DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE • Public Health Service • National Institutes of Health
200 YEARS
of American Medicine
     (1776 - 1976)
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 an exhibit at the

NATIONAL LIBRARY
  OF MEDICINE

8600 Rockville Pike
Bethesda, Md. 20014
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Cover:
Title page from Dr. John Jones' Plain
Concise Practical Remarks on the
Treatment of Wounds and Fractures,
1775. This was  the first full-length
medical book written by an American
and published in this country. 
          200  YEARS
of American  Medicine
          (1776  -1976)
  In recognition of the nation's bicentennial, the
National Library of Medicine is presenting  an
exhibit honoring selected American achievements
in medical science and practice and outlining the
development  of medical  education,  medical
literature, and public health in the United States.
Themes of the exhibit are described in the following
pages.
U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE
               Public Health Service
            National Institutes of Health

           DHEW Publication No. (NIH) 76-1069 
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Physicians
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and the  Revolution
  Many  American  physicians  played  an
important  role,  both  politically  and
professionally, in the winning of American
independence.
  A  decade in  advance,  John  Morgan
expressed the feelings of many young men
when in 1766 he warned against oppression of
American liberties.  Morgan later  became
Director General of the medical department
of the Continental Army. Joseph  Warren of
Boston was a leading figure in patriotic circles
that  included  Samuel  Adams  and  John
Hancock. He was killed at the Battle of Bunker
Hill.  Benjamin   Rush,  one  of  the  most
prominent American physicians  of  his day
and  three  other  physicians  signed  the
Declaration  of  Independence. Immigrants,
like Bodo Otto from Germany, and young
men   later  to   become  leaders  of  the
profession, like James  Thacher and James
Tilton, also supported the American cause.
  Regrettably,  the  colonies'  leading
physicians were often a quarrelsome lot, and
the history of their service is marred by the
bitter  feud  between   Morgan  and  his
successor  William  Shippen.  Nevertheless,
Morgan  and  Rush found time  to issue
pamphlets on military  medical  problems,
while others issued more substantial works
like  John Jones on  military surgery and
William Brown's pharmacopoeia.
  Two major European  nations  were also
active in the fighting; our ally France and our
enemy England. Both had comparatively well
developed  military medical  services, the
French under their distinguished physician-
in-chief, Jean Francois Coste. British accounts
suggest that their record for maintaining the
health of  the  troops  was considerably  in
advance of the Americans'.
On the preceding page is reproduced a letter from
George Washington to "The Honorable Joseph Jones
Esq. of Congress at Philadelphia." The original is in the
collection of the National Library of Medicine's History of
Medicine Division. The text follows.
Head Quarters Sep. 9th, 1780
Dear Sir:
  I have heard that a new arrangement is about to take
place in the Medical Department, and that it is likely, it
will be a good deal curtailed with respect to its present
appointments.
  Who will be the persons generally employed I am not
informed, nor do I wish to know; however I will mention
to you, that I think Doctors Craik and Cochran from their
services, abilities and  experience,  and their close
attention, have the strictest claim to their country's
notice, and  to  be among the  first officers in the
establishment.
 There  are  many other deserving characters in the
medical  line of the army, but  the reasons  for  my
mentioning the above gentlemen are, that I have the
highest opinion of them, and have had it hinted to me
that the new arrangement might possibly be influenced
by  a spirit of party out of doors [i.e., partisan politics],
which would not operate in their favor. I will add no more
than that I am

                 With the most perfect respect
                   Dear Sir
                    Your most obedient servant
                             G. Washington 
Medical  Education
  With  the  achievement   of  political
independence, Americans still had far to go to
reach  an equal degree of intellectual and
cultural  independence.  Still  heavily
dependent on Europe, American physicians
had made only slight beginnings  in the
development of American institutions. One
of the first  needs  was the  capability of
educating physicians in our own country.
  Before the Revolution, practitioners were
trained chiefly by apprenticeship; a few who
could  afford the time and expense traveled
abroad for further education. In 1765, John
Morgan and William Shippen of Philadelphia,
both graduates of Edinburgh,  founded the
first medical school in the country, now part
of the University of Pennsylvania. Additional
medical schools were founded at  Kings
College (now Columbia  University) in 1768
and at Harvard in 1783. In the 19th century,
however, groups of physicians throughout
the country began founding small proprietary
medical colleges, dividing among themselves
the  lectures and student fees. Entrance and
graduation requirements were sufficiently
low to insure a steady income. Laboratory and
clinical facilities were woefully  inadequate.
Large  numbers of poorly trained physicians
were released to practice on the public.
  As a result, the abler and more ambitious
students continued going to Europe. Early in
the  19th century  Paris hospitals were the
major  attraction;  after  the   Civil  War,
Americans  flocked to Austrian  and German
universities, some to learn a clinical specialty,
others  the  basic sciences. As increasing
numbers returned with an awareness of good
teaching and above all of the  possibility of
transforming both teaching  and  practice
through close  association with  research,
scientific medicine began to evolve in this
country.
  Reforms  were  also being  instituted  by
educational leaders from outside the medical
profession.  In the 1870s President Charles
Eliot  of  Harvard  introduced  a graded
curriculum  into  the  medical school,
lengthened the course from  two to  three
years, elevated  the entrance requirements,
and substituted part-time salaries paid by the
university for direct payment from student
fees. 
  Under the educational leadership of Daniel
Coit  Gilman,  the  new  Johns   Hopkins
University in Baltimore emphasized graduate
education in research.  The medical school,
opening in 1893, was conceived as part of the
university and  closely  integrated with the
Johns  Hopkins  Hospital.  In  addition to
upgrading   undergraduate  medical
education,  the  Hopkins  originated  the
residency training system.
  Public  and  professional  concern  for
medical education culminated in a survey of
all the medical  schools by Abraham Flexner
under the auspices of the AMA Council on
Medical  Education  and  the  Carnegie
Foundation  for  the  Advancement  of
Teaching. His report, Medical  Education in
the United  States  and Canada (1910),  had
immediate and far-reaching impact. There
were then 131 medical schools in the United
States, most of them proprietary. By 1920, 46
had closed or  were  absorbed by  stronger
institutions.  Others were strengthened by
merger, by university affiliation, and by the
infusion of support from private foundations
and state governments.
  By the 1920s the four years of medical
school  were  compartmentalized  into  two
years of basic sciences taught  by  discipline
and two years of clinical training.  Since the
1950s increasing emphasis has been  placed on
teaching basic concepts in a program planned
by interdisciplinary subject  committees and
tailored, in part, to the individual  student's
interest.
  An important factor in recent changes is
the growth of federal support for medical
research, mostly in medical schools, from $27
million in 1947 to $1.4 billion in 1966. In 1968-
69 approximately one third of faculty salaries
were paid from federal sources. The impact of
this federal support was generally  favorable
although  some  critics  claim   that
concentration on  research  has  diverted
faculties  from  their  primary  mission  of
developing physicians. The present decrease
in  federal support,  the  abundance  of
specialists, and the shortage of  primary-care
physicians  seem  to  assure  continuing
modifications   in   American  medical
education.
William H. Welch (1850-1934) 
Medical  Literature
  Closely  linked to the development  of
medical education, and equally important for
the advance of medicine in this country, was
the growth of suitable means  for recording
and disseminating new  medical ideas and
information.
  The first purely medical publication in this
country was  a broadside by the Reverend
Thomas Thacher, A Brief Rule to Guide the
Common People of  New-England  How  to
Order  Themselves and Theirs in the Small
Pocks or Measels, Boston, 1678. Most colonial
medical   publications  were  pamphlets.
Physicians who wished to publish scientific
observations generally submitted them to an
English journal.
  The first American medical journal, The
Medical Respository, was started in New York
in 1797. In the half century following, the
number gradually grew. Monographs also
appeared in increasing profusion, although
most of the  best ones  were  reprints and
translations of books published abroad.  In
1848 the Committee on Medical Literature of
the AMA, chaired by Oliver Wendell Holmes,
identified twenty American medical journals.
With rare exceptions, such as the American
Journal  of the  Medical  Sciences,  the
Committee found them wanting and stressed
the need for more conscientious editing and
the elimination of unworthy  articles  and
parasitical authorship. Similar criticisms were
leveled at monographs.
  The quality of American medical literature
markedly  improved  with  the  growth of
scientific medicine in the late 19th century. As
physicians returned from graduate training in
Austria and Germany, their reports of clinical
and laboratory  research  upgraded existing
journals  and created  a need for new ones
devoted  to the specialties. One of the earliest
was the  Journal of Experimental Medicine,
established in 1896.
  In  the 20th  century the tables turned.
American texts are translated into foreign
languages.   The  number  of journals  of
biomedical interest has grown in 100 years
from  less   than  50  to  more  than  700.
Improvements  in  medical  education,  the
growth  of  medical  specialties,  and  the
continuing expansion of basic research have
placed the American medical literature  in a
position  of primary world importance. 
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Public  Health
  In the application of medical knowledge,
public  health organizations have played  a
vital  role in improving  the  health of the
nation.
  Most early  public health activities  were
conducted on a part-time basis at city, town,
and village levels. However, in 1850 Lemuel
Shattuck urged Massachusetts to form a state
board of health to encourage and coordinate
local efforts. When finally established in 1869,
the Massachusetts State  Board  of Health
became the model for  other state health
departments.
  By mid-century also, recurring cholera and
yellow fever epidemics indicated a need for
coordinating sanitary  measures among the
states.  The  National  Board  of  Health,
established  in 1879, was an early effort to
provide the Federal Government with on-
going professional advice on these and other
health  matters,  but its  ambitions for an
extensive   national  health  role   were
premature. Such a role eventually fell to the
United States Public  Health Service after a
gradual evolution.
  Under the Act for  the Relief of Sick and
Disabled Seamen passed in 1798, a chain of
marine hospitals at inland and coastal  ports
gradually emerged under the loose direction
of the Treasury Department. In 1871 the
Department  brought  them  under  the
centralized control of a Supervising Surgeon,
later renamed  the Surgeon  General. The
Marine Hospital  Service  thus  created
gradually  took  over  quarantine
administration,  the  control   of  vaccines,
epidemiological  investigation,  and  other
health-related functions. By 1912 the agency's
growing scope  was reflected in  its present
name, the Public Health Service. During the
1930s the Hygienic Laboratory, an outgrowth
of bacteriological studies conducted during
the mid-1880s  by Joseph J. Kinyoun at the
Marine Hospital on Staten Island, becamethe
National  Institute  of  Health, located  at
Bethesda, Maryland. 
  Supplementing  governmental  efforts,
laymen and  physicians  have organized to
promote research, education, legislation,and
improved  methods. The  American  Public
Health Association  and other professional
societies were established in the 1870s and
later.  The  Pennsylvania  Society  for  the
Prevention  of Tuberculosis,  established in
1892, provided the model for other voluntary
associations aimed at this and other specific
health   problems.  Similarly,  wealthy
individuals  have supported public health
through the Russell Sage, Kellogg, Milbank
and  other  foundations.  The  Rockefeller
Sanitary  Commission  carried  out  a  far-
reaching  anti-hookworm  campaign in  the
South  from  1909-1914.  The  Rockefeller
Foundation has supported sanitary  work in
foreign  countries and  financed  the  first
American schools of public health.
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PAIKTBD BY ANN LITTL5 ATKINSON,  N. H.. IN 1830.


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  Another area of public health concern for
at least 150 years has been the improvement
and expansion of vital statistics. Even before
the  Civil  War,  the  American  Medical
Association  and  others  promoted  state
registration and the federal census  began
collecting   vital  statistics.   Following
improvements  introduced  by  John  Shaw
Billings in 1880 and 1890, a permanent Census
Bureau was created  in 1902.
  As mid-19th century statistics showed the
correlation of high mortality rates with filthy
conditions,  the   specialty  of  sanitary
engineering emerged  after the Civil War to
help  provide  adequate  sewer  and  water
systems,  and   to   organize  urban  street
cleaning  and  garbage removal. George  E.
Waring, a pioneer in  this field, dramatized
public sanitation by putting New York's street
cleaners into  white uniforms,  thus earning
them the sobriquet of "white wings."
  After 1880 bacteriology transformed public
health activity. Particularly important pioneer
applications were made by scientists of the
Army and the Department of Agriculture and
by health officials in Rhode Island, Michigan,
and New York. Scientific Bulletin No. 1 of the
New  York City bacteriological  laboratory
marked the beginning of laboratory diagnosis
as a routine procedure in  the  control  of
infectious diseases.
  Preventive  medicine  goes  back  to  the
introduction  of smallpox innoculation by
Cotton  Mather and  Zabdiel Boylston  in
Boston in 1721.  After 1800 it was replaced by
the  more  effective  and  less  dangerous
Jennerian vaccination. With the development
of bacteriology, European discoveries such as
Pasteur's   rabies   treatment,  diphtheria
antitoxin,  and  typhoid  vaccination  were
quickly introduced  into the  United States.
Thereafter, progress  in  immunology  was
 
slow; by World War 11 it was overshadowed by
new   drugs,  especially  penicillin.  The
introduction of  polio  vaccine in the 1950s,
following a massive research effort, was thus a
thrilling public and scientific event. Recent
decades have also seen important progress in
immunization  against  influenza,  measles,
allergies, and other diseases.
  Other public  health specialties  have also
developed.  Although  Benjamin M'Cready
had  made a general survey  of the  health
factors in different American occupations as
early as 1837, Alice  Hamilton still felt in 1910
that she was entering industrial medicine "as
a pioneer  into  a new,  unexplored  field."
Dental public health has also come of age, its
most  notable achievement, albeit  a  highly
controversial  one  in  some  communities,
being  the  fluoridation  of  public  water
supplies to reduce dental caries.
Alice Hamilton (1869-1970)
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   Photo of the National Institutes of
W  Health in Bethesda, Maryland, 1949. 
Scientific  Contributions
  Changes in medical education and the growth of medical literature formed essential institutional
bases for the increasing number of contributions to knowledge by American physicians, scientists,
and other health professionals and for their increasing ability to care for their patients. A few have
been selected by way of illustration; many others are equally deserving.
  — J. Marion Simms (1813-1883), for contributions to gynecology.
  — William T. G. Morton (1819-1868), for surgical anesthesia.
  — S. Weir Mitchell (1829-1914), for work in clinical neurology.
  — Joseph Leidy (1823-1891), for contributions to paleontology.
  — Abraham Jacobi (1830-1919), for establishing pediatrics as a specialty.
  — Joseph J. Woodward (1833-1884), for contributions to microscopy and photomicrography.
  — Mary Adelaide Nutting (1858-1948), for raising the standards of nursing.
  — Harvey W. Wiley (1844-1930), for his campaigns against food adulteration.
  — William H. Welch  (1850-1934), for his major role in introducingscientificmedicinetothe U.S.
  — John J. Abel (1857-1938), for the isolation of epinephrine and early studies in plasmapheresis.
  — Theobold H.  Smith (1859-1934), for demonstrating the tick transmission of Texas cattle fever.
  — Walter Reed  (1851-1902), for studies  on yellow fever.
  — Thomas Hunt Morgan (1866-1945), for the chromosome theory.
  — Charles Wardell Stiles (1867-1941), for solving the problem of hookworm disease.
  — Alice Hamilton (1869-1970), for work in industrial medicine.
  — Walter B. Cannon (1871-1945), for studies of the autonomic nervous system.
  — Eugene L. Opie (1873-1971), for contributions to the pathology of diabetes mellitus and
    tuberculosis.
  — Florence R. Sabin  (1871-1953), for research in neuroanatomy and embryology.
  — Joseph Goldberger (1874-1929), for demonstrating the role of dietary deficiency in pellagra.
  — Oswald T. Avery (1877-1955), for work with  the transforming factor in pneumococci-DNA. 
— Michael M. Davis (1879-1971), for efforts to improve health care delivery.

— Donald D. Van Slyke (1883-1971), for studies on acid-base balance and the gas and electrolyte
   equilibria in the blood.

— Paul R. Hawley (1891-1964) and Paul B. Magnuson (1884-1968), for improving medical care for
   veterans.

— Richard  H. Shryock (1893-1927), for studies  in the social history  of medicine.

— Alfred Blalock (1899-1964), for work on shock and contributions to cardiac surgery.

— Percy L.  Julian (1899-1975), for work in steroid chemistry.

— Charles  R. Drew  (1904-1950), for studies on blood  plasma and blood preservation.

— John H.  Gibbon (1904-1973), for developing the heart-lung machine.
Silas Weir Mitchell
(1829-1914), shown
in his clinic at the
Infirmary for Nervous
Disease in Philadelphia.
Mary Adelaide Nutting
(1858-1948), leading
figure in U.S. nursing
education.
Joseph Goldberger
(1874-1929), member of
the U.S. Public Health
Service who conducted
innovative experiments
in the study of pellagra.
Charles R. Drew (1904-
1950), leading
researcher in the study
of blood plasma and
blood preservation. 
National  Library
  During the past  century of outstanding
progress in medicine and public health, the
National Library of Medicine has continued
to play  an important role  in making  new
knowledge more readily available.
  The Library has  descended from a small
collection  of  books begun by  Surgeon
General Joseph Lovell about 1818. As the
years passed, it grew slowly; in 1840 a clerk
wrote the titles — about 200 altogether — in a
little notebook  that he titled grandly, "A
catalogue of books in  the library of the
Surgeon General's Office, Washington City."
The collection  continued to expand  at a
modest pace until  1871, when the decision
was made to develop it into  the "National
Medical Library."   This, to  the  Surgeon
General and his staff, meant a collection that
contained every medical book published  in
the United States, and as many as possible  of
all other publications relating to medicine
and allied sciences. Assistant Surgeon John
Shaw Billings was given the responsibility for
carrying out this decision.
  Billings,  who had  been  managing the
library  since  1865,  greatly  accelerated the
collecting of all medical publications. He
sought  new and old books, American and
foreign periodicals, reports of civilian and
military  health  organizations, dissertations,
pamphlets, manuscripts,  portraits and prints.
He  purchased  from  booksellers  and
physicians,  exchanged  duplicates  with
individuals and with other  libraries,  and
Surgeon General Joseph Lovell (1788-
1836)
persuaded physicians,  institutions, editors,
and publishers to donate publications. Within
a few years Billings had acquired practically
every issue of every medical journal  ever
published in  the United States and Canada,
and 75 per cent of all medical periodicals ever
published throughout the world. By 1875 the
library was already more than twice as large as
the next largest American medical library.
  With this resource at his command, Billings
conceived   and  established  medical
bibliographies of importance to physicians
throughout the world. In 1879 he founded the
monthly  Index  Medicus,  published
commercially under the editorship of his
colleague Robert Fletcher. In 1880 he brought
out the first volume of the Index-Catalogue of
the Library of the Surgeon-General's Office, a
monumental  work  that  made  the Library
internationally famous.  For three-quarters of
a century volumes continued to appear, 61 in
all, until it was superseded by  more  rapid
indexes in the 1960s.
  After Billings retired in 1895, the librarian's
¥W>m
John Shaw Billings (1838-1913) 
of Medicine
 chair was occupied by a succession of medical
 officers,  among  them  Walter Reed. The
 Library building on the Mall, opened in 1887,
 soon became gorged with material. Within 25
 years librarians were asking for more space,
 but wars, depressions, and priorities kept the
 Library  in   its  increasingly  obsolescent
 structure. Finally, in 1956 Congress passed a
 law formally establishing the Library as the
 National Library of Medicine, transferring it
 to the  Public  Health Service, and providing
 for a new building. In 1962 the Library moved
 from Washington to its new home adjacent to
 the National Institutes of Health.
  Because of  the great  increase in medical
 publication starting in the late 1940s and the
 demands for faster bibliographic service, the
 Library turned to new technologies in the
 1950s to speed the availability of indexes and
the transmission of data to users. A partially
mechanized   publications  system  was
introduced  in  1960 to produce Index
Medicus, only to be superseded four years
later by  a computerized  system named
Library building on the mall, opened in
1887.
Reading room, Army Medical
Library. Dr. Billings is shown
seated at right (ca 1890). 
MEDLARS  (MEDical  Literature Analysis  and
Retrieval   System).  In  the  1970s,  using
MEDLARS and other data bases, the Library
developed  MEDLINE and a number of other
nationwide  on-line  bibliographic  retrieval
systems. To  speed   service  to  medical
researchers, educators, and practitioners, the
Library provided leadership and funding for
the development of a network of  regional
medical libraries. Congress gave the Library
authority   to  bestow  grants-in-aid  and
established the Lister Hill National  Center for
Biomedical  Communications  to  apply
advanced technology to the dissemination of
medical information.
  A  century and a half  after its birth  the
Library has  grown from a few books on the
shelf of a room in Washington to a collection
of more than  a million  publications,  the
largest medical library intheworld,operating
one  of  the world's  largest bibliographic
information retrieval  systems. Its services are
known and used throughout the world.
Right: MEDLINE terminal. MEDLINE
(MEDLARS-On-Line) is the library's
computerized data base.
 
Images  of  the
        American  Physician
  Pictures of physicians, other than formal
portraits, have tended to fall into one of two
groups: the kindly "family doctor," or the
caricature.
  The "family  doctor"  concept  is  usually
visualized as a  one-to-one relationship in a
simple setting between a compassionate
doctor and a worried but hopeful patient,
often with family. It has  been repeatedly
impressed on the American consciousness by
magazine art,  such as that of the  skillful
illustrator Norman Rockwell, by advertising,
and by movies.
  Caricature, on  the  other hand,  has
traditionally lampooned not only medical
men but also quacks and patients. In America,
medical caricature has been largely confined
to magazine  and  newspaper  cartoons.
Recently it has been appearing in fine prints
by contemporary American artists and seems
to express a growing concern with  perceived
depersonalization and increasing costs of
medical care. As America moves into its third
century, these views of sensitive  observers
reflect  some of the serious social  problems
facing medicine in the years ahead.
Children's Clinic, by Mabel Dwight
Virgil Partch's contemplative doctor. 
DHEW Publication No. (NIH) 76 -1069