Dr. John Shaw Billings and the American Climatological Association, 1968
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Reprinted from Transactions of the American Clinical and Climatological Association, Vol.80, Printed in U.S.A. DR. JOHN SHAW BILLINGS AND THE AMERICAN CLIMATOLOGICAL ASSOCIATION BY MARTIN M. CUMMINGS, M.D. AND (by invitation) CHARLES ROOS National Library of Medicine BETHESDA, MARYLAND [Presented after dinner at the 81st meeting of the American Clinical and Climatological Association, Fontana, Wisconsin, October 15, 1968. The illustrations accompanying this paper are included through the courtesy of the National Library of Medicine, Bethesda, Maryland 20014.] As I stand before the distinguished members and guests of the American Clinical and Climatological Association, I am reminded of the experience of another tuberculosis specialist who came bearing a paper to be read before this body in 1887. The story is, I think, interesting enough to let Dr. Edward Livingstone Trudeau (for that is who it was) tell it in his own words. "Dr. Alfred Loomis (first President of this Association) had always been very friendly to me and had always taken an interest in my work, both at the Sanitarium and in my little laboratory. I had a new proof of this when he wrote me in the fall of 1886 that he had presented my name for membership in two societies-the American Climatological Association and the Association of American Physicians; that I had been elected to both, and that he wanted me to write a paper for the Climatological Association which met in Baltimore the following May (1887). I had never belonged to any medical society or attended medical meetings, but I was much pleased at Dr. Loomis's interest and decided to write a short paper for the Climatological Association, describing the influence of extremes of environment on my inoculated rabbits. In the winter I wrote the paper, which was entitled, "Environment in its Relation to the Progress of Bacterial Invasion in Tuberculosis," and we went to town in May so that I might be present at the meeting of the Climatological Association. "I left my wife and children in New York and went down on the afternoon train to Baltimore with Dr. Loomis. It was the beginning of June, and terribly hot when we reached Baltimore that evening. I hardly slept at all that night. I don't think this was entirely due to the heat, however, as I was beginning to dread the idea of speaking in public before a large audience of doctors, and I am sure this kept me awake. The next day it was just as hot and I could eat no breakfast. I went to the meeting and found a large hall packed with medical men. I sat next to Dr. Loomis and listened to the papers on the program, but it seemed a long session and the dread of having to speak before such an audience increased. "It was almost time for my paper when I began to feel dizzy and faint. I leaned over to Dr. Loomis and said, `Doctor, I feel badly.' He turned around and looked at me and said, `Get up and get out.' I tried to, but just before I got to the door darkness overtook me and I fainted. The next thing I remember I was lying on the

Page  2 floor in the hall just outside of the meetingroom, and I could hear the hum of the voices. Dr. Loomis was leaning over me and saying, `Where is your paper?' I gave it to him, and then lay there in a sort of half-conscious state listening to Dr. Loomis's strong voice as he read my paper. Then came loud applause, and soon Dr. Loomis came back and handed me the paper and said, 'That was a good paper."' You may conclude from these remarks that tonight your evening would be better served if I fainted immediately; you could then decide whether you really wanted an after-dinner speech to be read by your President, Dr. Lewis, or maybe you would prefer to have no speech at all. Dr. Trudeau was no weakling as you can see (slide). Indeed this alfresco has reminded more than one feminine viewer of Lady Chatterly's gamekeeper. But I am determined not to suffer the same fate-for as the first Director of the National Library of Medicine to be elected to this Association in this Century,[1] I am much too eager to tell you of the contributions of my most distinguished predecessor, the subject of my talk tonight. It is not given to many to be seriously considered a universal or Renaissance Man, but John Shaw Billings came close or succeeded in being so. Surgeon, medical administrator, architect, statistician, medical historian, librarian, he was also a great "fisher of men." William Henry Welch, one of the many men he "landed" (in this case for Hopkins) said of Billings: "His name and that of his intimate friend of many years Dr. Weir Mitchell ... were of all the physicians of this country the best known in Europe..." Now there is a thread between the meeting of this Association in Baltimore in 1887 and Dr. Billings. In the minutes of The American Climatological Association, as it was then called, we read: "At the close of the afternoon session on Wednesday, the members visited by in vitation the hospital of the Johns Hopkins University under the guidance of Dr. J. S. Billings." It was not by chance that Dr. Billings had been chosen or had volunteered for this assignment. For, though not a member of the Association, he knew personally or had worked professionally with many of its members. As Vice President of the National Board of Health, he had served with James L. Cabell (its President) and Homer A. Johnson (a charter member of this Association). He had written a chapter on Hygiene for William Pepper's System of Medicine; he would know personally his fellow Washingtonian, Alexander Garnett, as he would his fellow officers Washington Matthews and Alfred L. Gihon. On the following morning in Washington in the Reading Room of his own library he would speak on the use of a medical library to an audience which included Alfred L. Loomis (first president of this Association), Frederick

Page  3 C. Shattuck, and other members present in Baltimore. Dr. Edward Livingstone Trudeau, first Director of the Sanitarium in Saranac Lake, New York, tells us that he first met Welch and Osler at the Baltimore meeting-it is likely that he met Billings there also.2 Those who did not know Dr. Billings personally would come to know him as founder and editor of the Index Medicus and of the Index Catalogue of the Library of the Surgeon General's Office or as a past President of the American Public Health Association. Finally all would come to know him that day, at least, as the man who designed and served as medical consultant to the Johns Hopkins Hospital and recruited Drs. William Osler and William H. Welch to its first faculty. Unfortunately we do not have a record of his remarks made on tour that day. We do have, however, his Description of the Johns Hopkins Hospital, complete with diagrams, charts, and excellent interior and exterior photographs (Figs. 1, 2). From this we can know what was seen and infer what was said.3 [Fig. 1. The Johns Hopkins Hospital in 1890.] Subjects much discussed throughout the early Proceedings of this Association were the benefits of pure air in health and in disease (primarily tuberculosis), ventilation, and measures to prevent the spread of air-

Page  4 borne contagion. These and a corollary, heating, were of the greatest interest to Dr. Billings. He had been made aware of these problems as a Civil War surgeon. He had written of them in his celebrated Circular no. 4, A report on barracks and hospitals (1870), and Circular no. 8, Report on the Hygiene of the United States Army (1875). His series of papers Letters to a young architect on ventilation and heating had been revamped and published in book form as Principles of ventilation and heating.4 [Fig. 2. The Octagon Ward at Johns Hopkins Hospital, about 1890] He had designed and supervised the construction of the Army Medical Museum and Library (Fig. 3), and the renovation of heating and ventilation system of the Hall of Representatives of the U.S. Capitol. He had externalized the best of his experience and theories in the design and construction of the Johns Hopkins Hospital. Of this work Dr. Henry M. Hurd, first superintendent of the hospital, wrote in 1914: "No building up to that time or since had more enlightened arrangements of fresh and pure air, or more perfect construction apparatus for heating and ventilation." 5 Billings himself wrote of his hospital: ".... it is a great laboratory for teaching the practical applications of the laws of hygiene to heating, ventilation, house-drainage, and other sanitary matters. All pipes and traps are either exposed to view or can be

Page  5 seen by merely opening a door, and in the tunnel beneath the corridor you can study at your leisure the complicated and yet simple arrangement of pipes for gas, steam, water, sewage, etc., which are usually buried and remain a profound mystery to every one except the plumber, and often puzzle even him." 6 These interests alone constituted a common bond between members of the Association and Dr. Billings. [Fig. 3. Reading room and stacks of the Army Medical Library, Washington, D.C., about 1890.] But Billings' interests in the new hospital were not limited to engineering or construction or the teaching of these. He had new ideas of medical education in the broadest sense, new ideas of the relationship between the hospital and the medical school, of the role of the hospital in medical research. Some of these are referred to in his address at the opening of the Johns Hopkins Hospital, which introduces the volume cited earlier. They are more fully stated in many of the articles or monographs cited in the 171 item Hasse bibliography in Garrison[7], recently expanded8 but still not complete. These ideas, too, played a role in the design of the medical and surgical wards, the pathological laboratory, and the nurses' home.

Page  6 Fig. 4. Dr. John Shaw Billings. Billings has been described as a tall, courteous, somewhat melancholy figure (Fig. 4). He was much traveled and he spoke very well. He had already received an honorary LLD from the University of Edinburgh (in the company of Pasteur, Virchow and others) and one from Harvard -he would receive five more honorary degrees before his career was

Page  7 ended. No doubt members of this Association were well served that day. The second reference to Dr. Billings occurs in your Association's Transactions for the year 1893, the annual meeting having been held in Philadelphia: " ... at the invitation of Provost Pepper and Professor J. S. Billings a luncheon was enjoyed in the library building of the University." I shall discuss Billings' title as Professor a little later. Billings was host to the Association for the second time. In the intervening eight years from the last such occasion, new subjects had become of interest to the Association and new names had been added to its roster. Of the new subjects one much debated in the early volumes of our Proceedings (beginning with 1891) was the efficacy of tuberculin. These years have been rightly called the "era of tuberculin delirium."[9] Many distinguished members of this Association were involved in the early history of tuberculin in the United States-Alfred Loomis, Abraham Jacobi, Alexander C. Abbott and others-all friends of Dr. Billings. But Garrison and other biographers of Billings seem to have overlooked the role Billings himself played in this history. It was Billings, for example, who first obtained tuberculin from Koch and supplied it to William Welch for the first clinical trials by Osler and others at Johns Hopkins.10 On June 30, 1891, Billings wrote the following letter to Koch: My dear Dr. Koch. June 30/91 I have been, for several months intending to write to you but have been very busy, as I know you are also. Now however I wish to say to you that I remain as fully convinced of the importance and value of your work on the tuberculin as ever. I know very well that you made your announcements about it before you were ready and much against your will-and I do not think that you are a man to be troubled much by adverse criticisms, or denunciations, but it may nevertheless please you to know that your position is understood by your friends abroad as well as at home, and that we are perfectly satisfied to wait until you publish further information when you get ready. The lymph which I obtained from Dr. Libbertz I distributed widely to Hospitals and to Medical Officers of our Army, and personally, I was able to observe the effects of its use in but few cases. In four (?) cases of lupus its results were very satisfactory for the first four months but in each case the patient became unwilling to remain longer in Hospital and went away much improved but not cured. Of 8 cases of incipient pulmonary tuberculosis, two left the hospital free from cough or fever-with marked gain in weight no bacilli in the sputum-in fact no sputum-and apparently well. Three were much improved, in two there has been little change and one is worse. The climatic conditions under which all these cases were treated were such as we consider unfavorable. I do not write however to report cases but merely to assure you of my continued

Page  8 admiration for your work and my personal friendship for yourself. Can you not pay this country a short visit? I have a room in my house always ready for you, and you shall do as you like-see no one that you do not wish to see-make no speeches that you do not wish to make, and not be troubled in any way so far as I can prevent it. With kindest regards and best wishes believe me to be Your sincere friend John S. Billings Prof. Dr. Robert Koch Of the new members of the Association added since 1887 best known to Billings were Abraham Jacobi, Alexander G. Abbott and John H. Musser. Of these Dr. Jacobi must be singled out (Fig. 5). He helped Billings obtain appropriations from the Congress for the Index Catalogue almost twenty years earlier. He had had, and would continue to have, a distinguished role in American medicine and he would retain his interest in libraries. He became President of this Association in 1900, President of the American Medical Association in 1912, and in 1905-06 he succeeded to a post held by Osler from 1901-04, that of President of the Medical Library Association. Jacobi's comments in discussion of papers presented at the annual meeting of this Association mark him as a Nestor among his colleagues. He remained one of Billings' closest friends until his death. The year 1893 was for Billings an interlude between the two major periods of his life. He was in the midst of a gradual withdrawal from Washington and the National Library of Medicine and the eventual transfer of his activities to New York as designer and first librarian of the New York Public Library (Figs. 6, 7). I should point out that Billings had previously convinced Andrew Carnegie that he should share his wealth with the nation by building public libraries and scientific institutions. Billings himself organized the Carnegie Institution and served as Chairman of the Board after its founding. The interlude began and ended in Philadelphia. The prime mover throughout this transitional period was Dr. William Pepper (Fig. 8), Provost of the University of Pennsylvania and Professor of Medicine. Pepper was a charter member of this Association and was its second president (1886). Billings' relationship to Pepper was complex and before its culmination it was to involve all aspects of Billings' genius. I have mentioned that Dr. Billings contributed a chapter on hygiene to Pepper's System of Medicine in 1885. In 1886 Pepper in his Presidential address The climatological study of phthisis in Pennsylvania before the 3rd annual meeting of this Association spoke of Billings: "In addition to the material thus placed at my disposal, I have made liberal use of the mortality and vital statistics as prepared by Dr. John S. Billings for the census of 1880. Nor can I neglect this opportunity of referring to the great practical value

Page  9 of this colossal work. Despite the serious defects of the statistics resulting from the absence of any national system of registration of vital statistics such as is relied upon by all other civilized nations for the purpose of ascertaining the actual movement of population, the improved method employed in this tenth census and the ability shown by Dr. Billings in the arrangement and analysis of the results render the two volumes which have just appeared highly valuable to the profession and highly creditable to the genius and energy of their distinguished author.." [FiG. 5. Dr. Abraham Jacobi, President of the American Climatological Association in 1900.]

Page  10 [FIGS. 6 and 7. Dr. Billings' sketch for the plan of the New York Public Library and the plans drawn from this sketch.]

Page  11 FIG. 8. Dr. William Pepper, Provost and Professor of Medicine at the University of Pennsylvania. Second president of the American Climatological Association (1886). Here is a reference to Billings' work as Consultant to the U.S. Census Bureau, an experience which led him to the most remarkable invention of his period. In 1889 Dr. Billings had suggested "That the data collected by the census ... might be recorded on a single card or slip

Page  12 by punching small holes in different parts of it, and these cards might then be assorted and counted by mechanical means according to any selected groupings of these perforations." 14 This suggestion was taken up by Herman Hollerith and eventuated in the invention of the electric tabulating machine, the forerunner of today's computer. This machine was first used for the tabulation of vital statistics in Baltimore in 1887. It then served the 1890 Census of the United States. Today Billings' primitive computer has been transmuted into the machine retrieval of bibliographic information, which, within the National Library of Medicine, is known as MEDLARS, the most comprehensive computer-based reference retrieval system for medicine in the world today. In the 1891-92 academic year Billings, through the efforts of Dr. Pepper, combined these interests and lectured on hygiene and vital statistics, as Professor of Hygiene, at the University of Pennsylvania. In 1892 Pepper enlisted Billings' architectural talents in Philadelphia where he supervised the planning and construction of the Institute of Hygiene at the University. The laboratory was the "first structure of its kind erected in the United States" and Billings became its Director ("the one man best fitted for it in America" said Weir Mitchell).12 Alexander C. Abbott, whom Billings had known at Hopkins became the First Assistant of the Laboratory. In 1893, the date at which the Association met in Philadelphia, approximately one fifth of the membership of the Association were Philadelphians. Billings himself, in spite of his many commitments in that city, maintained his position as Director of the National Library of Medicine and continued to reside in Washington. But Pepper's influence persisted and in 1895 Billings resigned from the Army (with the rank of Deputy Surgeon General) and from the Library and moved to Philadelphia, assuming full-time duties as Professor of Hygiene, Director of the University Hospital and Director of the Institute of Hygiene. Billings' Philadelphia career culminated at a testimonial dinner in the same year at which he was presented with a silver box containing a check for $10,000. " .. from 259 physicians of the United States and Great Britain in grateful recognition of his services to medical scholars." 13 S. Weir Mitchell chaired the proceedings and they were attended by many members of this Association, foremost among whom were William Pepper and Abraham Jacobi. Although Dr. Billings had left the Library, his genius had not. The last volume of the Index Catalogue which he personally developed as the world's first comprehensive medical bibliography, was published as late as 1961 and the new Index Medicus, which he also started in 1879, began publication as a computer product in 1964. These are a few vignettes of an illustrious physician, who though not

Page  13 a member of this Association had a close relationship and profound influence on some of its early members. In tracing the connections of Dr. Billings to the membership of your Association, I constantly asked myself, how did he escape becoming a member himself? This question plagued me even more when I recently learned that he served as President of the Congress of American Physicians and Surgeons of which The American Climatological Association was a component member. Surely a man who could charm Andrew Carnegie out of $5,400,000 to establish the first public library system of this country, a physician who could establish the first true National Library in this country, the administrator who could design Johns Hopkins Hospital and recruit some of its first distinguished faculty, the surgeon who performed the first ankylosis of the ankle on the battlefield at Gettysburg, the scientist who obtained the first tuberculin from Robert Koch to be used for clinical trials in this country, the innovator who helped build the first electric tabulator for use in computation, surely such a genius would have qualified for membership. Was this due to lack of interest by Billings or to indiscriminate use of the blackball at the turn of the century? Perhaps someone here tonight can throw some light on this riddle. I close with this "Lament for J.S.B." There was a young doctor from D.C. Who was creative as could be Thus wouldn't it seem logical That membership in the Climatological Would be a foregone reality? My hero knew everyone from Alpha to Zeta For he indexed their published excreta Though he knew all the greats He was ignored by the Fates So we are left with a biographica incompleta. REFERENCES 1. Brigadier General (Dr.) Calvin DeWitt, Director of the Army Medical Library 1903-04, was elected to membership in 1897. 2. Autobiography Phila., Lea, 1916. p. 209. He further relates that he fainted of stage fright at the prospects of reading his paper before so large an audience and that the paper was read by Dr. Alfred Loomis, he Trudeau, the while, lying on the floor outside the room. p. 206-09. 3. The hospital was not officially opened until May 7, 1889. Welch tells us "The work of the pathological laboratory began in 1885. It was opened first in the biological laboratory (of the University) and later in 1886 in one of the hospital buildings which had been completed for the purpose. This was occupied by myself and my associate, Dr. Councilman, who was already here when I came..." Welch, William H., Papers and Addresses, v. 3, p. 21. 4. 1 ed. 1884; 2 ed. 1889. A "substantially new" work was published under the same title in 1893. The preface acknowledges the assistance of Alexander C. Abbott.

Page  14 5. Johns Hopkins Historical Club. Special meeting, May 26, in memory of Dr. John Shaw Billings. Johns Hopkins Hosp Bull 25: 245, 1914. Of interest for the history of the library was Billings' use of David L. Huntington and Robert Fletcher in his ventilation studies. Johns Hopkins Hospital. Reports and papers relating to construction and organization. No. 5. On heating and ventilation. Washington, Feb. 12, 1878, p. 76. 6. Billings, J. S.: Description of Johns Hopkins Hospital. Baltimore, 1890. p. 38. 7. Garrison, F. H.: John Shaw Billings; a memoir. New York, Putnam's 1915. Bibliography of the writings of John Shaw Billings, 1861-1913. p. 411-22. 8. Rogers, Frank B.: Selected papers of John Shaw Billings. (Chicago) Medical Library Association, 1965. Bibliography of the writings of John Shaw Billings, pp. 285-300. 9. Willis, Henry S., AND Cummings, Martin M.: Diagnostic and experimental methods in tuberculosis. Springfield, Thomas 1952. p. 183. Quoting P. H. Ringer. 10. Osler, W. H. and Others: Report on the Koch treatment in tuberculosis. Johns Hopkins Hosp Bull 2: 7, 1891. This is also noted in Cushing's Osler, v. 1, p. 341-2. 11. Transactions Amer. Clin. & Climatol. Assoc 3: 95, 1886. 12. The opening exercises of the Institute of Hygiene of the University of Pennsylvania, Philadelphia, February 22, 1892. Philadelphia, 1892. p. 9.