetics and the intensive study of patients presenting disturbances of metabolism. With removal to the new Hospital, this unit was greatly expanded.

A gift from the Rackham Fund in 1934 for the construction of a therapeutic pool greatly strengthened the facilities of the Department of Physical Therapy. It now occupies an entire wing of the basement floor and is one of the best equipped and most modern units in the country.

In 1938-39, the establishment of a blood bank in the Hospital was announced, and a member of the Internal Medicine Department was charged with developing the service. The bank is situated on the ground floor of the Hospital, and each service has a separate account for credit and withdrawal of blood from the bank.

Administration and Policies

In the memorandum outlining the functions of the Hospital drawn up by Dr. Abram Sager in 1869, certain fundamental principles were set forth, although it required time for some of them to be realized effectively. Dr. Sager assumed that the University "did not on the one hand design to offer [the Hospital] as a public charity, nor on the other, intend rigidly to restrict its benefits to those who were competent to meet the necessary charge for maintenance." He suggested that "the main object of a hospital … is to utilize for practical instruction all the clinical material that may present itself." With these objectives in view Sager suggested that the Hospital should be kept open throughout the entire year. This was twenty-four years before the University summer session was opened, and thirty-three years before the summer session in medicine was begun in 1902.

No person was to be admitted for treatment except upon his willingness to contribute directly or indirectly to the "main object of the institution." No patients should be admitted who were not willing to be utilized for class instruction.

The general management of the Hospital was to be under the control of the medical faculty, with the patients under the charge of the Hospital staff "consisting of the Professors of the Practical branches of the University." It was also suggested that "the charge for maintenance should be placed at the lowest rates consistent with the avoidance of actual loss." This last provision was for many years a bone of contention between the Regents and the clinical faculty, especially in later years when the cost of hospital care was largely augmented. The Regents insisted that the Hospital be self-supporting; the clinical faculty always maintained that low charges were

necessary to furnish the maximum amount of teaching material. Thus, for many years, the Regents maintained financial control of the Hospital's operations, and the medical faculty exercised immediate supervision over admission of patients and educational policies.

Whether a medical school should own its own hospital or utilize affiliated institutions has been much discussed during the past fifty years. Naturally, every school has defended its own system. To many, the use of a hospital by a medical school without the problems incident to its control appears advantageous. In reality, there always have been difficulties. President Charles W. Eliot observed in his report for the year 1888:

The School [Harvard Medical School] labors under some disadvantage because it has no official influence over the appointments in any hospital. It receives indispensable aid and furtherance from all the principal hospitals and Infirmaries in and about Boston, and it has always been in especially intimate relations with the Massachusetts General Hospital; nevertheless, there is not a single hospital, infirmary, or dispensary over the appointments in which it has the least control. Yet no clinical teacher in a medical school can do his work properly unless he has rightful access to a large hospital or infirmary. When, therefore, a vacancy occurs in some clinical department of teaching in the Medical School, the question before the Governing Board of the University is — not who is the most available man for the place in Boston or elsewhere — but who is the most available man as a teacher among the Boston practitioners already holding cognate hospital appointments given by other Boards of Trustees. (Harrington, p. 1079.)

The principle that the Hospital ought to be self-supporting had much to do with the remarkable success of the Medical School. Charges were to be so fixed that the Hospital was to pay its own way and was to be no financial burden upon the University. It was not possible to carry out this program completely, and after the first few years state appropriations for maintenance supplemented the income from patients for board, medicine, unusual appliances, and special nursing. This state support, first provided in 1877 to enable the Hospital to keep open during the summer term, was continued through the summer of 1918. In 1892 the superintendent stated that his current report included only running expenses, not maintenance or permanent expenses (R.P., 1891-96, p. 104), though just what the difference was between maintenance and running expenses is not clear. Since 1918 the principle of self-support has been followed with a fair degree of consistency, with deficits in one year balanced by increased income in others. Without the rigid adherence to this rule in recent years one can imagine the mounting expense of the present Hospital of some 1,350 beds, with an annual budget, in 1940, of more than two million dollars.

During the period while the new Hospital was in the course of construction and immediately after it was occupied, the question of full-time service on the part of the clinical members of the Hospital staff was under serious — and sometimes heated — discussion. The faculty had voted in June, 1919, that the chairs of surgery and internal medicine should be filled by teachers giving full-time service to the University, with a salary from University funds supplemented by a further amount from the income of the Hospital. The appointment of Dr. Hugh Cabot as Professor of Surgery in 1919, an active advocate of the plan, made certain its adoption at Michigan, even though many members of the medical faculty were doubtful about its desirability or practicability.

In a statement made to the Regents by Dr. Cabot in January, 1920, he defined

full time as "the requirement on the part of members of the Department of Surgery to give their whole time to teaching and to the care of patients at the University Hospital." By this plan, he maintained, teachers would devote their entire time and thought to the work of the Hospital, and the resulting conflict between duty to the University and the support and education of a family would be avoided. He pointed out that the income of a teacher in a clinical service arose from two sources, his work as an instructor and his "market value" as a practitioner of medicine. This fact must be recognized in assessing a proper income for such teachers, or the best men would be unwilling to limit their incomes to the ordinary University professorial salaries. He proposed that while his salary as a teacher should be equivalent to salaries in other departments of instruction, the clinical instructor should also be paid an additional amount from patients' fees, to be collected by the University and allocated in accordance with the importance of his medical and surgical services. The amount of the whole compensation should be fixed so that it would bear some relation to the income he would receive as a practitioner.

A few months later, in December, 1920, the Regents adopted a resolution establishing full-time chairs "as soon as the new Hospital building is prepared." In the final event, the plan proved only partly successful. The salaries in the Medical School were criticized by members of the other faculties of the University, while the medical profession in the state was equally critical because of what they felt was a threat to the practice of doctors in local communities throughout the state.

With the opening of the new Hospital, the question was again brought up for consideration, and in February, 1927, the Regents declared full-time service in the Medical School to "comprehend the policy of using the surplus earnings of the full-time departments … for increasing and supplementing expenditures for salaries, supplies, and equipment." Nevertheless, the whole question continued to be a vexing one, and in May, 1929, a committee composed of Regents, members of the medical faculty, and University officers was set up to study and report on the problem. This committee reported informally from time to time, and their consideration eventually led to a resolution on the part of the Regents that on and after July 1, 1932, full time should "cease to be mandatory in the clinical departments" (R.P., 1929-32, p. 868). Within a few years after the passage of this measure, the status of some members who had been serving on a full-time basis had been changed to part time.

The question of part-time service had been affected also by the fact that throughout the early years of the Hospital little or no accommodation was given to private patients. After 1881 patients were those referred to the Hospital from the local communities or by the state. This restriction upon the patients admitted to the Hospital gave rise to the establishment of other hospitals in Ann Arbor. These included a number of private hospitals maintained by members of the University's medical staff. With the coming of Dr. Cabot a few private surgical patients were admitted to the Hospital, and the situation was finally clearly defined in December, 1932, when the Regents approved special provisions on two floors of the surgical wing for the private patients of part-time members of the faculty. In 1939-40, a little more than 41 per cent of the patients were referred by physicians or were University students. A relatively small number (about 3 per cent) were

employees of the Hospital; the remainder were admitted to the Hospital under the various state laws for indigent adults and children.

Hospital superintendents. — When the first little hospital was established on the campus in 1869, John Carrington became janitor or steward (the terms appeared interchangeably), and his wife was matron. He was to prepare the dietary for the hospital patients, keep the fires, and care for the rooms and beds, in return for which he and his family were to "have residence" in the Hospital and receive seventy-five cents per week for each patient. Another couple continued this arrangement for a year or so. After that for a period of some fifteen years, there is no record of a hospital steward, but in 1874 the position of hospital physician was created. It was first held by Dr. Robert J. Peare, denominated by Dr. Sager as "the physician in immediate charge of the inmates." Dr. Alexander C. Maclean was appointed Hospital Surgeon in 1877 and was also designated Hospital Superintendent, with the understanding "that he shall be furnished a room in the building … and also contingent upon his assuming the general control of the work of the matron" (R.P., 1876-81, p. 125).

The increasing number of patients and the difficulties of satisfactory administration under this system led eventually to a series of recommendations by the medical faculty submitted to the Regents in June, 1888. Among other measures, it was suggested: "That the price of board be raised to four dollars per week, … That a competent matron and steward be engaged to conduct the culinary department, … and that the present system of boarding patients … be abolished." In December, 1888, the auditing committee reported that they had selected Joseph Clark as steward of the hospitals at a salary of $1,000. Two and one-half years later he was given the title of Superintendent of the Hospitals, including the Homeopathic Hospital.

On completion of the Catherine Street Hospital group in 1891, a series of new rules and regulations provided that the superintendent should have charge of admitting and discharging patients and should also keep records of patients as well as a property inventory, provide for the patients' diet, hire all servants, collect all moneys from patients, and have oversight of each department of the Hospital (R.P., 1886-91, p. 532).

This was the beginning of a more systematic administrative policy. Clark continued to serve until his death in 1897, when he was succeeded by his son, Harry W. Clark, upon whose resignation in 1900, E. S. Gilmore became superintendent. Gilmore, in turn, was followed in 1908 by Jay B. Draper, who had previously been superintendent of the Pontiac Asylum. Draper was hardworking and conscientious, but apparently had little administrative ability. A rigid policy of making the Hospital "pay its own way," although it resulted in a surplus, gave rise to many complaints and was responsible for a general decline in efficiency and morale.

This condition led to an investigation by a committee of the medical faculty, which reported that in all medical affairs the Hospital should be under the direction of the medical faculty. There had been hospital committees of the medical faculty before the Catherine Street Hospital was built, but their powers were limited, particularly in the matter of finances. As a result, with the approval of the Regents, a new Hospital committee, with extended powers, was created in January, 1912. Dr. Reuben Peterson was made Medical Director, with Dean V. C. Vaughan and Dr. De

Nancrède, Dr. Hewlett, Dr. Canfield, and Dr. Barrett as the other members.

This committee, eager to improve conditions, found that their efforts were still limited by the fact that they had no direct control of Hospital finances, which were administered by the Regents. Although friction was bound to result, this system of control worked with fair success until it was given up in 1918. That it worked at all was probably due to the support of Dr. Walter H. Sawyer, chairman of the Regents' Hospital Committee, to whom the Board naturally turned for advice. Then too, any plan of management would have been strained to the breaking point by World War I and the confusion resulting from the enlistment of a great part of the Hospital staff.

A summary of a report made to President Hutchins by the Medical Director in 1915, outlines the general situation of the Hospital at that time. In this report it was pointed out that the reorganization of the Hospital along modern lines was no easy task, since, under nonmedical management, the unsanitary condition of the old building had resulted in many cases of erysipelas, tonsilitis, and bronchial infections among both patients and nurses. This condition had been remedied and the Hospital had been made clean and sanitary, reducing these avoidable diseases to a minimum. One of the best general kitchens in the state had been installed, as well as a bakery, ward serving-rooms, and a nurses' diet kitchen.

The report also stated that the new Interns' Home had obviated the humiliation of losing the best senior students as interns to other hospitals. A Hospital usher who received patients as they entered and saw that they were escorted to the proper departments, also ended many complaints. An increase in the teaching and supervisory staff of the Training School for Nurses made unnecessary the use of outside nurses unless they were employed by the patients. A trained social service worker, first appointed in 1912, also gradually changed the general tone of the Hospital, bringing the patients to feel that the authorities were interested in them as well as in their bodily ills. Moreover, the twenty-four bed Contagious Disease Hospital brought relief from financial loss caused by quarantines arising from the presence of contagious diseases in the wards. Compulsory Wassermann examinations were given free of charge to all Hospital patients.

As a result of these progressive measures, a deficit incurred in the years 1911-14, because of the increased number of patients, became a surplus in 1914-15. The report mentioned many inadequacies in the plant and emphasized the impossibility of making it over into a modern hospital. It also called attention to the need for a new nurses' home. Despite these deficiencies and handicaps, the report concluded that the institution was as good a teaching hospital as existed anywhere in the country. One great advantage in the increase of control on the part of the Hospital committee lay in the knowledge thus acquired by the faculty members of the committee of the difficulties of hospital management.

Superintendent Draper was killed in a streetcar accident on November 13, 1915, and Robert G. Greve, then in the office of the Secretary of the University, was appointed temporary Superintendent of the Hospital. He held the position until 1918. This was a period of peculiar difficulty because of the problems arising from World War I and from the limited number of nurses, especially during the influenza epidemic of 1918. Moreover, the war also placed those connected with the Hospital in a peculiarly embarrassing position, because the faculty, as teachers, were urged to remain at their posts in

order that the Army would be assured an adequate supply of doctors, whereas the War Department naturally welcomed enlistment of highly trained doctors and surgeons in the Army Medical Corps.

When it was evident that war was imminent, this situation was discussed at a meeting of hospital clinicians held in March, 1917. A statement was drawn up by this group pointing out that the Medical School, in its clinical program, differed from other schools, since its staff was never more than sufficient to ensure good medical and surgical care. The staff at that time included forty-one physicians, all of whom were members of the medical faculty, and their teaching duties were necessarily closely interrelated with the care of their patients. A loss of eight men (20 per cent of the staff) was the maximum depletion that could be allowed if the clinical teaching program were still to be maintained. Reduction of the faculty beyond a certain point would either limit the number of admissions to the Hospital, with a corresponding lessening of service to citizens of the state, or else result in inadequate instruction and the lowering of standards in the treatment of patients.

The members of the staff expressed their willingness to do what was best for the country and signified their readiness to serve in the Medical Officers' Reserve Corps, although it was suggested that a plan be devised which would prevent too serious a reduction of the teaching staff. But, as the war progressed, conditions in the Hospital became worse, and eventually the personnel was depleted by nearly 50 per cent.

When the new and greatly enlarged University Hospital became a certainty in 1917, it was evident that the old system, under which a member of the medical faculty served as medical director, was inadequate and that a medical superintendent and director should be secured who could give his whole time to the administration of the Hospital. Dr. Peterson, then absent under an Army commission, accordingly resigned, and Dr. Christopher G. Parnall, of Jackson, Michigan, a graduate of the Department of Medicine and Surgery in 1904, and experienced in hospital executive work and instruction, was made Medical Superintendent and Director in April, 1918, with the expectation that he would give his whole time to the affairs of the Hospital. Somewhat later he was also made Professor of Administrative Medicine.

In Dr. Parnall's first annual report, which covered the year ending June 30, 1919, it was pointed out that the University Hospital had become one of the great teaching hospitals of the country. Despite yearly admissions numbering nine thousand and an equally large number of outpatients, there was a long waiting list, especially in the surgical service. The Hospital served, in effect, as an infirmary for the entire state, with patients referred to it from every county — particularly from those without adequate hospital facilities. Dr. Parnall served as Superintendent until 1924. During his term of office he promoted many new ideas in organization and administration and was responsible for the planning and designing of the present Hospital building.

After Dr. Parnall's resignation Mr. Greve again served for a short time as Acting Director prior to the appointment of Dr. Harley A. Haynes, who came to the Hospital after many years' experience as director of the State Hospital at Lapeer. In the course of his tenure many radical changes took place in the policies and administration of the Hospital and in its organization in relationship to the University. Dr. Haynes's institutional experience helped him to keep the Hospital doors open during legislative and financial difficulties, during panics and

war, and aided him in the solution of multiple problems ever present in such an institution.

Shortly after Dr. Haynes was appointed, Dr. Albert C. Kerlikowske ('24m) became Chief Resident Physician and, in 1928, Assistant Medical Director of the Hospital.

Development of intern system. — Throughout the early years of the Hospital, the problem of interns, or house physicians, was never satisfactorily settled. Although essential to the proper conduct of a hospital, for many years they occupied an inferior position and were more or less looked down upon by the hospital chiefs. By 1890, however, it came to be recognized in medical schools that experience was a valuable asset for young doctors before they went into practice.

Thus, although the beginnings were very modest, a system of internship gradually developed. A Hospital physician, later called resident physician, was first appointed in 1874 and doubtless performed many of the functions of an intern. In 1895 both a house physician and a house surgeon were listed in the Announcement. The first interns under that designation, four in number, were listed in the Calendar for 1899-1900 and were given a salary of $125 a year with room and board.

For some years after those first appointments the intern system was far from satisfactorily organized. Some ambitious students in applying for positions as interns secured recommendations to more than one hospital, leaving to their faculty sponsors the duty of explaining their failure to accept appointments in other hospitals to which they had applied. This led, of course, to great confusion.

To meet this situation the medical faculty in 1911 appointed a committee to systematize the entire program. To this committee, composed of Dean Vaughan, Dr. Hewlett, and Dr. Peterson, all requests and recommendations for internships were to be referred. Dr. Peterson in laying the matter before the Council on Medical Education of the American Medical Association reported that the committee felt that a firsthand knowledge of the best hospitals throughout the country should be obtained and that appointments to positions in these hospitals, as well as certification of the students' fitness, should be made. A plan for a fifth clinical year in the medical curriculum at Michigan was considered, but was never put into practice.

The admission of students to internship in the Hospital was thus gradually systematized. The situation was strengthened in 1922 by the passage of a law requiring all medical graduates to serve one year in an accredited hospital before beginning to practice. In 1940 thirty-five interns were on the Hospital staff. They rotated among the various clinical services. There were also approximately forty assistant residents, who served for a second year, and thirty resident physicians, who stayed for a third year.

As the University Hospital expanded and more and more interns were required the question of adequate quarters for them, as well as for the house physicians, became pressing. An old residence, moved to the Hospital site, was made over into an interns' home in 1914 at a cost of $2,500, and three years later an enlargement was authorized, so that the building accommodated fourteen men. The third floor of the Hospital Administration Building was also used, as well as a near-by residence taken over for the purpose. These makeshifts were so unsatisfactory, however, that in 1939, a new building for interns, housing some seventy-five men, was erected at the rear of the main Hospital building.

Medical museums and memorials. — In 1935, largely at the suggestion of Dr. Peterson, it was decided to start a collection of medical and surgical apparatus which had been in use in the Hospital. Cases containing items of interest were placed in the teaching amphitheater and in a small room off the Hospital library. The material thus exhibited includes instruments, splints, stethoscopes, and old X-ray equipment.

To preserve the memory of some of the men whose lives were an inspiration in the organization and development of services within the Hospital, from time to time memorial tablets have been placed on walls within the Hospital. These memorial tablets have thus commemorated the services of Regent Walter H. Sawyer, Albion W. Hewlett, James G. Van Zwaluwenburg, George E. Frothingham, Aldred S. Warthin, A. B. Palmer, and Reuben Peterson.

It would be impossible to enumerate the many generous gifts which the Hospital has received over the years, all expressing the particular interests and desires of the donors. They comprise buildings, research and teaching funds, scholarships and fellowships, as well as small individual gifts, all of which have contributed to the development and growth of the Hospital and its services to thousands of patients.

Reuben Peterson[Died November 25, 1942.]

Wilfred B. Shaw

SELECTED BIBLIOGRAPHY

Announcement, Department of Medicine and Surgery Annual Report of the University Hospital of the University of Michigan "The University Hospital." "Conference Meeting Ann Arbor." "Out-Patient Teaching in the Departments of Medicine, Surgery, and Ophthalmology at the University of Michigan Hospital." "Dean Cabot on the Medical School." "The University Hospital: Its Past, Present, and Future." The Harvard Medical School: A History, Narrative and Documentary. "The University Hospital, University of Michigan." "Hospital Facilities Are Increased." "Department of Chemical Laboratories, University of Michigan Hospital." "Medical Faculty Minutes" Compiled Laws of the State of … Public Acts [of the Session of] "Minutes … Executive Committee of the Council.…" "New University Hospital Completed." "Official Minutes of the … Annual Meeting … 1926…" "Report of the Committee on Medical Education." "The History of the University of Michigan Hospital." "The New Contagious Hospital at the University of Michigan and Its Proposed Plan of Operation." "University Hospital Report, 1914-15." "The Relation

of the Medical School to the Hospital or Intern Year" "The University Hospitals." President's Report Proceedings of the Board of Regents … "Report … Committee … to Survey … Hospital Charity in Michigan Hospitals." University Hospital Bulletin University Hospital Number. University of Michigan Regents' Proceedings …, 1837-1864. A Doctor's Memories.

The Relationship of the Hospital to the State

In the year 1939-40 the University of Michigan Hospital received 26,728 patients. Of these, 6,619 were to some extent dependent on the counties or on the state, and the expenses of 715 other patients were guaranteed by public officers and payable from public funds (P.R., 1939-40, pp. 308-9).

Although the University Hospital opened in 1869, it received no state support until 1875, and only since the 1880's have there been laws governing the care and maintenance of public patients. Nevertheless, as early as 1859 the concept of a state almshouse to be maintained by the University for clinical as well as charitable purposes was presented to the Michigan State Medical Society.

Ten years later, when the Regents were planning a hospital, the medical faculty set forth the scope and purposes of the institution, stating that its main object should be "to utilize for practical instruction all the clinical material that may present itself" and adding that they believed the Regents neither designed it to be a "public charity" nor meant to restrict its benefits only "to those who were competent to meet the necessary charge" (R.P., 1864-70, p. 366). A maintenance charge sufficient to cover food and medical and surgical supplies was recommended, and all patients were to be utilized for clinical instruction. The medical faculty was to have general control.

Summer operation of the Hospital was postponed until 1878, although at that time there was no instruction during the summer. Until 1872 charges to patients covered only their food. After that date all except "paupers" paid for medical supplies.

References to "paupers" and "charity patients" seem to indicate ability of the patients in some cases to pay for food and supplies, but the scanty records are not clear. Indigent patients must often have found even nominal fees impossible, especially in cases of long or chronic illness. Since medical service was free, fees from the well-to-do could not have provided for the poorer patients, and yet the Hospital was attempting to maintain itself from fees adjusted to the actual cost level. How this difficulty was solved, the records do not state. Possibly, charitable agencies maintained some patients.

The year in which the Hospital was established, Henry P. Baldwin, a Detroit philanthropist, became governor of the state. He had visited jails and county almshouses and had been shocked by the unsanitary conditions, lack of medical care, and nonsegregation of criminals. He was aroused over the conditions of children forced to remain in these places of ignorance, disease, and crime. Illnesses which might have been temporary often

went untreated, eventually became incurable, and made patients permanently dependent on public funds.

Governor Baldwin secured the appointment of a state investigating commission, the adoption of children into normal homes, and the authorization of a central school to care for them before adoption, thus avoiding the county almshouse. He also demanded a remodeling of the state's charitable and penal systems. The state public school thus established in 1871 was opened at Coldwater in 1874, the first institution of its kind in the United States. In 1879 the investigating commission became the State Board of Corrections and Charities and so remained until 1921, when it was replaced by the Department of Social Welfare.

While this commission was examining the county almshouses, a committee of the University medical faculty reported, in 1870, on the first year of operation of the Hospital. Although additional beds had been secured during the year the Hospital had been filled to capacity, and the committee recommended a large state hospital in connection with the Department of Medicine and Surgery. While there were no immediate results of the proposal, discussion of the plan undoubtedly had some bearing on later developments.

A "state almshouse hospital," on the general plan of such institutions in Massachusetts, was proposed. Free medical service and medicines prepared inexpensively by the pharmacy were offered the state for its invalid poor in return for the benefit of clinical material. The commission believed that with help from the legislature such a plan would be feasible.

The Regents, however, were slow to act on this recommendation, although a committee conferred with Governor Baldwin's commissioners. Then a new Regent, Dr. Charles Rynd, serving as head of the committee on the Medical Department, reported unfavorably on the value of large hospitals for instruction, preferring the old preceptor system.

Later, however, the committee changed its view, for in the spring of 1872 (R.P., 1870-76, pp. 189-91) it strongly urged the establishment of a large state hospital at the University, the best place "in the West" for pursuing the "higher clinical field of thought." It requested a large and modern hospital:

Not only are our alms-houses the repositories of many persons who are thus incarcerated to languish, suffer on and die without that aid to which the suffering poor are justly entitled, but many persons of wealth and refinement labor from diseases which if treated at all by the private practitioner, are treated but poorly, and with indifferent and unsatisfactory results.

R.P.

President Angell, in 1872, made a vigorous plea for a state hospital for almshouse patients or a large hospital for special diseases, the funds to come either from private or from public benefactions. At the same time Dr. Alonzo Palmer reported the medical faculty's views to the Regents and promised to have a hospital plan ready for consideration at the next meeting.

A joint committee of Regents and faculty members was then appointed to confer with the governor's committee on state charities. This joint committee discussed the necessity for such a hospital and favorably considered a proposal to build it at Ann Arbor, but it was not deemed "judicious to ask for an appropriation" (R.P., 1870-76, p. 251). Possibly some new difficulty in the controversy over the proposed homeopathic school made the University reticent in pressing any demands for state funds. When the Homeopathic Medical College

was established three years later, the legislature contributed several thousand dollars toward the construction and equipment of a larger and more modern University Hospital, provided a stated amount could be raised in Ann Arbor.

Act No. 207 of 1875, granting funds for the old Pavilion Hospital, was the first specific appropriation for the University Hospital, henceforth called a "state hospital." Though no funds were provided for running expenses, it did set a precedent for a series of future appropriations separate from grants for buildings and equipment. These were also distinct from somewhat later state disbursements made under public-patient laws.

No sooner was the new building completed in 1876 than the faculty requested, as it had in 1869, that the Hospital remain open throughout the year and that the medical session be extended from six to nine months. These requests were approved by the legislature in May, 1877.

During the vacations of 1878, 1879, and 1880, the Hospital remained open, but for the following eleven years it was closed in the summer, although the appropriations by the legislature continued, averaging until 1891, about $4,000 a year. Throughout this period these grants were used for Hospital running expenses. In the year 1891-92 the Hospital received $10,000 from the state in addition to funds for the new Hospital on Catherine Street, then in the course of construction. The following year an additional $8,000 was received for salaries and general expenses, but no direct grants for expenses were made during the next four years.

The opening of the Catherine Street Hospital in 1891 brought a marked increase in receipts, but, nevertheless, over the four-year period, 1893-97, there were regular deficits to be made up from the University's general fund. Despite financial difficulties, however, the Regents directed that the Hospital be kept open in summer, although the effects of the nationwide financial crisis in 1893 forced its closure during the summers of 1895 and 1896.

Relief came in 1897, when Act No. 203 provided $3,000 a year regularly "for the use and maintenance" of the University Hospital and the Homeopathic Hospital, provided the hospitals were operated during the summers. Though this law has never been repealed, it remained in practical effect only until July, 1919. After that date the payments were refunded to the state, and whatever annual deficits have been incurred have been offset by the surpluses of other years.* 1.1

First public-patient laws, 1881-97. — The metamorphosis of the University Hospital into a state hospital accommodating many public patients has been slow. There have been three types of public-patient laws: those for children, those for adults, and those for either adults or children suffering from certain specified disorders. Of these, only the first two types came before 1900.

The board in control of the State Public School at Coldwater first advocated state laws for hospitalizing public patients in the University Hospital. The secretary of this board wrote to President Angell in 1878, suggesting that it would afford great relief to the Cold-water school if the state would provide for dependent children afflicted with chronic diseases requiring surgical operations, since they were not admissible to the school and had of necessity to be returned to the poorhouses, where they could receive no proper treatment. He

suggested that the Regents might recommend appropriate action to the legislature and that the "State Hospital at Ann Arbor" was the proper place for such patients.

This letter was printed in full in the Regents' Proceedings, but the committee on the Medical Department reported that they had no funds for such a program. They promised, however, to join in a request that such children be provided for, and eventually the two boards secured the passage of Michigan's first law for the treatment of the invalid poor in the University Hospital, the children's act (No. 138) of 1881.

This act provided not only for sick and diseased children from the State School at Coldwater, but for all children suffering from conditions preventing eventual self-support. Transportation, board, nursing, and other expenses were to be paid by the state upon recommendation by the proper authorities, but admission depended upon the decision of the resident physician at the University Hospital as to whether or not the child could be benefited.

Thirteen children were treated under the provisions of this law during the first year, but many were turned away because of the Hospital's crowded condition. Transportation and maintenance for these thirteen children amounted to $634.68; the following year the corresponding payment was $434.84.

President Angell made it clear in his report for 1878 that he did not consider the Pavilion Hospital adequate and insisted on aid for adults, as well as for children, pointing out that the University's hospitals had already returned more than their cost to the state.

The Hospital's congested condition was relieved to a certain extent by a legislative grant for an eye and ear ward in 1879, but once more no provision for adult invalids was made. The subject was not mentioned again until 1888, when certain groups endeavored to have at least part of the clinical work transferred to Detroit. President Angell in opposing such a step emphasized once more the need of a larger and more modern hospital:

It would doubtless be a real economy for the counties, which may now be burdened with the cost of maintaining through life persons who have curable maladies, to send such patients here. To some extent they do this now. But with ampler accommodations more patients could be cared for, and the interests of the counties, of the patients, and of our medical school would at once be subserved.

(P.R., 1888-1902, p. 22.)

In 1889 the legislature made a grant of $50,000 for the new Hospital, to be supplemented by a contribution from the city of Ann Arbor. A note of disappointment tempered President Angell's expression of gratitude. The appropriation would not permit the erection of a large hospital such as had been projected in earlier years, but it was his belief that the clinical facilities might be made "reasonably satisfactory."

At the same session the legislature passed the first state law (Act No. 246 of 1889) for the admission of three classes of adult public patients: those who had become county charges because of severe injury and were in need of special treatment to prevent their becoming permanently dependent; those dependent upon the counties because of acute disease or physical injuries and requiring major operations to preserve life; and such obstetrical cases as were a public charge upon the counties for care and treatment.

Unlike the preceding children's law, this act charged the transportation and maintenance of these patients to the counties and left local enforcement to local officers and physicians. While such medical service to adult county poor to

some extent already was provided, the new law afforded a statutory basis for the procedure and undoubtedly encouraged further use of the Hospital.

Two laws enacted in 1897 authorized further medical aid, primarily for children. Act No. 42 required that the physician attending at the birth of a child of "any indigent poor person" should report, under penalty, any deformity or malady curable by surgical operation. On certification by the proper local officers, the child was to be brought at state expense to one of the University hospitals for treatment.

Under the first children's hospitalization act of 1881, only those enrolled in the State Public School at Coldwater or those who, if restored to health, could enter that school had been admissible for treatment. By an amending act (No. 233 of 1897) the same benefits were extended to any dependent persons in the state schools for the blind, deaf, and feebleminded, as well as to anyone entitled to enter one of these institutions. Actually, for two years the Hospital had been caring for the children from the School for the Blind at Lansing, at a charge of $2.50 a week.

This substitution of "dependent persons" for "dependent children" might seem to indicate that a large number of adults would be admitted under the new law, but this was not true, since the state charitable institutions existed chiefly for the benefit of defective children. Nevertheless, this oldest public-patient law is still in effect, and today patients recommended by the Michigan Children's Institute, which took the place of the State Public School in 1935, are treated under its provisions.

First special-disease laws, 1901-7. — In 1899 President Angell reported that the University had established an informal but valuable relationship with the state institutions for the insane, in each of which University graduates had been installed as resident pathologists, acting as assistants to the state's head neuropathologist at the University.

There had previously been grants to particular clinics, but until the present century no state provision had been made for the maintenance in the University Hospital of persons suffering from any specified diseases. The first such law was Act No. 161 of 1901, under which the construction of the Psychopathic Ward was begun. It was passed not upon the request nor with the consent of the Regents but in response to the efforts of friends of Professor William J. Herdman, head of the Department of Psychiatry. The Regents, however, accepted the gift, provided the unit be maintained at no cost to the University, and actual construction began in 1902.

The first special-disease law put into full effect was the rabies law of 1903 (Act No. 116), approved a few weeks after the Regents established the Pasteur Institute for the treatment of Michigan residents. It undertook to defray the expenses of indigent persons infected with the virus and assigned to the local boards of health the responsibility of sending them to the University, with transportation and other expenses to be paid by the township, village, or city.

Although the new Psychopathic Ward was practically completed and plans for its administration were under discussion in the spring of 1904, it was not occupied until Act No. 140 of 1905 shifted the payment of the director's salary to the state and introduced partial state control. It specified that a joint board composed of the Regents and the trustees of the state asylums should select a clinical psychiatrist to manage the institution and to oversee the clinical and pathological research in the state asylums and that this same psychiatrist, as a member of the medical faculty, should give instruction

in nervous and mental diseases. The same act also appropriated $14,000 for equipment and $5,000 a year for running expenses for each of the following two years, out of which the new appointee's salary was to be paid.

The following year by Act No. 278 the State Psychopathic Hospital ceased to be a department of the University Hospital and became an almost autonomous state institution. For many years thereafter, under an unusual arrangement, it was conducted in a non-University building on the University Hospital grounds. Its control was vested in a board of eight trustees, four Regents and four asylum trustees appointed annually by the four asylum boards.

Under the two acts of 1901 and 1907 expenses of all public patients except wards of the state were paid by the counties, although whenever possible these costs were to be reimbursed by relatives or guardians. Some public patients were sent by probate judges for curative, preventive, or diagnostic purposes and others came from the asylums. Private patients were also received and cared for at fixed rates.

Legislation for children, 1900-1913. — Between 1880 and 1910 the population of Michigan almost doubled. During this period measures for the relief of persons only partly dependent became more numerous. An 1889 law for veterans and their dependents gained popularity, and the children's law of 1881 was supplemented by amendment, by legislation for veterans' families, by the juvenile court act of 1903, and by other legislation relative to desertion and broken homes. A 1907 act for dependent, neglected, and delinquent children reflected the growing number of local hospitals, since under it county probate courts were authorized to place any child requiring special medical attention "in a public hospital or in an institution."

This measure might seem to have encouraged local treatment, but the University Hospital was gaining special recognition for its work in pediatrics, and after 1906 the Palmer Ward clinic supplied the impetus for modernizing and amplifying the hospitalization statutes affecting the University. Previous laws were considered inadequate since they provided only for certain classes of persons and "discriminated against the normal child who developed an illness requiring hospital care, in favor of the imbecile who never could be made into a good citizen" (Hosp. Rept., 1918-19, pp. 113-14).

The result was a new children's law (Act No. 274, 1913) which became the model for similar measures in other states. Under its terms deformed or afflicted children whose conditions could be remedied and whose parents could not provide proper treatment were to be reported to the probate judges and cared for at state expense at one of the University hospitals. County agents and superintendents of the poor not on fixed salaries were to be compensated for their time and expense in making the necessary investigations, and the examining physicians were guaranteed a standard fee.

While this 1913 law did not affect the Coldwater State School hospitalization act of 1881, in effect it replaced and led to the repeal in 1915 of the infants' hospitalization act of 1897. Unfortunately, the provision for compulsory report and treatment of deformities present at birth was not included in the new law. The Afflicted Children's Act was in force until the new Crippled Children's Act was passed in 1927.

The adult public-patient law of 1915. — Free treatment for adult residents of any Michigan county who would be benefited by medical and surgical treatment but who were financially

unable to obtain it was provided in 1915 by Act No. 267, which also provided obstetrical service for mothers unable to pay for it and for the care of children born of women hospitalized under the statute. As in the children's law, the prospective patient was committed to treatment by a probate judge only after he had obtained a satisfactory financial and medical report, and the expense of the necessary investigation had been guaranteed.

This act for the adult poor specified that transportation and maintenance were to be paid by the counties, which were to reimburse the state for any funds advanced to the Hospital for these expenses. Although University authorities felt that this was a defect, since the county officers might be inclined to send patients to county houses, where they could be treated at less expense, rather than to the University, between July 1, 1915, and June 30, 1940, more than 70,000 patients were registered in the Hospital.

The effect of the laws of 1913 and 1915. — These new laws for adults and children extended the benefits of hospitalization. In fact, the only important restriction other than that pertaining to medical and financial needs was that the maladies and deformities to be treated could be remedied. The broader scope of these laws and also, possibly, the guarantee of payment of the agents' fees and expenses resulted in a notable increase in public patients. In 1913-14, 255 children were treated under the 1913 children's law; the next year there were 615. In 1915-16, 604 children were treated under this act, and under the 1915 adult law 411 patients were treated; during the following year 707 children and 647 adults were treated. Two years later more adult patients than children were being received under these laws.

Psychopathic hospital law of 1917. — Under Act No. 310 of 1917 the trustees of the State Psychopathic Hospital were given the right to establish centers for the treatment, care, and maintenance of patients at places other than the Psychopathic Hospital and to provide for the preservation of mental health in former patients. A $3,000 increase in the state's annual appropriation to the institution took care of the additional expense for these new services.

The children's law of 1921. — A new children's law in 1921 (Act No. 137), primarily affecting local hospitals, empowered the counties to contract with agencies and institutions licensed by the State Board of Corrections and Charities for the care, maintenance, and medical treatment of children, all expenses to be paid from county funds.

Special-disease laws, 1921-25. — A general reorganization of all the public charitable, corrective, and penal institutions was effected in 1921 (Act No. 163), when the State Welfare Department was created to take the place of the old Board of Corrections and Charities. The State Psychopathic Hospital was particularly affected, since the old separate asylum boards were abolished and their powers transferred to the State Hospital Commission, one of four set up within the new department. All non-Regent trustees of the State Psychopathic Hospital were to be appointed by the governor, and while the medical director's functions of visiting and inspecting the other state hospitals were now a part of the activities of the new State Welfare Department, that department was to have no part in the management of the Psychopathic Hospital nor control of its board of trustees.

A new general insanity law (Act No. 151) superseded in 1923 the old Act No. 217 of 1903. It not only defined the functions of the new State Hospital

Commission and of the institutions under its control, but also affected the mode of dealing with State Psychopathic Hospital patients. The same year authorization was given for sterilization operations at the University Hospital (Act No. 258, amended by Act No. 71 of 1925).

The University's Pasteur Institute ceased to be the only clinic in the state for treatment at public expense of persons infected with rabies when, in 1925, Act No. 321 was passed authorizing local health boards to make the necessary arrangements at the Institute or at some other treatment center for Pasteur treatment at an expense to the counties not to exceed $200 in any one case. It was held by the attorney general in 1929 that this act by implication repealed the old rabies law of 1903 and in effect shifted the costs from cities and townships to the counties. At the same time everyone in need of treatment became entitled to receive it regardless of economic status.

The adult-patient law of 1925. — A new general poor law in 1925 (Act No. 146) repealed the old law of 1869, which had made it "the duty" of county poor superintendents to send to the University county charges who would remain indigent because of severe injury unless specially treated, as well as those who needed major operations to save their lives. While the new law still provided that superintendents of the poor might arrange for the hospital care of such persons, they were no longer compelled to do so. Furthermore, patients might be committed either to the University Hospital or to any other hospital the superintendents of the poor might select — an "alternative" provision later inserted in the three laws under which the University Hospital now receives most of its public patients, the adult-patient act of 1915 and the two general laws for crippled and afflicted children (1881 and 1913).

The 1925 version of the poor law providing for medical aid was in most respects, however, identical with that of 1889, except that the terms "poor person" and "infirmary" were used in place of "pauper" and "poor-house." The retention of the terms "obstetrical wards" and "hospitals of the University" revealed a certain obsolescence in the statute, since for nearly twenty years there had been separate buildings for obstetrical patients and the Homeopathic Hospital had been merged with the University Hospital in 1922.

The years following the opening of the present Hospital building in 1925 witnessed significant developments in all three types of public-patient laws. The major law for the hospitalization of indigent adults (Act No. 267 of 1915) was materially altered by four amendatory acts. In 1927 Act No. 317 directed the University Hospital superintendent to send reports on persons hospitalized under the 1915 law to the probate judges and to release the counties from liability for hospitalization periods longer than six months, unless an extension order was obtained. In 1929 the boards of county auditors were made responsible by Act No. 293 for investigating the financial condition of prospective patients seeking aid under the 1915 adult-patient act and were permitted to arrange with patients to repay the counties for benefits received.

Under the earlier poor law and under certain other statutes, adults were treated in local hospitals, but those hospitalized under the adult-patient law of 1915 had to be committed to the University Hospital. This was changed in 1933 by Act No. 222, giving the probate judges the privilege of selecting other hospitals if they saw fit.

Act No. 304 of 1939 denied officials

any authority to compel a patient to undergo an operation or treatment as provided under the terms of the 1915 adult-patient law. Only with the consent of the guardian or of the nearest relative could such treatment be undertaken for patients not in condition to decide for themselves. The same held true for children.

Since physicians not at the University were permitted to charge fees, the title of Act No. 267 of 1915 was altered in the 1939 law to omit the word "free" from the phrase "to provide free hospital service and medical and surgical treatment." Stricter financial controls were also prescribed, and any falsification regarding financial need was punishable by fine or imprisonment. Also, the optional repayment agreements were made compulsory. Where there were county boards of auditors, the Department of Social Welfare might conduct financial investigations and become responsible for obtaining repayment pledges.

Upon the enactment of this 1939 law the attorney general distinguished between the hospitalized group of special patients in the amended Act No. 267 of 1915 and the group given medical aid outside of hospitals under a 1939 welfare act (No. 280).

In certain instances county costs for administering the poor law of 1925 (No. 146) might be recharged to the smaller governmental units, which the afflicted adult act of 1915 did not permit. This led the attorney general to rule in March, 1939, that supervisors might not charge back expenses incurred under the 1915 act to the townships or cities.

Special-disease laws, 1925-40. — The Psychopathic Hospital act of 1927 (No. 207) was the first special-disease law affecting the clinical work of the Medical School after the opening of the new University Hospital. It repealed the amended law of 1907 and embodied the changes brought about by the abolition of the several asylum boards and the creation of the State Hospital Commission and the augmented State Administrative Board in 1931. In all matters not prescribed, the trustees of the State Psychopathic Hospital retained sole control. Non-Regent members were appointed by the governor for four-year terms, whereas the four Regent members continued to be selected annually by the Regents. The new law required that medical officers of the state mental hospitals receive University instruction, at the expense of the respective institutions.

A new law for sterilization (No. 281), repealing the amended act of 1923, was passed in 1929. The largest number of cases registered under it in a year was sixty-three in 1930-31; there were none in 1939-40.

The first tuberculosis legislation affecting the University Hospital was passed in 1929, when Act No. 115 abolished the board of trustees of the Howell State Sanatorium and created the state Tuberculosis Sanatorium Commission. The commission was given control of any sanatoriums to be established and the power to transfer patients from state tuberculosis sanatoriums to the University Hospital for special treatment, with the usual costs chargeable to the counties for all indigent patients except state wards. A fund for a one-hundred-bed University Hospital addition for tubercular patients, equipped for diagnosis and special surgical treatment rather than for prolonged care, was granted in 1929 by Act No. 324.

In 1935 the legislature, by Public Act No. 173, abolished the State Psychopathic Hospital board and transferred its functions to the Board of Regents. Since the Psychopathic Hospital still remained, nominally, a semi-independent state institution and not a part of the

University Hospital, the Regents, in acting upon Psychopathic Hospital affairs, assumed that they were serving as a state board succeeding the old board of trustees (R.P., 1932-36, pp. 718 and 810). This act under which rules were to be formulated by the Regents, replaced, in general, all references to the regulations of the State Administrative Board as set forth in the Psychopathic Hospital law of 1927. The governing board retained the power to provide aftertreatment, but the provision for city or community dispensaries and mental hygiene departments was omitted.

The laws concerning institutions for mental diseases, feeble-mindedness, and epilepsy were revised in 1937, when, under Act No. 104, the State Hospital Commission within the State Welfare Department was replaced by a new, separate commission of the same name. Also, Acts No. 85 and 243 providing for the new five-story Neuropsychiatric Institute addition to the University Hospital, superseded and repealed the Psychopathic Hospital act of 1927 and abolished the State Psychopathic Hospital as an organization, but stipulated that the Regents should keep the property (see Part II: The Neuropsychiatric Institute and the State Psychopathic Hospital) .

The main purposes of the Institute as outlined are: (1) to emphasize early diagnosis and treatment, (2) to establish a clinic for study of the prevention of mental illness, and (3) to conduct training and research in all phases of mental disease. The Institute, as part of the University Hospital, is controlled by the Regents. It does, however, receive state aid. In the three years ending June 30, 1940, this annual grant averaged about $105,000.

The provision that the medical director of the Psychopathic Hospital was also to be ex officio neuropathologist of all the state mental hospitals was discontinued by Act No. 85, as were the regulations regarding the visits by the outstate hospital staff members to the neuropathological laboratory at Ann Arbor. It also provided that all patients in the old Psychopathic Hospital should either be discharged as normal or declared insane, feeble-minded, or epileptic and committed to a suitable institution. State hospital patients might be transferred to the new Institute for treatment or for purposes of research, at the expense of the Institute. The law also permitted the temporary referral to the Institute of all persons suspected of mental disorder. Though not definitely committed, their detention periods could be extended to provide time to determine whether commitment to a state hospital was desirable.

While the only voluntary patients in the old Psychopathic Hospital were private patients, under the regulations of the Institute an indigent person might apply for admission under a private court order. The Institute was also organized to make special provision for the care of children. Up to June, 1940, patients were received under several different laws. Thus, transfer patients were admitted under Act No. 85 of 1937; adults came under Act No. 267 of 1915; and children entered under Act No. 138 of 1881, as well as under the two general laws for afflicted children, Act No. 174 of 1913 and Act No. 283 of 1939, and also under the crippled children's law, Act No. 158 of 1937.

Children's hospitalization laws, 1925-40. — More than half the laws affecting the University Hospital passed between 1925 and 1940 concerned children, and the changes were far-reaching. After Act No. 236 created the Michigan Crippled Children Commission in 1927, any crippled child could be treated either at the University Hospital or at any

other hospital having an orthopedic surgeon, the commission to approve both surgeons and hospitals. Surgeons' fees in all hospitals except the University Hospital as well as transportation and hospital expenses were to be paid by the state. The commission was to locate as many as possible of the state's crippled children and report what was being done for them. It was to conduct diagnostic clinics and, in general, to secure the best possible surgical and medical treatment for the children, as well as to take charge of their convalescent care and education. By a further act (No. 317), in 1929, the commission was given the additional responsibility of follow-up supervision.

In the same session in which the Crippled Children's Act was passed, Act No. 274 of 1913, known since 1927 as the Afflicted Children's Act, was amended to provide for the treatment of obstetrical cases.

Although the 1927 Crippled Children's Act was supposed to end hospitalization of crippled children as provided under the old 1913 law, there is evidence that the law was sometimes used for the local hospitalization of "afflicted" but not crippled children. In fact, many probate judges continued to send crippled children to the University Hospital under the 1913 act.

In 1926-27, 2,614 patients were registered in the University Hospital under the children's act of 1913; the following year there were 2,760, and in 1928-29, 3,356. Apparently, no statistics are available on the corresponding numbers of patients registered under the Crippled Children's Act of 1927 until 1929-30, when there were fifty-three children under the Crippled Children's Act as against 4,244 under the Afflicted Children's Act, with seventeen children registered from state institutions under the amended Act No. 138 of 1881.

In June, 1931, the Crippled Children Commission obtained authority to pass upon hospital bills incurred under the Crippled Children's Act, but since the hospitals and courts were not obliged to report on children committed under the Afflicted Children's Act, it still had no way of estimating the total hospitalization of crippled children. Two years later an amendatory act (No. 248) sought to improve the situation, but conflicting provisions made the law difficult to administer. It introduced the use of local hospitals for "afflicted" children, gave the Crippled Children Commission charge of the administration of the Afflicted Children's Act, and forced a sharper separation of "crippled" and "afflicted" cases by making it illegal to hospitalize a crippled child under the Afflicted Children's Act.

Since under the adult acts only patients more than twenty-one years old were entitled to aid and under Act No. 248 of 1933 only persons under eighteen could be treated under the Afflicted Children's Act, there was no legal way to hospitalize "afflicted" persons between seventeen and twenty-one years of age. Act No. 5 of 1934 removed this difficulty.

Contradictory provisions in Act No. 248 regarding fee schedules and modes of payment as between the counties and state brought some confusion. The first difficulty was temporarily solved by the adoption of a satisfactory fee schedule. The commission also decided in 1933 to approve no hospital bills under the Afflicted Children's Act except those for fifteen-day treatment periods for which advance permission had been obtained, thus preventing state payment for children not hospitalized under proper probate court orders.

Hurley Hospital at Flint, Fairmount Hospital at Kalamazoo, and the Northern Michigan Children's Clinic at Marquette had been regarded as "branches"

of the University Hospital, but when Act No. 248 went into effect the two former hospitals were made approved hospitals for afflicted children, the Marquette clinic remaining as a branch of the University Hospital.

In a 1935 ruling the commission provided reimbursement to the state by the counties for expenses incurred in cases of children suffering from adult types of tuberculosis, venereal diseases, or other communicable diseases and committed to hospitals under the Afflicted Children's Act. This became law in 1939.

The sweeping change of policy involved in Act No. 248 of 1933 caught most local officials unaware, and thousands of court orders under the old children's law of 1913 had to be returned for correction. But despite flaws, mostly corrected later, the act had a more pronounced effect on the over-all administration of children's hospital relief than did the special legislation and establishment of the Crippled Children Commission in 1927. The University, in June, 1933, was the only institution approved under the Afflicted Children's Act. A year later, in 1933-34, there were more than one hundred approved institutions with a resultant decrease in the University Hospital of nearly twelve hundred patients committed under the Afflicted Children's Act. Registrations under the Crippled Children's Act rose from 190 to 1,049, and the commission reported that the University Hospital increase accounted for more than three-fourths of the year's increase in cases for all hospitals under the Crippled Children's Act.

As a result of continuing dissatisfaction with the allocation of fees between state and counties, the old children's law of 1913 was once more amended. In 1935 Act No. 94 made transportation expenses of afflicted children rechargeable to the counties, but left treatment fees payable by the state. But then a new difficulty arose; the state appropriation for children's medical care was not adequate to cover physicians' fees. The commission estimated in 1936 that about one million dollars should have been added to the fund to cover these fees. The physicians, however, agreed to accept a nominal fee of one dollar a case during the 1934-36 biennium, and within a year a more liberal schedule was tentatively adopted.

The Afflicted Children's Act was further amended in 1935 by Act No. 208, which required that before a child could be hospitalized an agreement to reimburse the state for expenses was necessary between the auditor-general and the child's parents or guardian. Within two years such repayments rose from $841.92 to $11,723.88.

Three amendatory statutes in 1935 also changed the Crippled Children's Act of 1927. One (No. 169) shifted transportation costs to the counties, directed hospitals to report on the admittance and discharge of patients, and specified that no person should be considered a recipient of pauper aid because of inability to pay for a child's treatment. Another act (No. 182) prescribed that all collections from parents and school districts, as well as gifts to the commission, should be deposited to the commission's credit in the state's general fund. A third (No. 207) made repayment pledges by parents or guardians mandatory and fixed the amount per day payable by the state and local school districts for hospital schools. In 1937 these amendments were consolidated in Act No. 158, which replaced Act No. 236 of 1927.

This new law included the needed definition of "crippled child" and gave the commission additional responsibility, financial backing, and greater authority to enforce its decisions. It became responsible for handling each case committed

by a probate judge. Collections, legislative appropriations, and gifts were to be held, as before, distinct from other state funds, but the new law omitted the provision that such funds be disbursed "as appropriated by the legislature." The commission and the auditor-general had the right to check all disbursements.

The new law emphasized preventive measures. Aid to children suffering from conditions that lead to crippling was authorized, and facilities for finding and serving such children, and those already crippled, especially in rural areas, were improved. In addition to diagnostic clinics, an expanded outstate service provided preventive treatment, minor orthopedic operations, follow-up supervision, and outpatient and convalescent service. In special cases transportation to clinics and treatment centers was furnished.

The commission was authorized to approve homes or hospital outpatient departments where adequate care and prevocational training could be provided those crippled children who would benefit very little from treatment. Rates for medical and hospital service were fixed for the first time: $4.50 a day for hospital service, doctors' fees at $75 for a major operation, and $200 for any one patient in a single year. One-half the costs of custodial cases was to be recharged to the counties; local school districts continued to furnish some support for the hospital schools, but under the new Crippled Children's Act all other expenses were paid by the state.

The desired definition of "afflicted child" was furnished by Act No. 217 of 1937, which also effected certain other changes in the Afflicted Children's Act, but two years later the old much-amended children's act of 1913 was replaced by Act No. 283. It extended the commission's jurisdiction in "afflicted" cases, established further financial controls, and systematized provisions added to the old act by the various amendments. It also limited the state's liability, allocating to the counties according to population three-fourths of the fund available each year, with the remaining one-fourth to be distributed according to need. The rate at which counties could consume their quota was also limited, and they were not allowed to reimburse themselves from later allotments. The commission was thus relieved from approving more services than could be paid for from available funds, and the state from the necessity of making supplementary appropriations.

In 1932-33, the year before the local hospitals were permitted to receive afflicted children under Act No. 274 of 1913, the number of patients in the University Hospital under the Afflicted Children's Act was nearly twice the number under the Afflicted Adult Act of 1915. By 1935-36 more patients were registered under the adult act of 1915 (No. 267) than under all three children's laws. In 1939-40, by far the greatest number of patients received under any one law was registered under the Afflicted Adult Act of 1915.

Helen Travis

SELECTED BIBLIOGRAPHY

Annual Report of the University Hospital of the University of Michigan Compiled Laws of the State of …, 1897. Public Acts [of the Session of] President's Report Proceedings of the Board of Regents …

The Heart Station

During the period when Dr. A. W. Hewlett held the chair of medicine at the University (1908-16) there was widespread interest in the irregularities and other abnormalities of the heartbeat, and knowledge in this field was expanding very rapidly. Dr. Hewlett himself had made important contributions to this subject, and Dr. J. G. Van Zwaluwenburg was also deeply interested in it. As soon as the necessary funds could be obtained Dr. Hewlett purchased a string galvanometer, and electrocardiograms were taken for the first time at the University Hospital in the spring of 1914.

Dr. Frank N. Wilson, who was appointed Assistant in the Department of Internal Medicine upon his graduation with the class of 1913, was assigned the task of installing and operating this instrument. Since no other space was available it was placed in Dr. Hewlett's private office, a small room separated by a thin wooden partition extending half way to the ceiling from the general office of the department, which was on the second floor of the Medical Wing of the Old University Hospital. The electrocardiographic tracings were carried downstairs, where a tiny darkroom was available for their development. In spite of these meager and inconvenient facilities, many interesting observations were made and a number of papers were published. With Dr. Hewlett's help arrangements were made for recording the venous pulse, taken with a Frank capsule, simultaneously with the electrocardiogram, and this added greatly to the value of the tracings. One of the most important studies carried out dealt with the production of atrioventricular rhythm in normal subjects after the administration of atropin.

In 1916 both Dr. Hewlett and Dr. Wilson left Michigan and during the next four years relatively few tracings were taken. When Dr. Wilson returned to Ann Arbor in 1920 the equipment had been removed from its old location. It was not in good working order, and there was no available space where it could be installed. Nothing further was done until 1922 when Dr. George Herrmann, a Michigan graduate, joined the staff. At that time, with the help of Dean Vaughan, a special appropriation was obtained which made it possible to purchase new equipment and to construct a small laboratory where it could be set up. This laboratory included a small passageway and some space beneath the stairs leading to the medical amphitheater. As a result many of the waves on the tracings obtained were produced, not by the patient's heartbeat, but by the students rushing to and from their classes. In the early summer of 1922, when this new laboratory was completed, Sir Thomas Lewis of London visited the University, and this visit did a great deal to stimulate interest in electrocardiography.

In order to defray the expense of operating the new laboratory, the Hospital made a charge for each clinical electrocardiogram taken. A technician, Miss Evelyn Turner, was secured, and she soon became expert at operating the galvanometer. During the next three years about 4,500 electrocardiograms were taken and several research projects were carried out, among which may be mentioned Dr. Herrmann's studies on ventricular hypertrophy.

When the new University Hospital was under construction, arrangements were made for a wiring system whereby it became possible to take an electrocardiogram on any patient in the Hospital without making it necessary for the patient to leave his bed. In 1924 Professor Willem Einthoven visited Ann Arbor, and negotiations were begun with him at that time for the construction in Holland

of a new galvanometer which would make it possible to take two electrocardiographic leads simultaneously. After much delay this galvanometer, which was actually constructed in Einthoven's laboratory, was obtained in the summer of 1927. It proved to be a wonderfully fine piece of apparatus, and much of the research work carried out in the Heart Station since that time could not have been done without it.

The Heart Station was moved to the new Hospital in the autumn of 1925. Dr. Herrmann was succeeded by Dr. Paul S. Barker. The additional help, space, and equipment made it possible not only to serve the Hospital more adequately, but also to do research which has been of the utmost importance. Studies of the distribution of the electrical currents produced by the heartbeat within the body, of the electrocardiograms produced by human bundle branch block, of precordial leads, of the areas of the electrocardiographic deflections, and of experimental and clinical coronary occlusion may be mentioned.

In 1932 Dr. Franklin D. Johnston joined the staff. He not only has taken an active part in many of the studies already mentioned, but also has done a great deal of work on the registration of heart sounds and on the adaptation of the cathode-ray oscillograph to the study of the electrocardiogram.

Frank N. Wilson

SELECTED BIBLIOGRAPHY

"The Department of Internal Medicine." Calendar Catalogue … "Medical Faculty Minutes" Proceedings of the Board of Regents … "The Heart Station of the University of Michigan Hospital."

The Tuberculosis Unit

On January 25, 1926, under the direction of Dr. George Sherman, a fifty-bed unit was opened on the second floor of the Convalescent Hospital for the medical treatment of tuberculosis. This was the first time in the history of the University Hospital that separate beds had been set aside for this specific purpose, although in 1902 George Dock, who was then Professor of Medicine, had written an article urging that a special hospital for this purpose be constructed. While this arrangement served its purpose well as a beginning, it was soon appreciated that the space for beds, offices, X-ray facilities, and laboratories, was inadequate. In order to remedy this situation the legislature of Michigan appropriated $250,000 to add two floors to the University Hospital for the care of patients with pulmonary tuberculosis. They were first occupied by patients on July 21, 1931. Accommodations are provided for ninety-eight patients in six single rooms, ten two-bed rooms, and eighteen four-bed rooms. There are ample workrooms for examinations, treatments, laboratory examinations, including fluoroscopy, and a room for the demonstration of patients and X rays to students.

The unit is a part of the University Hospital and Medical School. A medical staff is maintained by the Department of Internal Medicine, through which are rotated all of the instructors and interns.

Dr. John B. Barnwell has headed the medical staff since 1928. In this way the Hospital is sending out into practice in the state of Michigan, year after year, physicians who are especially trained in all of the modern phases of the treatment of tuberculosis. The Department of Surgery maintains a division of chest surgery under the leadership of Dr. John Alexander, who is directly responsible for the tuberculosis patients who are admitted primarily for surgical measures.

Instruction of medical students in regard to tuberculosis is carried out in the last three years of their course. In the second year, one or more groups are giving instruction in physical diagnosis. In the third year, groups may elect work in tuberculosis. All fourth-year students pass through the unit in small groups for discussion of diagnosis and treatment.

Cyrus C. Sturgis

SELECTED BIBLIOGRAPHY

"Enlarged Tuberculosis Unit in Operation." "Some Reasons Why There Should Be a Hospital for Consumptives in Connection with the University Hospital." "Hospital Facilities Are Increased."

Social Service Department

The Social Service Department of the University Hospital began with the passage of the Michigan Medical Care Acts, the first of which (Act No. 274), passed by the legislature in 1913, permitted judges of probate to send to the University Hospital children suffering from congenital defects or diseased conditions. Shortly afterward, a similar measure (Act No. 267) authorizing the care and hospitalization of adults, was passed by the legislature. These acts determined in large part the designation, number, and type of patients received for clinical teaching purposes. They came particularly from indigent or marginal groups for which such care was otherwise not available: children who were wards of the state, congenital cripples, psychopathic cases needing medical care or surgical treatment, children with curable maladies or deformities whose parents were unable to provide proper treatment, crippled children, sterilization cases, and tuberculosis cases.

These measures brought many new patients needing special services to the hospital. Efforts to provide some sort of social service for hospital patients had, as a matter of fact, begun almost with the opening of the old University Hospital. The University Hospital Circle of the King's Daughters was formed in 1892 to give assistance to patients. These efforts, however, were voluntary and not always continuous. Within the Hospital, moreover, the nurses' service in 1912 had designated a particular nurse to act as a part-time social worker.

Mary C. Merriweather was Supervisor of Social Service in 1918 and Imogene Poole in the years 1919-21. Offices were assigned the Social Service Department in 1919, and in 1920 Dr. Christopher Parnall, then Director of the Hospital, reported that the Rotary Clubs were interested in maintaining in the Hospital a social service worker who would care particularly for the welfare of children sent to the Hospital under Public Act 274. In 1921 Mrs. Elmie W. Mallory (Ph.B. Buchtel '97, A.M. Michigan '20) was made Supervisor of Social Service in the Homeopathic Hospital. When the

University Hospital and the Homeopathic Hospital were combined in 1922, Miss Dorothy Ketcham was appointed Social Service Director to integrate the Social Service Division of the University Hospital. Mrs. Mallory became Director of Social Service in the State Psychopathic Hospital.

In his report for 1920-21, Dr. Parnall said: "The role of a University Hospital in a broad program of education is to teach people the means of protecting and restoring health and preventing disease, both directly and through those who by their preparation and calling are fitted to serve in this field." With a social service program thus recognized, the first few years were spent in defining objectives, in improving methods so as to increase the satisfaction of the patients, in selecting personnel, and in establishing an improved system of records.

The Hospital School. — Among the important objectives of the service was the Hospital School. The King's Daughters of Ann Arbor supported the first teacher and have continued to help the program. Through the Michigan Crippled Children Commission the state also made funds available for the instruction of crippled children. New activities directed toward constructive programs were introduced in 1918 by Claudia Wanamaker. Since 1925 the Ann Arbor Kiwanis Club has given financial support to the program. In 1928 Galens, a senior medical society, undertook the support of a hospital workshop. The hospitalized child has been able to continue his schooling in this way, advancing with others of his age and in some cases graduating from school at the proper time. Although state funds make no provision for teaching preschool children, who at times make up almost half the total enrollment, a definite program has been set up for them as funds have become available.

Occupational therapy. — At first, occupational therapy for adults was carried on through voluntary service. Miss Helen James was appointed in July, 1920, to take charge of social work among dermatological cases being treated by Dr. Udo J. Wile. The work was financed through the Michigan Department of Health. Miss James introduced basketry, sewing, and similar activities, and an early exhibit revealed the value of such employment.

The facilities for occupational therapy include a large central shop and supplementary ward units. Some work can be carried to the patient's bedside. The central shop, largely equipped through the Galens' support, is a large, pleasant room for wheelchair or bed patients. The shop is equipped with looms, sewing machines, a jigsaw, carpenter's benches and tools, leather and reed tools, rug frames, a knitting machine, hoops, hooks, needles, as well as art and craft magazines and instruction books. It is open all day and has an average attendance of one hundred. The type of work varies according to the patient's individual interests and the length of his stay in the hospital. Some accept the idea of occupation eagerly and engage in comparatively vigorous activity; others require a limited or graduated program.

An important part of the social program is the library service. In 1935 a regular library service was set up on a full-time basis, and books were distributed on schedule. This service covers every unit in the Hospital. Reading lists are provided, and awards in the form of reading certificates are made on the basis of achievement.

Social service in the Hospital grew up as a result of case work with the individual patient. The work concerns itself particularly with the patient and with his reinstatement, if possible, as an effective member of society. The program

in the University Hospital has adhered closely to lines laid down by the American Association of Medical Social Workers, the American Hospital Association, and the American College of Surgeons. As standards for personnel have improved new methods have been adopted for handling the work of the department. These improvements include a system of case recording, staff and group discussions, statistical sheets developed for the use of the case workers and the consultant, plans for better student instruction, and better and more accurate medical data. A further function of social service has been the matter of follow-up, which often concerns physician, judge, patient, and family.

Dorothy Ketcham

SELECTED BIBLIOGRAPHY

"The Crippled Child's Education at the University Hospital." "The Department of Social Service, University Hospital." "The Medical Aspects of the Depression." Michigan Hospital Handbook. 100,000 Days of Illness. A Study of 276 Children Hospitalized at Intervals over a Fifteen-year Period. Public Acts. Morse, Harriet. Crafts in a General Hospital. Occupational Therapy, October, 1936. President's Report Proceedings of the Board of Regents …

Metabolism Research

The first deliberate attempt by a member of the Department of Internal Medicine to advance the knowledge of metabolic processes in patients was begun by Dr. L. H. Newburgh when he came to the University as an Assistant Professor in the fall of 1916. He suspected that the kidneys could be impaired by food very rich in protein. The first experiments were carried out in the Hygienic Laboratory because the department was without an experimental laboratory in the University Hospital. Shortly thereafter, the old laundry behind the hospital was renovated and in part given over to the members of the department for their investigations. Dr. Newburgh was assisted in the study of nephritis produced by diets rich in protein and its products by Dr. Theodore L. Squier, Dr. Phil L. Marsh, Dr. Arthur C. Curtis, and Miss

Sarah Clarkson (d. 1931). More recently the work has been conducted by Dr. Margaret W. Johnston; and Dr. Richard H. Freyberg has been concerned with the question of the recoverability from the injury produced by the diets.

As late as 1918, the treatment of diabetes mellitus was still very unsatisfactory. Dr. Newburgh and Dr. Marsh began at that time to try to improve the dietary control of the disease, and by 1922 they were able to report that the disease could be adequately controlled in most adult patients by the plan they had developed. Dr. Floyd H. Lashmet and Dr. Newburgh undertook a study of the edema that occurs with one form of chronic nephritis. They were able to work out a plan that usually succeeds in eliminating the edema and preventing its recurrence.

Obesity is one of the most important causes of chronic illness in middle life. Earlier students had thought that the condition was often hereditary and unavoidable. This conception seemed highly unlikely. In order to study the question adequately, methods for measuring the exchange of energy and of water first had to be devised. Dr. Frank H. Wiley was of the greatest help in developing these two techniques. Dr. Newburgh and Dr. Margaret Johnston, using these new methods, then demonstrated that obesity is always caused by an inflow of energy greater than the outflow and that it can always be overcome by appropriate dietary methods.

Dr. Newburgh, Dr. Johnston, Dr. Jerome Conn, Dr. Florence White, and Dr. Elisabeth B. Stern engaged in an elaborate investigation of the normal and abnormal metabolism of carbohydrate. Dr. Coral A. Lilly for some years investigated the nature of dental caries as related to diet.

Since the opening of the University Hospital the group has had adequate laboratory space and a sufficient appropriation for current supplies. Salaries for fellow workers have always had to be obtained from sources outside of the regular budget. The work has been seriously hampered by inadequate financial support.

L. H. Newburgh

SELECTED BIBLIOGRAPHY

"Professor of Medicine Augments Teaching with Research."

University Hospital Pharmacy

During the years (1869-90) forming the initial period in the history of the University Hospital, there was no obvious need for a separate pharmaceutical service.

In 1892, when the University Hospital was moved to new quarters on Catherine Street, the rules and regulations adopted for the conduct of the newly created post of Apothecary were as follows:

The Apothecary shall be subordinate and responsible to the Resident Physician. He shall have the immediate care and custody of all drugs, medicines and other articles belonging to the department and be responsible for the same. He shall compound and make up all medicines which may be prescribed with exactness and promptitude. He shall deliver no medicines or other articles unless the same shall be duly entered upon the prescription or order books, or ordered in writing. He shall put up the medicines intended for each ward separately and shall annex to them labels containing the names of the patients for whom they are respectively prescribed, with written or printed directions for their use. He shall deliver them promptly to the nurses of each ward to be by them administered

to the patients. He shall be responsible for the correct preparation of all prescriptions. He shall have charge of all the instruments belonging to the Hospital and shall be responsible for them and their good order. He shall keep an account of them and shall never allow them to leave his possession without taking a proper receipt or ticket from the person so taking them. He shall make an inventory of all instruments belonging to the hospital, when he enters upon his duties; and, on giving up his charge, he shall furnish the Superintendent a like inventory countersigned by the Resident Physician. He shall keep the dispensary and everything pertaining to it clean and in perfect order, and the same shall remain open from 8:30 a.m. to 8:00 p.m., in his charge. He shall observe economy in everything relating to his department, be particularly careful in the preparation and delivery of medicines, and permit no noise, confusion or disorder in his premises.

R.P.

Having thus outlined his duties, the Regents authorized that an apothecary be appointed in the University Hospital for one year at a salary of $200. In carrying out the intent of the Regents the executive committee appointed James Perry Briggs ('91p) to the position.

Mr. Briggs's duties covered a very wide field. He prepared all the sutures used in the operating rooms, and, after the initial pictures taken by Carhart and Herdman, he was assigned the task of taking the first X rays used here, continuing all work of this nature until the Department of Roentgenology was established.

Mr. Briggs's association with the institution cannot be passed without mention of his wide acquaintanceship, especially in the "old Hospital," and his kindness to those with whom he worked. He was particularly happy to help the nurses. He removed stains from uniforms or best dresses and provided remedies for headache, a cold, or a cold sore. His "favorite prescriptions" were never disclosed, and no record of them has ever been found.

A bronze tablet now placed at the location of the present Hospital Pharmacy befittingly states: "In Memory of James Perry Briggs, Ph.C., Pharmacist to the University Hospital, 1891-1927. Universally Respected and Beloved by Those Connected with This Hospital During His Long and Faithful Term of Service."

Mention of Perry Briggs, despite the fact that a written record of the Hospital Pharmacy is his biography, would be quite incomplete without coincident mention of "Pat Scully." The bronze tablet opposite that of Mr. Briggs tells its story. This continuing association of these two names is very satisfying to their friends: "In Memory of Patrick Henry Scully Who Devotedly Served This Hospital In Many Capacities For More Than Half A Century. 1875-1929."

In 1920 Amos Ludwig Kroupa (Ph.C. '22) became Assistant to the Pharmacist. He retained this post until 1936, when he accepted an appointment as Chief Pharmacist at the Evangelical Deaconess Hospital at Evansville, Indiana.

In 1925 Harvey A. K. Whitney (Ph.C. '23) joined the staff, and he became Chief Pharmacist upon the death of Mr. Briggs in 1927.

The department has gradually grown in range of activities and in personnel. During a changing materia medica the Hospital Pharmacy has been allowed to engage in many manufacturing activities that were previously prohibited. The staff in 1940 consisted of eleven registered graduate pharmacists and five unlicensed assistants. The products of the department are obtained from the three kingdoms and are prepared to be administered by all natural bodily orifices, as well as some man-made, as when access is to the circulatory system.

One interesting development in the growth of the department has been the

establishment of a pharmacy internship plan, adapted from present medical practices. Six pharmacy interns are quartered with the medical interns and enjoy the same privileges. The plan calls for the selection of a candidate from among the recent graduates of one of the member schools of the American Association of Colleges of Pharmacy. Such an applicant when accepted receives an appointment as junior grade pharmacist for one year. He may be reappointed for a second year as senior grade pharmacist.

H. A. K. Whitney

Hospital Records and Statistics

The very first record available on any patient in the University Hospital is dated October 5, 1881. This is Case No. 1, which is listed in a leatherbound book and is the first of a series of records maintained by the Department of Gynecology, at that time under the direction of Dr. Edward Dunster. This book is entitled "Gynecological Clinic Record, Medical Department" and contains the records on patients seen in that department from October 5, 1881, to December 5, 1882.

The history sheets in this record book were outlined forms calling for routine statistical information about the patient, such as age, marital status, number of children, age of oldest, and age of youngest. Ten lines were reserved for enumeration of the symptoms and three lines for the physical examination. Space was also left for a rather detailed gynecological history. At the bottom of the sheet was a space for diagnosis. Opposite this page was a ruled sheet for recording treatment.

The diagnosis noted on this first patient was menorrhagia, and on the treatment sheet under date of October 26 is a note, "No abnormal condition of the interior of the womb. Mucous lining removed with curette." Under date of November 8 appears another note — "Uterine mucous lining again removed." Patient No. 3 was diagnosed "vesico-vaginal fistula traumatic." On the treatment sheet under date of October 28 is noted: "Fistula closed; eight sutures (silver) (one horse hair)"; November 4: "Stitches removed; operation incomplete due to neglect after operation (anesthesia, ether). Patient left Hospital." January 17: "Returned; second operation successful. Patient dismissed." These examples are typical of the extent to which examinations were written up and operations described at that time.

Record systems were apparently established about the same time in other departments, each one maintaining its own separate case number for the patient and retaining in the department all available information learned.

It was interesting to find a sheet in this original book entitled "Examination of the Urine." This contained statements as to the physical characteristics including reaction, color, and specific gravity. After this, was chemical examination, which called for urea, phosphates, bile, albumen, urates, and sugar. The microscopical examination called for crystals, anatomical elements, casts, and, finally, other morphological elements. At the end were reserved a few lines for pathological indications.

It is difficult to determine just when indexing of diagnoses was actually begun; however, shortly after the history forms were established, these various clinical departments formulated their own individual systems of recording diagnoses and operations. No uniform system was used, some preferring to list the diagnoses alphabetically, and some

by numbers. Operations were recorded in a similar manner.

Shortly after the University Hospital was opened in 1925, Dr. Harley A. Haynes, the Director, obtained the services of Miss Florence G. Babcock, at that time record librarian of the Peter Bent Brigham Hospital in Boston, who assumed charge as Record Librarian. At the same time the various departments were persuaded to submit all information pertaining to a given patient to a central record room, where it could be included in a unit patient record. In addition to including the various examinations made by different departments on any one patient, the record thenceforth was to include all X-ray reports, pathology reports, bacteriology reports, and other special laboratory procedures. On admission to the Hospital, each patient was to be given a registration number, and this was to be employed uniformly by all the departments in which the patient was seen. Coincident with the formation of the unit system, the Hospital staff adopted the Massachusetts General Nomenclature of Disease as the standard nomenclature to be used in the Hospital.

The staff doctors were then requested to list the various diagnoses and operations on the front sheet of each patient's unit-record, and these in turn were recorded on special cards in the central record room by trained record librarians. For reference purposes the diagnosis, secondary diagnosis, name, operated or not operated, registration numbers, service, sex, age, registration date, date of death, date of previous registration, and classification were recorded.

With this new system it became possible for the doctors to obtain for study all cases of any one diagnosis seen in the University Hospital, regardless of who made the diagnosis. In addition, all information pertaining to a patient could be obtained in one record.

In 1933 the executive staff of the Hospital entertained the advisability of establishing a large cancer clinic. In the course of developing this clinic various methods of recording routine statistical information were studied, and the so-called Hollerith punch card system was adopted. Dr. H. M. Pollard, at that time Instructor in the Department of Internal Medicine, was appointed to take charge of establishing this unit for hospital statistics. He was succeeded July 1, 1937, by Dr. Isadore Lampe, Instructor in the Department of Roentgenology.

Space was made available for this new unit on the ground floor of the University Hospital, and adequate tabulation machinery was obtained. From July 1, 1934, all routine statistical information relating to patients, and all their diagnoses and operations, have been recorded on punch cards. This includes the patient's registration number, age, race, status, classification, service, residence, all diagnoses and operations, Kahn report, death, autopsy, X-ray report, pathology report, and condition on discharge.

The nomenclature employed beginning July 1, 1934, was still the Massachusetts General System, but diagnoses were given numbers which could be utilized in the punch card system, and in so doing, space was made available for the addition of new diagnoses.

A doctors' study room was built in connection with the Statistical Unit and furnished with comfortable chairs convenient for studying records. All doctors studying cases utilize this room, so that records are not distributed to various offices.

This whole method of tabulation for hospital records is proving highly satisfactory and serves as a great stimulus to the staff physicians making careful and accurate statistical analysis of various diseases, forms of treatment, and results.

The records themselves have been improved by typing all inpatient histories and physical examinations. Outpatient notes are still made in longhand; case summaries, and in some instances progress notes, are typed. An effort is made to have all statements relating to types and results of treatment as specific as possible so that the information may be made available for study at any future date.

H. M. Pollard

SELECTED BIBLIOGRAPHY

"The Records of the Hospital." "Gynecological Clinic Record, Medical Department," "Minutes of the Executive Staff of the University Hospital,"

Notes

• * 1.1

  The grants for the running expenses of the Neuropsychiatric Institute in recent years constitute another exception to the rule of self-support.