Thursday, July 23, 2015

The Beginnings of Modern Medical Attitudes

From: Research notes of Dr. Michael  Echols

A typical physician of 1820 was likely to a regard a seventeenth century medical text as of clinical importance; but a typical physician of 1880 was very unlikely to so regard it. Inspired by the incredible success of antisepsis and anesthesia in surgery, and by the leap in medical and surgical knowledge which almost always follows a major war, many physicians born between about 1820 and 1845 saw by the 1870s little practical need to preserve the pre-antisepsis, pre-anesthesia literature, let alone enshrine it, in institutional libraries. To be sure, they did not neglect reading in the furtherance of their clinical practice, but while their fathers preferred the venerable old medical books supplemented with case reports in the journal literature, they tended to limit their reading to current state-of-the-art breakthroughs in their particular fields, as recorded in the journal literature. At first they were able to fill their professional reading needs with private journal subscriptions and book purchases, but as topics became more diverse, more narrowly circumscribed, and as the literature on these topics became more vast, the next generation of physicians (George Milbry Gould's generation) came to discover that as individuals they could not each keep up with all the current literature relevant to their respective clinical practices, and thus had to rely upon libraries whether they wanted to or not. The last third of the nineteenth century was beginning of the complex specialization in medicine which we all recognize today -- and the literature of the time, both in quantity and in orientation, accurately reflected that. The standard bibliography of nineteenth century American medicine shows only 1406 medical titles published in the 1840s, but 10378 in the 1890s. Individual finances simply could not keep up with that explosion. As Charles Perry Fisher noted during his tenure as Librarian of the College of Physicians of Philadelphia, individual physicians practicing prior to 1879, when Index Medicus first appeared, were obliged to acquire and maintain private collections of medical journals, often at great expense, only to have these gatherings of a lifetime scattered and wasted after their deaths. The increasing difficulty for physicians to maintain current professional literature collections on their own was even more pronounced in the outlying areas.

Medical books tend to be more expensive than most books. This has always been the case. Medical libraries have always been hard-pressed financially to keep their holdings comprehensive (or at least adequate) with regard to the current state of the clinical art. For example, in the July 1866 catalog of prominent Philadelphia medical publisher Henry C. Lea, prices ranged from $1.00 for small duodecimos such as a popular work on skin care to $14.00 for Joseph Maclise's Surgical Anatomy and $15.00 for the four-volume Cyclopaedia of Practical Medicine, with most of the standard texts costing in the vicinity of $4.00 to $6.00. A modern medical text may seem cheap at these prices, but not in the days when most trade books sold for less than a dollar, medical journal subscriptions typically ran between $5.00 and $10.00 per annum, and postage was figured in half-cents. Nowadays a typical medical title will cost in the hundreds and a typical medical journal subscription could cost in the thousands per annum. Unlike individual physicians, medical libraries cannot pass these costs on to their patients, but rather must simply do without or else go begging. In this regard, institutional medical library management today is no different from what it was in the nineteenth century.

There seems to have been a generation of physicians and surgeons who came of age during the Civil War or shortly thereafter, who had no interest in the preservation of the records of bygone medical eras, and who believed that the typical contents of institutional medical libraries were of little or no clinical importance. This group dominated American medical culture in the 1880s. Their attitude that medical progress did not require libraries but only modern clinical and experimental results was gradually supplanted in the 1890s under the leadership of Gould, Charles D. Spivak, and Osler, among others.

Yet medicine is a conservative profession. For example, in the nineteenth century it was a frequent conceit among the Fellows of the College of Physicians of Philadelphia that theirs was the most conservative organization in America, not necessarily in the political sense, but certainly in the cultural sense. Such conservativism can be detected in the kind of support given in the 1870s to the most prestigious medical libraries, such as the New York Academy of Medicine and the Army Medical Library (now the National Library of Medicine). These white men, mostly rich and highborn, seem to have been motivated, over against the remarkable medical and surgical progress of the Civil War and its immediate aftermath (progress in which many of them indeed participated), to protect and preserve "the way we did things," i.e., the methods, results, and curiosities of their own bygone era, the antebellum American medical world. To illustrate this point, when the new library building of the New York Academy of Medicine was dedicated in October 1879, the average age of the sixteen participants on the podium was 61 (average birth year 1818), which means that most of them were already established professionals when the Civil War broke out. The entire cost of this project was paid by subscriptions and donations, so that at the time of dedication "not a single cent of debt remained."

In contrast to this prestigious societal medical library of the 1870s strongly supported by the "Old Guard," consider a medical library which was severely neglected from the 1870s to the mid-1890s, when it was under the governance of much younger physicians, about half of whom had little or no antebellum medical or surgical experience. In 1872 the average age of the eighteen physicians on the original faculty of the Syracuse University College of Medicine was only 47 (average birth year 1825). The older faculty such as Towler and Frederick Hyde supported the library, but, with the notable exception of John Van Duyn, most of the younger faculty gave little notice to it, and even Van Duyn's interest in the library was not manifest until much later in his career.

These younger physicians were mostly of the generation that provided such breakthroughs as first allowing women into the profession. They regarded themselves as progressive and perhaps even radical, both culturally and clinically, while the older generation would offer such laments as this, in 1879: "We regret to be obliged to announce that at a meeting of a councilors held on October 1, it was voted to admit women to the Massachusetts Medical Society."

Despite the financial hardship on individual physicians who tried to maintain their own respective collections of medical literature, institutional medical libraries were generally neglected, even scorned, for much of the second half of the nineteenth century, except by a few sagacious physicians such as John Shaw Billings, Samuel Smith Purple, Joseph Meredith Toner, Charles D. Spivak, and James R. Chadwick. Throughout the nineteenth century the institutional medical library remained a low budget item. Institutional acquisition of medical books was almost entirely by gift, by swapping duplicates, or by bulk purchase of used books, almost never by deliberate purchase of specific new titles.

Some of the slack in medical acquisitions was taken up by public libraries and other non-medical institutional libraries. In the nineteenth century, many public libraries, even free libraries, had substantial medical collections. Gould, for one, vigorously advocated that public libraries should acquire medical titles. But these collections eventually dwindled, mainly because public librarians could not meet the demands of physicians in either collection development or reference service. For example, in 1875 an anonymous physician (perhaps Chadwick) argued for the creation of an easily consulted medical library in Boston, because: "Admirable as the Boston Public Library is (in some respects), it must be confessed that so far as its medical department is concerned a liberal expenditure of both time and patience is often required before the seeker can obtain, if he obtains at all, a sight of the book or journal required." This same article announced the organization of the Boston Medical Library Association in response to this perceived need.

With a few notable exceptions, e.g., the libraries of Transylvania University, Harvard University, the New York Academy of Medicine, and the Boston Medical Library Association, private institutional medical libraries in the mid- to late nineteenth century tended not to have firm financial foundations. Although libraries had grown in size, funds for acquisition tended to be inadequate, and standards of service were almost nonexistent. In 1876 Chadwick reported on the situation of medical libraries in Boston. Harvard relied upon donations of volumes and money, and was extremely well off. The Boston City Library's medical collection consisted mostly of donated volumes from Boston's sizeable community of physicians, and was quite fortunate in both the variety and completeness of its journal runs. Four other medical libraries in Boston were funded by dues or by subscription, with varying degrees of success. In 1890 E. D. Ferguson reported that the Library of the New York State Medical Association was supported entirely by members' gifts of books, journals, and money.

Demand increased for the federal government to become involved, not in financing medical libraries, but in financing a single gigantic medical library. Should such a library be an outgrowth of the Army Medical Library which Surgeon General Joseph Lovell (1788-1836) had begun, and thus be a separate entity? or should it be just a department of the Library of Congress? This debate resounded through medical circles in the late 1870s and early 1880s.

Leading the political fight for the establishment and firm Congressional support of a national medical library were not the younger physicians, readers of the current literature, but the "Old Guard," whose main agenda was the preservation of old medical literature and the honoring of the pantheon of physicians. For example, Frederick Horner, who may have had ulterior motives insofar as he lived just across the Potomac in Alexandria, Virginia, gave lip service to the "original research" favored by young physicians, but his motivation was really that of the "Old Guard": "We need a safe repository [independent of the Library of Congress] for the invaluable writings of the fathers of American medicine and surgery ... and of the glorious galaxy of living men ... [and this proposed facility should include a] hall for statuary and a gallery for portraits of eminent members of the profession ..."

Considering options of involvement of the American Medical Association, the Library of Congress, and the Medical Society of the District of Columbia, Toner was in favor of venerating the entire medical tradition, but especially the American medical tradition: "The value of books to the medical man cannot be over estimated. They are the inexhaustible fount of knowledge from which the discoveries of the day, and the accumulated experience of ages may be drawn. The physician whose studies lead him to consult early American medical literature must be painfully struck with the perishable character of our professional literature, and the meager or fragmentary collections which have been made." In 1882 Toner announced his gift of 20000 volumes to the Library of Congress.

Billings is the real hero of this era. The federal government became heavily involved in medical librarianship only during the Civil War when Billings began to pursue his vision of making the Surgeon General's library the greatest medical reference collection in the world. As early as the mid-1890s the worldwide health care community generally acknowledged that he had achieved this goal, not only through developing the collection, but also through his founding of Index Medicus in 1879 and Index Catalogue in 1880. Billings denied reports that he was the founder of the Army Medical Library, naming Lovell and Hammond as his predecessors, but acknowledged that between 1865, when he assumed office, and 1880, the holdings of that library grew from 1800 to 50000 volumes. Even as early as 1878, one physician visiting the Army Medical Library expressed sheer amazement at the breadth and depth of the collection (e.g., bound volumes of pamphlets which had belonged to Claude Bernard). He praised Billings, the administration, and ambiance of the library, which was then housed in the old Ford's Theatre, scene of the Lincoln assassination, and which was well on its way toward outgrowing these walls.

In 1876 George F. Shrady applauded one of Billings' pet projects, Index Catalogue, claiming that it would place the world's medical literature in front of those who could not travel to Washington. In 1878 Shrady expressed the strong support of the medical community for Billings' plan to create this "index, as it were, of the medical literature of the world," even at the then huge cost to the taxpayers of $25000 for 3000 copies each of the first two volumes. The medical community's praises of Congress for its creation of a national medical library and for its funding of Index Catalogue were not in short supply. By 1883 a groundswell of support for Billings' program had arisen in state medical societies and other professional medical organizations. Gross successfully offered a strongly worded resolution at the annual meeting of the Medical Society of the State of Pennsylvania urging Congress to appropriate money for "the erection of a fire-proof building to contain the library and museum of the Surgeon-General's Office," noting with regret that such a bill had already once failed to be passed. James Reeves offered a similar resolution to the Medical Society of West Virginia, which passed it unanimously.

Image: The Surgeon General's library



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