[U.S. Department of Health, Education, and Welfare. Public Health Service. National Institutes of Health, National Library of Medicine.]
[Bicentennial of Medicine in the United States, 1776-1976]
[Masur Auditorium, Clinical Center, NIH, May 6, 1976]
[Martin M. Cummings, MD, Director, National Library of Medicine]
Martin M. Cummings, MD: Good morning, ladies and gentlemen. Thank you for coming. The colloquium celebrating the bicentennial of medicine in the United States is now convened. I have the great pleasure and honor to introduce the distinguished Director of NIH, Dr. Donald Fredrickson, [Martin M. Cummings, MD]
a person with a known sensitivity for medical history, who is well-recognized for his contributions as a medical investigator, and now administrator of the world's largest medical research institution. Doctor Fredrickson.
[Welcome. Donald S. Frederickson, Director, National Institutes of Health.]
Donald S. Fredrickson, MD: Thank you, Doctor Cummings. Ladies and gentlemen, it's a great pleasure for me, both professionally and also personally, to welcome you, so distinguished an audience, to the National Institutes of Health today.
This organization has a number of sources of pride, most of which I think are real. None of them are greater than the fact that it is also home of the National Library of Medicine.
In seeking to trace back and identify some of the sources of this opportunity for holding such an important colloquium, and for the production eventually of a two-volume [?], I think that we ought to recognize at least three people. The germ of this idea I believe probably came from Ms. Mary Corning from the National Library of Medicine as long ago as 1973,
and that seed was nurtured by the able director of the library, Doctor Cummings, and then it was brought into full flower by Dr. John Bowers, and the Josiah Macy Foundation, a man and an institution which have been responsible for making reality of many of the contemporary important ideas for gatherings such as this, and publications such as this in contemporary biomedical science.
Yesterday we received a letter on the stationery of the White House, and I should like to read to you its contents. "Americans are proud that this nation's leadership in medicine has contributed so prominently to the relief of pain, the prevention of communicable diseases, and the treatment of sick and disabled individuals in our own country, and throughout the world.
It is most fitting that the National Library of Medicine is hosting a special colloquium on the bicentennial of U.S. medicine, and I am happy for this opportunity to welcome the distinguished foreign guests and U.S. participants in this outstanding program. Our great National Library of Medicine contains the world's published records of advances in medical science.
But more than this, it uses this knowledge to provide information to all who need it for their research, education, and healthcare services. This colloquium will serve both as a reflection on past accomplishments, and as a bold acceptance of the challenges that lie ahead. I hope that it will be a rewarding and profitable experience for all who attend." Signed, Gerald R. Ford.
Well, these are indeed two very brief days for our colloquium in which to look backward, so that we might better see the future. But clearly this very act of examining the substance of medicine throughout these 200 years will allow us to provide a record, which may also help the scholars of tomorrow to know and understand our problems of today. Welcome again to the National Institutes of Health.
Martin M. Cummings, MD: Thank you, Dr. Fredrickson. In addition to the President's letter, we have received messages from Senator Hubert Humphrey, Senator Ted Kennedy, and Senator Warren Magnuson. Each have contributed to the patronage of your National Library of Medicine.
Also, each of these distinguished men have called for the improvement of biomedical communications, to better serve the medical needs of our nation. The program which follows has been organized to present a review of the progress and accomplishments of American medicine during the past two centuries.
Leaders of contemporary medicine have prepared essays, which are being published in a two-volume edition by the Josiah Macy Junior Foundation this month. Thus it is fitting that our first speaker of this meeting is Dr. John Z. Bowers, President of the Macy Foundation, who will speak on influences on the development of American medicine. Dr. Bowers.
[Influences on the Development of American Medicine]
[John Z. Bowers, M.D., President, Josiah Macy, Jr. Foundation]
John Z. Bowers, MD: I'd like to talk briefly now about three major influences on the development of American medicine. The first was foreign, the second the flowering of the American university during the second half of the 19th century, third the influence of private wealth and philanthropy.
In 1776, two centuries ago, Europe was at the apogee of the age of the enlightenment, while life in Colonial America was still determined by practical necessity, and the art of survival on getting a toehold. Education rested largely in the hands of the clergy. In 1776, there were a total of 17 colleges in the United States, known as the nine significant colleges, and they were under a variety of religious sponsors --
Puritan Harvard, the first, founded in 1636, Congregational Yale, Anglican William and Mary, and Kings later to become Columbia, Quaker Pennsylvania, Baptist Brown, Presbyterian Princeton, Dartmouth, and Dutch Reform Queens, now Rutgers.
All the schools placed the emphasis on the classics -- Latin, Greek, and theology. The curricula were tightly structured, students had no opportunity to elect courses. Benjamin Franklin of Philadelphia was our first leader of science. [John Z. Bowers, MD]
Best known for his studies in electricity, Franklin was also interested in medicine, and published treatises on smallpox, electrotherapy, infant mortality and gout, and developed the first flexible catheter. He solicited the funds for the creation of our first hospital, the Pennsylvania Hospital, which opened in 1752.
But Franklin found the hospitality in the salons of France, England, and Scotland far more rewarding than the sterile life in America, and only returned to the United States and the revolution because he felt that his country needed his services. And as with Franklin, our students of medicine turned to Europe. First, a few went to Lydon, but the great majority went to Edinburgh.
And between -- in the last half of the 18th century, more than 100 Americans graduated at Edinburgh. They were drawn there because of the Scottish influence in our universities, and the fact that Edinburgh was now becoming the leading medical center of the world. Before or after Edinburgh, they frequently studied anatomy with William and John Hunter in London, or walked the wards of the famous London hospitals.
Three of them, of course, were most distinguished men -- Benjamin Rush, the Sydenham of America; William Shippen; and John Morgan. The latter two founded our first medical school in 1765.
Morgan's charter of excellence for that first medical school would represent what we consider to be best in medical education today. He included a sound background in science, he added literature, and the ability to read Latin, Greek, and French, the availability of a teaching hospital, and for the medical school to be an integral part of the university.
But his clarion call was soon abandoned, as the national emphasis turned to expansion to the west, with intense competitiveness based on ruthless individual enterprise. And during the age of Jackson, egalitarianism that derided the development of the mind as elitist, any efforts to control individual enterprise, such as standards for training physicians or their licensure, were swept away.
Science was taught in the colleges in a limited manner, beginning at Harvard in the 17th century. But the first major thrust did not occur until Benjamin Silliman established a science program at Yale in 1804. Based on chemistry, mineralogy, and geology, Silliman's program subsequently flowered into the Sheffield Scientific School, the first graduate school to be established in an American college.
And the first American PhDs were awarded at Sheffield in 1863 to three graduates, one of whom, Josiah Willard Gibbs, became America's first physical chemist, and the founder of chemical thermodynamics. The Lawrence Scientific School subsequently emerged at the other New Haven House -- New England House of Intellect, Harvard.
While the Sheffield School led in the natural sciences, the emphasis in Cambridge was on the life sciences. But by this time, Harvard was moving to a more liberal position, based on Unitarianism, while Yale clung more zealously to pious, Congregational commitments.
Thus in 1827, we find Peter Parker of Framingham, Massachusetts, subsequently the first American medical missionary to China, being cautioned when he was tempted to enroll at Harvard, that quote, "The situation at Harvard was such as to not at present render it desirable for pious students.
Yale is the true home of the sons of prophets." It was this stubborn adherence to the sons of the prophets that lost Yale a golden opportunity to build on its leadership role established by Benjamin Silliman. Its greatest loss was a man named Daniel Coit Gilman, destined to become our most creative and scholarly university President, who was a librarian at Yale, and had assisted in the development of the Sheffield School.
But when Gilman was recommended for the Presidency of Yale in 1871, his name was rejected, and the choice went instead to another congregational divine, the Reverend Noah Porter. James Smithson, the son of an English peer, was responsible for the establishment in 1846 of our first national scientific center, the Smithsonian Institution.
After graduation from Oxford, Smithson went on to studies in mineralogy and chemistry, leading to his election as a fellow of the Royal Society. Whether he was displeased with his relationships with his society, or distressed at his illegitimacy, so that he wished to reject his British lineage, we do not know. But Smithson willed his entire fortune -- a half a million dollars -- to the United States of America, which he had never visited,
and he designated to be used to found at Washington the Smithsonian Institution, for the increase and diffusion of knowledge among men. Its first Director, Joseph Henry, who was a physicist, and Benjamin Silliman, shared the mantle that passed to them from Franklin as leaders of American medicine.
For the study of medicine, American students continued to go overseas. But now the emphasis moved to graduate training after medical school. During the first half of the 19th century, they turned to Paris, and her great teaching hospitals, now the world's leading medical center. The emphasis in France was on the ward and the autopsy, on the correlation of the clinical and autopsy findings.
French medical education concentrated almost exclusively in the hospitals, and the basic medical sciences were termed by the French for many years, appropriately, the accessory sciences. The attitude towards scholarship in America in 1830 was expressed by James Jackson, Physician-in-Chief at the Massachusetts General Hospital.
His son was working in Paris with Louis, the leading clinical scholar in France. He was so impressed with young Jackson's potential, that he wrote to the senior Jackson, urging that his son be allowed to devote three or four years to complete scholarship.
The father would have none of it. He wrote Louis, quote, "because in this country his course would have been so singular as a scholar, as in a measure to separate him from other men. We Americans are a business-doing people. We are new, we have as it were just landed on these uncultivated shores. There is a vast deal to be done, and he who will not be doing it must be set down as a drone."
The neglect of the basic sciences in France was in sharp contrast to developments across the Rhine. Research was the watchword in the German schools, in both the clinical as well as the basic science departments.
And by 1870, Germany and Vienna had become the mecca for American graduates who returned to lead the reform of American medicine -- Welch, Flexner, Vodic, Mall, and Russell Chittenden.
American colleges were now becoming more hospitable to science, led by Harvard, with the election of Charles Elliot as President in 1869. Elliot represented a new type of college president for America. He was described as neither a teacher nor a research scholar. He was above all an administrator, with the skill and foresight of a man of business.
At the same time, businessmen came to dominate boards of trustees. Elliot guided the transformation of Harvard, from a small college with colleges -- from a small college with a few loosely attached professional schools, to our first unified, modern university. For academic reform, his first target was the medical school. And as we know, he was strongly opposed by the senior professors.
But he was responsible for the introduction into medical education, for the first time, of a graded curriculum, a full academic year instead of four months a year, an admissions process instead of simply paying the fees, extending the curriculum from two to three years, and the introduction of written examinations.
When Elliot proposed written instead of oral examinations at Harvard, the head of surgery, Henry Bigelow, eloquently described the incompetence of Harvard students, which I suspect applied equally across the country.
Bigelow told Elliot, "I had to tell Elliot that he knew nothing about the quality of Harvard medical students. More than half of them can barely write. Of course they can't pass written examinations." Elliot also advanced science and teaching and medicine, by terminating the rigid undergraduate curriculum, dominated by the classics Latin and Greek,
which at that time represented at least four-sevenths of the curriculum. But there was no opportunity for students to choose their career until Elliot introduced electives at Harvard College in 1876. This gave a major fillip to the teaching of medicine, to the lore of science, to the introduction of brilliant young men and women into medicine.
The next major act was the Morrill Act, which we usually associate with the development of cow colleges. Morrill was a senator from Vermont, and he was convinced that the need was to get rid of the curriculum insisting on reviving ancient European society.
He wished to have, quote, the teaching of science to be the leading idea in our colleges. The act called for the donation of public lands to the states, based on the number of representatives in the Congress, with the revenues to be used for agricultural and mechanic colleges as separate institutions.
A second Morrill Act gave each college 25,000 dollars, on the stipulation that they should teach military training. This was because Morrill believed that the south had won its early victories in the Civil War because there were so many military academies turning out future colonels and generals.
Daniel Coit Gilman shared with Elliot leadership in creating the modern American university. While Elliot believed that the primary duty of every member of the Harvard faculty was to teach students, Gilman put the emphasis on creative scholarship. Thus, when Johns Hopkins opened under his presidency, there was no undergraduate program.
Years later, Abraham Flexner, who revered Gilman, restated his impact. Research was not recognized in America as one of the dominant concerns of higher education until the flag was nailed to the mast on the opening of the Johns Hopkins University. By the end of the 19th century, American medical science was preparing to flower.
The need was for a major infusion of funds and scientists. A young developing nation at the beginning of the Civil War, we became in less than four decades, the mightiest industrial power in the world, based on a capitalist society. The educational enterprise was given a major impetus by the national commitment to a common school, extending through primary and secondary education.
Institutions of higher learning proliferated rapidly, from 593 enrolling 52,000 students in 1870, to 977 enrolling 238,000 students 30 years later. Thus at the turn of the century, American institutions of higher learning were turning out far more well-educated young men and women than all of the institutions of Europe, including those of Great Britain.
During the last quarter of the 19th century, the new tycoons were beginning to turn a part of their fortunes to social and educational benefits. In 1889, Andrew Carnegie from Scotland, enunciated his gospel of wealth: the man who dies rich, dies disgraced, to pass away unwept, unhonored,and unsung.
Carnegie's name is enshrined in the annals of medical education through the Flexner study, but a principle motivator in the Flexner study was the first President of the Carnegie Foundation for the Advancement of Teaching, Henry S. Pritchett. He realized that to establish a proper retirement program, which we know today as TIAA, it was necessary for the foundation to have far more information on the state of education.
So with the approval of his board, he launched a series of studies, and his first focus was on medicine, on law, and on theology. And in 1908, he told his board essentially what we look on as the fundamental aspects of the Flexner Report. I think that Henry Pritchett could be described as the unsung hero of the Flexner reform,
because after determining these needs, he then brought Flexner on the staff to do the study. There has been considerable discussion about the role of the AMA Council in the Flexner study. The improvement of medical education was a central mission of the council, but it was encountering opposition in its efforts from the leaders of the medical profession.
Thus it was agreed that an interdependent report by a disinterested body would have the greater impact, and be a greater stimulus to developing public opinion. Two last points. Why did not the Carnegie philanthropies, which had triggered the report, move in to lead the reform of American medical education?
It was because from the beginning of the study, Andrew Carnegie had made it perfectly clear that he was making no commitment to rectify any deficiencies that Flexner might uncover. In fact, Flexner carried a memorandum to that effect on his visits to the medical schools.
Carnegie, through his endowment of the Scottish university's trust, was accustomed to excellence, as exemplified by the Scottish schools. And as Alan Gregg suggested, the stark facts of the Flexner Report were so eloquent that as to alienate Carnegie's sympathies, from rectifying a program that was so glowingly remiss in its educational responsibility.
Thus, the implementation of the reforms proposed by Pritchett and Flexner passed to John D. Rockefeller. As we know, he was a devout Baptist, he was deeply influenced by a man named Frederick Gates, who was a Baptist minister. Gates was convinced as early as 1888, from his exposure to allopathy and homepathy, that if there existed a science of medicine, that medicine was not being taught or practiced in America.
He noted that medicine could only effect a cure in about one case in 100. He then spent the summer of 1894 reading Osler's Principles and Practices of Medicine, and became convinced that there was no scientific base for medicine.
Yet the tide could not move forward without distinguished leadership. Such leadership appeared in the person of Welch, the founding dean at Hopkins. And herewith, to the mantle that had passed from Franklin to Silliman, to Joseph Henry as the leaders of American science.
The Rockefeller Institute, recommended by Gates, with Welch as President of the board of directors, was the first enterprise, and it was founded in 1902. At a luncheon in 1910, Gates asked Flexner -- and he had studied the report very carefully -- what he would do if he had one million dollars to make a start in the work of reorganizing medical education.
Flexner subsequently advised Gates that the best investment would be to support the clinical faculty at Johns Hopkins to become full-time. Flexner joined the staff of the general education board in 1912, to launch a program which in the ensuing years awarded a total of 94 million dollars to 25 medical schools.
The primary aim was to support full-time faculty members, to strengthen the university relationships, and to foster medical research. Thus, by the beginning of the 20th century, American medicine, a late bloomer, was taking decisive steps towards the position of honor it enjoys today. Thank you.