Worcester Medicine
Summer 2004

FROM THE EDITOR
Why Churchill in Worcester Medicine?
By J. Paul Lock, MD

President's Message
By George Abraham, MD, MPH

The Most Important Patient of Our Time
By William G. Lavelle, MD

File of Life Program
Physicians, do your patients have this on their refrigerator?
By Nancy Pederson-Gac, and Tom Moore

As I See It
By Bruce Karlin, MD

:LEGAL CONSULT:
The New Informed Consent?
By Peter Martin, esq.

Historical Perspective
The Story Behind Worcester's Poor Farm
By Sande Bishop


Why Churchill in Worcester Medicine?
BY J. PAUL LOCK, MD

What relevance does the famed British leader Winston Churchill have to doctors in Worcester?
The response is simple. There are certain professional and personal values in common to all medical doctors that supercede the specific "frays" of the moment.
Worcester Medicine is the official publication of the Worcester District Medical Society, and as such, strives to unite physicians on the basis of values held in common.

Which brings us to Churchill, the subject of Doctor Lavelle's scholarly oration given at the District Medical Society's 2004 meeting. People mistakenly think that Churchill's greatest accomplishment was standing up to the tyrants of the Third Reich. We beg to differ, agreeing with author William Manchester that Churchill's greatest achievement was the ability of this one man to stand alone in 1938 as a "back bencher", because his views about right and wrong were not popular with ruling powers in Parliament.

This journal prints pieces by local writers dealing with issues fundamental to the practice of medicine. The articles are subdued, but the messages are often disquieting. Worcester Medicine gives voice to doctors like Bruce Karlin and Robert Lebow who recognize wrong and then offer remedies. The readership of Worcester Medicine is also fortunate to have the sage advice of Attorney Peter Martin and the historical perspectives of Sande Bishop in each issue.

Peter Lindblad's writing on Medical Error Prevention that appeared in the previous issue of Worcester Medicine needs to be read and then read again, by every doctor – irrespective of their practice format or system alignment. The importance of Peter's article supercedes the frays of the moment, even if it was printed by a local medical journal!

Finally, let no physician forget the quiet elegance of the obituary articles that appear in Worcester Medicine. There's a kind of nobleness that happens when the name of a physician, now removed from the obligations of busy clinical medicine, is written for the last time in a medical journal.

President's Message
BY GEORGE ABRAHAM, MD, MPH

As our new year begins, I'd like to thank each of you for the opportunity to serve as your president for a second term. It is especially rewarding to be at the helm of an organization that works hard to meet the many challenges that face us in the practice of medicine today. I am proud to see the wonderful things physicians do for our community, and the fact that altruism is still alive.

As always our political efforts remain strong. We continue to represent physicians' interests to the legislature and have expressed our point of view to the media on issues of public health and professional consequence: the smoke free workplace bill, compensation of medical injuries, liability reform and the use of clean syringes. 37 physicians have appeared on our TV program, 'Health Matters' educating the public on disease prevention and treatment options.

WDMS programs are thriving and it gives me pride that our organization is respected and admired. WDMS has forged relationships with other organizations and continues to explore new programs and initiatives.

Armed with the collective power of our membership, we are an important voice in promoting a healthy society. I realize how difficult it is to make time for society activities but I encourage those who are not involved to become active. Our profession depends on a unified front. Recently the AMA declared Massachusetts as the 20th state in medical liability crisis due to a deteriorating medical liability climate and the growing threat of patients losing access to care. We need to do whatever we can, otherwise we may see our colleagues and our profession steadily vanish.

Sincerely,

George Abraham, MD, MPH
President

Dr. Abraham is Director, Ambulatory Care and Preventive Medicine, Associate Program Director, Internal Medicine Residency Program, St. Vincent Hospital @ Worcester Medical and Assistant Professor of Medicine, University of Massachusetts Medical School.


The Most Important Patient of Our Time
BY WILLIAM G. LAVELLE, MD

On November 30, 1874, a baby boy was born two months premature at Blenheim Palace, Oxfordshire, England. The infant was christened William Spencer Churchill and was to become the man many call the greatest Englishman of all time and the savior of Western civilization.

Churchill's early preschool years were spent in Dublin, Ireland. Young Winston sustained the first of three serious head injuries while a small child. It occurred while he was riding a donkey in Dublin's famous Phoenix Park. He saw several horsemen approaching and because of a vivid child-hood imagination, decided they were the feared Fenians about to attack. The small boy kicked his donkey and was thrown to the ground suffering a concussion.

As a young military officer, Churchill inadvertently offended one of his peers at a dance, was pulled to his feet and knocked around the room until unconscious. Churchill awoke with his head in a spittoon. Churchill also had a succession of childhood illnesses including a near fatal pneumonia and a persistent inguinal hernia. On one occasion, while trying eagerly to impress his classmates, he threw himself from a bridge, once again suffering a concussion and severely injuring a kidney.

The young Churchill eventually found his way to Sandhurst military academy and graduated as a commissioned officer in the British cavalry. Following graduation, he traveled as a war correspondent to Cuba and there celebrated his 21st birthday. In Cuba, the young journalist developed a life-long attraction to Havana cigars and afternoon siestas. After returning to England, he embarked for India. It was while disembarking from a boat in India that Churchill slipped and severely injured his right shoulder. Forever after when riding a horse during a cavalry charge, or while playing polo, he was forced to have his arm strapped to his chest because of chronic dislocation.

Strangely enough, this injury may have saved his life. While involved in the last cavalry charge of the British Empire at Ombdurman in the Sudan, Churchill found himself surrounded by enemy dervishes. Lieutenant Churchill shot and killed the enemy around him and survived.

In 1900, at the age of 25, Churchill followed his father by becoming a conservative member of the first and greatest of all parliamentary bodies. Churchill continued to be worried about a slight speech defect or lisp, which caused him to have difficulty pronouncing the letter S. He would parade up and down on walks with his girlfriends and repeat, "Spanish ships I cannot see, for they are not in sight".

In 1904, after only four years as a conservative member, Churchill became a liberal. He continued as a member of the liberal party until 1922. During that year, while running for re-election for the parliamentary seat in Dundee, Scotland, he became ill at a critical moment of the campaign. He went to bed with a fever and abdominal pain. Within a short period of time, he was diagnosed as having acute appendicitis. He was taken to the operating room where his appendix was successfully removed.

Against his physician's orders, Churchill rose out of his sick bed in the immediate postoperative period, and with assistance was transported to various campaign stops on a litter from which he gave his traditional re-election speech. It was quite ironic that a man with his love of alcohol lost that parliamentary election to a prohibitionist. Churchill was quoted as saying, "In a twinkle of an eye I awoke to find myself without a seat, without a party and without an appendix".

Those 18 years had been quite eventful for the young politician. He left parliament in 1922 without his appendix, but he was back in 1924 as Chancellor of the Exchequer, once again a conservative. Churchill commented, "Anyone can rat once, it takes character to rat twice".

From 1929 to 1939, Churchill entered what his biographers have called the "wilderness years". Much has been made of Churchill's unhealthy life style at that time, which included 12-15 large Havana Cuban cigars a day as well as drinking a prodigious amount of alcohol. Clearly there was not a waking moment when he did not have alcohol in his blood. He rose at 8 a.m. and began drinking Johnny Walker Red scotch with soda. He had a very formal lunch, during which he consumed Pol Roger champagne, wine, and brandy and smoked one of his ever-present cigars of which there were over 3,000 in his humidor.

Following lunch, he would settle down for a siesta. Dinner was the daily main event, scheduled to take place around 8:30 p.m. and consisting of his lunch routine on a far grander scale. Following dinner and lively discussion, Churchill and his male dining companions would leave the table and gather for port, brandy, and cigars until approximately 10 p.m. Before the evening was over, he usually dictated four to five thousand words, frequently working until three or four in the morning.

Churchill during this period continued to suffer episodes of severe depression. He called them his "black dog". He felt that his chance for political greatness was slipping away as he moved from the sixth to seventh decade of his life.

Two events occurred during this period that could have easily cost Winston Churchill his life. The first occurred during one of Churchill's frequent visits to the United States. In December 1931, he stepped onto New York's Fifth Avenue, accompanied by his bodyguard/detective W.H. Thompson. He carefully looked down Fifth Avenue to make sure no car was approaching, stepped onto the street and was immediately struck by a speeding car coming in the opposite direction. Reports at the time say that he was "nearly killed".

One year later, while traveling in Germany and Austria, he became dangerously ill, contracting paratyphoid fever. It required a long hospitalization during which he had more than one relapse. For many months he was too weak to take part in any political activity. In fact, most of this time, this very active man was confined to a nursing home.

On September 30, 1939, Hitler invaded Poland and the world saw what Churchill had feared and forecast was about to begin. The world now entered a period when the fate of the entire western civilization would depend on this 5' 6", over- weight, eccentric, proud Englishman.

On May 10, 1940, Churchill became Prime Minister at the age of 65. From that day until June 1941, Great Britain stood totally alone against the greatest military power yet assembled. At home, great pressure was being put on the British government to negotiate a peace with Hitler that would have removed Great Britain from the war. Churchill's war cabinet voted by majority to end the war and make peace with Hitler. King George favored a negotiated peace. It was only by the slimmest majority Churchill was able to eke out approval from the larger cabinet to move forward despite the over-whelming odds favoring British defeat.

Joseph Stalin, no friend of the democratic west, was quoted when speaking of Churchill's role; "I could think of no other example in history where the future of the world so depended on the courage of one man". President Harry S. Truman said; "If you had gone like France, we might well be fighting the Germans on the American coast at the present time".

On December 24, 1941, in the White House, Churchill requested his personal physician Lord Moran (Sir Charles Wilson) to take his pulse while he was standing on his bedroom balcony. His pulse had reached 105 and he began to become very nervous. His lisp became pronounced and he described palpitations. Two days later, Lord Moran was summoned to the White House again. Examining Churchill, Lord Moran was certain that he had suffered a coronary occlusion. The treatment was total rest for at least six weeks.

As an ethical physician, Lord Moran was faced with a terrible dilemma. If he released this information, the world would hear that the Prime Minister was " an invalid with a crippled heart and a doubtful future". The doctor felt this would have a disastrous effect both on America, which had just joined the war, as well as on Britain. He also knew that if he did nothing, and Churchill suffered another severe attack, perhaps a fatal one, the world would say that, "I had killed him for not insisting on rest and treatment".

Lord Moran took his stethoscope out of his ears, replaced and listened again, and when Churchill inquired, "Is my heart all right?" Dr. Moran answered, "There is nothing serious". Two days later, on December 28, when they pulled out of the White House grounds, Churchill became severely short of breath and required them to stop the car and open the windows to help him breathe.

By this time, Churchill was diagnosed and had been treated for pneumonia on three or four separate occasions. Perhaps the most severe episode occurred immediately after the Tehran conference. The aging leader was touring North Africa and became gravely ill. He developed a very high temperature and was diagnosed with pneumonia involving his left lung. Once again, with the help of sulphonamides, he rose from a serious illness and returned to his post in London. Four years later the war ended. During that period Churchill suffered at least two more poorly recorded cardiac events.

Two weeks after the victory in Europe, Churchill lost his position as Prime Minister when the labor party won an overwhelming victory. In September 1945, he complained of chronic digestive problems and was diagnosed with diverticulitis.

The former Prime Minister became increasingly hard of hearing, frequently requesting to have his ears washed out. In 1950, he was seen at the Ear, Nose and Throat Department at King's College by Dr. Victor Negus, who diagnosed high-frequency sensorineural hearing loss. He had trouble with a chronic skin condition that required medication to relieve severe itching. Lord Moran thought it was perhaps due to his lifelong habit of two daily baths in very hot water, a diagnosis Churchill failed to accept. He developed increased swelling in his groin region for which, following unsuccessful treatment with a truss in 1947, Brigadier Edwards, a surgeon in the British army, recommended surgery.

Churchill was told to discontinue smoking because he was seven times more likely to have serious complications than a non-smoker. Churchill in response to Dr. Moran is quoted as having said, "I have taken more out of alcohol and tobacco than they have taken out of me". The advice went unheeded. At the time of the operation, multiple abdominal adhesions from his prior appendectomy operation were found. In 1947, Lord Moran described definite hardening in his retinal vessels and felt that his circulation was becoming quite "sluggish".

Churchill consulted Dr. Frank Anderson, an ophthalmologic surgeon at St. Mary's hospital in London, for problems with his vision and ingrown eyelashes. Churchill mentioned that he also consulted Dr. Alexander Flemming, the discoverer of penicillin, about his eye problem, but "He wasn't interested in me as patient, but a very unusual bug in my nose, a staphylococcus, which was very resistant to penicillin". Then, addressing Lord Moran with his famous grin, he said, "The bug seems to have caught my truculence. This is his finest hour".

In 1953, Churchill began having intermittent hemoptysis. He continued, however, to smoke. On occasion he consulted a chiropractor and had gone to an osteopath whom he indicated had "knocked me all about, but I was not the better".

Churchill continued to have periods of deep depression, but he had little regard for psychiatry. Again, while speaking with Lord. Moran, he said, "You know Charles, I don't like psychiatrists. One of them said that insulin produces a state of coma. When I asked if there was any danger in the treatment, he talked of irreversible coma". Churchill straightened up with a look of great contempt and said "Irreversible coma, indeed, what he means is death".

In his later life, Churchill was plagued with a series of strokes, some of them quite severe. On August 24, 1949, Churchill sustained a significant cerebral vascular accident while playing cards in Monte Carlo. He was left with problems writing as well as walking. He complained that there seemed to be, "A veil between me and things". He also lost sensation in his arm. Lord Moran tried to calm the former Prime Minister, "Winston, sensation doesn't matter". Churchill's prescient reply was, " Life is sensation, sensation is life".

Unfortunately, Churchill suffered another major stroke that left him with his left arm and leg paralyzed and twitching, a serious speech impediment, and a terrible problem with fatigue. He would also become extremely emotional without warning. He suffered from both dysarthria and dysphagia. Winston worked diligently with physical and other therapists and astonishingly, four months later addressed the British Conservative Party while standing, without any slurring of speech. Finally, after many promises to his deputy Anthony Eden, in 1955 he retired as Prime Minister. Thereafter, a further series of small strokes and a fractured hip visited Churchill. In July 1964, with great reluctance, he stepped down from the parliamentary seat that he had held for over six decades.

On January 25, 1965 two months after his 90th birthday while playing cards with his private secretary in London, Winston Churchill slumped to the table apparently unconscious, without a palpable pulse. Then unexpectedly, the great man looked up briefly and said in a firm strong voice, "No more" and died.

Acknowledgements:
I would like to acknowledge Sir Martin Gilbert, Sir John Keegan and Lord Moran. Without their important contribution to the Churchill record, this oration would not have been possible.


Physicians, Do Your Patients Have This on Their Refrigerator?
BY NANCY PEDERSON-GAC, AND TOM MOORE

The File of Life is a valuable partner in the delivery of pre-hospital medical care, particularly for elderly and "at risk" patients. The File of Life is in a quickly identifiable bright red plastic magnetic envelope that hangs on the refrigerator door. In the envelope is a standardized card that lists a person's medical history, allergies, medications, the physician's name and telephone number as well as family contact information. In an emergency, everything paramedical personnel need to know is quickly and efficiently available.

The File of Life program has been endorsed by a wide variety of organizations* in Worcester. First Responders would like to find the bright red File of Life envelope in every home where they are called for an emergency.

Physicians are being asked to help in the following ways:

  • Encourage your patients to have a File of Life

  • Have File of Life available cards in your office

  • Assign a member of your staff to assist patients complete the card.

A File of Life can be obtained by calling Worcester Emergency Medical Services at 508-856-8171.

A Symposium for physicians, nurses, social workers, case managers, First Responders, etc, is now being planned for Saturday, November 13, 2004. It will address File of Life issues as well as Pre-Hospital Care, Comfort Care and DNR, a Caregivers' Guide, medical and legal implications, and End of Life Care. Please save the date.

*Worcester Police Department, Worcester Fire Department, Worcester Emergency Medical Services, Central Massachusetts Area Health Education Center, Saint Vincent Hospital, UMass Memorial Health Center, Age Center of Worcester, Executive Office of Elder Affairs, Worcester office of Department of Public Health, CVS, Massachusetts College of Pharmacy and Worcester District Medical Society.

As I See It
BY BRUCE KARLIN, MD

Malpractice litigation is a wasteful use of medical care resources. It does not correct the problems for which it was intended. Medical injury goes uncompensated since attribution to negligence or to disease is difficult. We have no ways to assess the true scope of the problem. Is it bad doctors or is it the vagaries of diseases and their treatments? Are doctors simply the uneasy witnesses of patients overwhelmed by diseases whose detection and treatment elude science? Or, is the science mature and the practitioner inadequate?

The answer will not spring full blown from the head of Zeus. There needs to be trial legislation that can help resolve the question of blame. I offer a simple example that could serve as the template for other legislation to help us reformulate malpractice: the 'fair compensation' mammogram.

I propose legislation to include the cost of injury in the cost of the mammogram. We would ask that the cost of a mammogram be increased to subsume all the cost of failure to diagnose lawsuits. Patients would waive the right to sue for failure to diagnose, but be paid an equal portion of the added cost of the test within the year for a negative mammogram and a positive biopsy. There would need to be review of the results and ongoing refinement of the legislation - perhaps the time frame should be more than a year perhaps less. Perhaps low-grade cancers should not be compensated.

With such legislation in place we could put credible numbers on the false negative and false positive rates for this test. We might also actually evaluate each interpreter's accuracy and correct the less accurate readers.

If this trial is successful we could peal away additional layers of litigation with other fair compensation strategies. There would still remain a core of cases where there was negligence and the malpractice suit would serve its retributive purpose.

The New Informed Consent?
BY PETER MARTIN, ESQ.

For over twenty years, Massachusetts law has held that what a physician is legally required to disclose to a patient for purposes of informed consent is limited to relevant medical information about the proposed treatment. A very recent trial court decision may signal that Massachusetts courts will join a trend in other states to expand the physician's informed consent obligations to include disclosure of financial or other information related to the proposed treatment. As a result, physicians may have difficulty determining how much and what kind of information now must be disclosed in order to secure a patient's informed consent.

In 1982, the Massachusetts Supreme Judicial Court decided the Harnish case, a decision that established the rule that it is medical malpractice for a physician to fail to divulge sufficient information to enable the patient to make an informed judgment as to whether to grant or withhold consent to a medical procedure. What information a physician should disclose "depends upon what information he should reasonably recognize is material to the [patient's] decision." The Harnish court discussed the rule in terms of medical information, including the nature and probability of the risks involved, the benefits to be reasonably expected, the inability of the physician to predict results, the likely result of no treatment and the available alternatives and their risks and benefits. Ever since, the Harnish decision has been the seminal Massachusetts case on the doctrine of informed consent.

Early in June of this year, a trial court heard a medical malpractice case involving the death of a patient undergoing experimental treatment at Caritas St. Elizabeth's Medical Center. Roger Darke suffered from chronic heart disease and, when it was determined his earlier vein grafts had occluded, his physician suggested that he consider an experimental gene therapy conducted at St. Elizabeth's by Dr. Jeffrey Isner. Dr. Isner and the hospital were both 20% owners of a company called Vascular Genetics, Inc. which was formed in connection with the experimental gene therapy program. The trial court determined that because of this ownership interest, both the hospital and Dr. Isner had a financial incentive to encourage patients to participate in the gene therapy program. After consulting with

Dr. Isner, Mr. Darke agreed to participate in the gene therapy program, and within a day after undergoing the procedure, he died. The trial court assumed that the gene therapy was a substantial contributing factor to Mr. Darke's death.

The particular issue before the trial court was not whether the hospital and physician were liable for failing to disclose their financial interest in the experimental program, but merely whether to permit the jury to hear the allegation that the hospital and Dr. Isner were liable because of that failure. To make that decision, the court took as true relevant allegations in the plaintiff's complaint. The court noted that this issue was a matter of first impression for Massachusetts courts.

In its decision, the court referred to cases in other states in which the disclosure of non-medical information was deemed essential to informed consent. It cited a California case in which a physician failed to tell a patient of the physician's intent to use the patient's cells in potentially lucrative medical research; a Minnesota case regarding a physician's failure to disclose that the physician received payments from a drug company for prescribing a certain drug and another Minnesota case in which an HMO failed to disclose that its contracted physicians had a financial incentive not to refer their patients to specialists. The court also cited to various professional organizations' ethical codes and federal regulations on clinical investigations, and noted that the cases and other materials indicated “a trend towards requiring physicians to disclose non-medical information to the patient." Finally, the court cited the expert opinion of a medical ethicist, who stated that in the context of highly experimental treatment, the physician's and the hospital's failure to disclose their financial interest in Vascular Genetics fell below the applicable standard of medical care.

At this time it is unclear what effect the court's ruling will have in this particular case or whether the ruling, if appealed, would be upheld. Assuming, however, that the decision becomes the rule in Massachusetts, Massachusetts would join the noted "trend" and require Massachusetts physicians to consider what non-medical information is relevant to their patients' informed consent decisions. This, in turn, will require physicians to try to discern which of the physician's relationships their patients would consider relevant to the patient's decision to agree to a proposed treatment. These relationships conceivably could go beyond the ownership and compensation arrangements cited in this case; what about familial relationships or any other factor that a patient might reasonably believe could influence the physician's clinical judgment? Mr. Darke's attorney was quoted in the press as saying the ruling might not require, for example, that a physician disclose his or her salary to the patient, but it might require disclosure of financial incentives above the physician's normal compensation that are related to the outcome of experimental treatment.

If this decision is interpreted as being limited to experimental treatments, it will likely have only limited application. However, given the wide range of examples from other states cited by the court, which go beyond the research context, this decision may lay the groundwork for a rule in Massachusetts that requires physicians to disclose non-medical information for purposes of informed consent of a type and extent never seen before. The ultimate outcome of Darke v. Estate of Isner, et al. bears close watching.

The Story Behind Worcester's Poor Farm
BY SANDE BISHOP

In the index of records at Worcester City Hall, one particular entry beckoned further investigation -- "1834 Hospital Records." Neither Worcester City Hospital nor Memorial Hospital existed until the 1870s; St. Vincent Hospital opened its doors twenty years later. What hospital were the selectmen concerned about in the 1830s?

At a meeting on December 8, 1834, Worcester selectmen reported, "Considering the great and increasing influx of foreigners into our town, it cannot be doubted that infectious disorders will frequently be brought among us...." Town officials diligently considered various options for "the security of our own citizens." They discarded the idea of taking a house by eminent domain as a temporary hospital during an outbreak of disease, even though the law authorized "the impressments of houses."

Perhaps they remembered the time during the Revolution when the British billeted soldiers in American homes, acknowledging “the obnoxious character of a law which justified the turning a man out of his own castle." The men thoughtfully continued, "...Who of us would wish to have an infectious disorder within our buildings?" Thus, the selectmen recommended "the erection of a suitable building to be used as a Hospital."

After further discussions about the size of the building, the selectmen voted in May 1836 to construct a "building, two stories high, of proper proportions, with four rooms and a kitchen upon the lower floor." In June, they voted to assess the estates of the inhabitants of Worcester the sum of $1,800 for construction. There never seemed to be any question where the Hospital would be located: It had to be "sufficiently distant from public travel and other buildings ...as not to expose any one to danger." The Poor Farm was the place. Thus, an enquiry into the hospital leads to a study of Poor Relief in Worcester history.

Historically, society has assumed responsibility to care for those unable to help themselves. The origins of Worcester Poor Relief extend deep into English tradition and law. Several Acts, some dating to the fourteenth century, influenced Worcester Poor Relief in the nineteenth century. Responsibility for support of the indigent always fell first on the family. Because relatives sometimes were unable or unwilling to provide for their dependents, laws evolved to provide rudimentary assistance to those in need.

In fourteenth-century England, after the Black Death, men roamed the countryside looking for work. To restrict the movement of vagabond laborers and make towns responsible for the relief of their own "impotent poor," Richard II introduced regulations in 1388 (often considered the first English Poor Law).

Over the next centuries, further laws defined and developed care for the poor. When Henry VIII dissolved the monasteries, charity moved from voluntary support to a compulsory tax administered at the parish level. His daughter Elizabeth required every parish to appoint Overseers of the Poor, who were responsible for finding work for the able poor and setting up parish houses for those incapable of supporting themselves. Collection of necessary funds, never a popular job, fell to parish Overseers of the Poor, elected by the parish vestry.

In 1662, another piece of English legislation, commonly known as the Settlement Act, passed. While the principles were traceable to the 1388 law, the new Act allowed local justices to remove (generally to their parish of birth) any newcomers deemed likely to be a cost to the parish.

Puritans, arriving in Massachusetts on the Mayflower, wanted everyone to achieve at least a minimal level of financial success. They recognized that some would be rich, some poor, and they thought the fear of Hell would inspire Christian charity for those in need. For good measure, however, they duplicated Poor Relief laws they had been familiar with in England.

Each Worcester Town Meeting records a budget item for support of the poor. Direct assistance was an early way to assist those who needed help. For example, in 1756 Worcester Town Meeting voters allotted the sum of two pounds thirteen shillings and four pence for the support of Margaret Ditty, while directing the selectmen to "take an Inventory of her Effects." By 1758, the responsibility passed from selectmen to elected Overseers of the Poor and the record reads, "Gard'r Chandler esq for sundrys for Margaret Ditty by order of the Overseers of the Poor 8/6."

The principles of the Settlement Act were also transported across the ocean with the early settlers. Worcester records are rich with examples of paupers being transported. In the 1760s, several examples are listed: "To Henry Ward for Transporting a poore Person to Shrewsbury, 4/6;" "To Cornelius Stowell for Carrying a Poore family to Leicester and one to Shrewsbury, 12/-;" and a more complicated transaction involving Dr. Green. The warrant contained the article, "To See if ye Town will grant a sum of money to ye widow Jane Ricky to pay Doct'r Greens account for Doctering her Daughter in her late sickness." A later article, possibly referring to this case, records, "Voted not to Allow Dr. John Green's account, as in the opinion of the Town, the Town of Bolton ought to discharge the same."

By 1807, paupers were no longer repatriated to their birth towns. Intertown payments supported transient indigents, and the state provided public welfare for those with no traceable hometown. The May Town Meeting report reads, "From the town of Mansfield for support of Prince Libbins child $21.46" and "by cash rec'd of State Treasurer allowed the town to support the state paupers $178.26."

The increasing cost of welfare justified a new solution. In 1818, the town bought Samuel Jennison's farm on Lincoln Street from his widow Rebecca. Known as the Poor Farm, it, at one time, covered about 600 acres, along the Boston Post Road on the Worcester-Shrewsbury line, extending from the present Clark Street School past Lincoln Street to the former Jamesbury plant site and across Mountain Street. Life on the Poor Farm was in many ways grim.

"It shall be the duty of the superintendent and matron to see that inmates labor in such a way...that no one may be permitted to lead an idle life... No person shall be allowed to converse or have intercourse with any person...without permission... no pauper shall leave..."

In 1845, the Report of the Overseers stated, "...The whole expenses to be $1,238.74. The produce of the Farm the past year was, Hay sufficient to keep the usual amount of stock - 330 bushels of corn, 101 bushels of rye, 140 bushels of oats, 585 bushels of potatoes, 60 bushels of roots, 14 bushels of beans, 2530 lbs of pork fattened, 1320 lbs of beef fattened."

In 1846, of 382 Farm residents, 45 were from Worcester, 55 from other Massachusetts towns, "49 from other states, 10 are from England, 9 from Canada, 6 from Scotland, 4 from Germany and 204 are Irish."

Americans feared pauperism and it is significant that the Poor Farm was located away from the community, ostracizing the inhabitants, and also on the Boston Post Road, where it was visible to travelers, suggesting public punishment and disgrace. A report by the Overseers for the Poor of Worcester, 1873, noted "many persons...would rather die than go to the Almshouse."

Eventually, the Farm became a piggery. Tons of Worcester garbage were collected daily to feed the pigs, and proceeds from the sale of pork helped the City's coffers. By 1932, the overwhelming stench of 8,000 pigs convinced everyone it was time to close the Farm.

And so the puzzle of the Hospital at the Poor Farm was solved: "The great and increasing influx of foreigners" bringing "infectious disorders" was almost surely the Irish laborers who had come to Worcester to construct the Blackstone Canal and Boston-Worcester rail-road. Building the hospital at the Poor Farm made perfect sense, as the selectman reasoned, "All the means of a comfortable subsistence might be provided them [the ill] collectively, at much less rate, than in their scattered situation and according to the present system of supporting them -- that there would always be well ones enough among them to nurse and take care of the sick and that the large bills for nursing, to which the town is now subjected would thereby be avoided...".