Sir William Osler & Dr. John Shaw Billings, 1972
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sir william osler and dr john shaw billings martin m cummings m.d i have chosen to recount some significant contributions of two versatile physicians who were teachers historians and bibliophiles they are sir wllliam osler and his friend dr john shaw billings the first librarian of the national library of medicine i will attempt to trace their relationship to books computers and medicine these two accomplished and distinguished men were close friends and admirers there are a number of references of one to the other scattered throughout the medical literature one of the most inspiring of these was osler's address at the convocation memorializing billings' death 1 i speak of dr billings with the reverence inspired by a friendship of nearly thirty years and i bring officially the appreciative recognition of his great work of the bibliographical society of great britain of which he was a much esteemed honorary member and of which i happen to be president osler referred to blllings work as a bibliographer and compared him to such great students of medical literature as conrad gesner haller ploucquet haeser young eloy boyle forbes and watt he concluded however their labors are lilliputian in comparison with the gargantuan undertaking which occupied the spare moments in some thirty years of dr billings life director national library of medicine - an address before the hillsborough county medical association inc tampa florida march 1 1972

Page  2 page 2 slides 1 and 2+2a harvey cushing remarked that osler and billings had many common tastes and interests which had drawn them together 2 in common too were circumstances relating to their birth and early youth both were born of english ancestry in sparsely settled regions of their respective sister countries osler at bond head ontario and billings some 300 miles away and eleven years earlier 1838 in cotton township switzerland county indiana both would one day play major roles in the same capital cities of the eastern seaboard however the path of billings was the more troubled after graduating from miami university oxford ohio in 1857 he entered the medical college of ohio founded incidentally as the second medical school west of the alleghenies by daniel drake , there he spent two years of privation graduating in 1860 blllings was then appointed demonstrator of anatomy at the college but the war between the states soon divided the nation and he spent the next three years as an army surgeon his notebook and letters ( tell of his activities in major battles of that conflict chancellorsville gettysburg wilderness or somewhere in virginia though the war had put an end to billings' academic career it thrust upon him another in 1864 he was assigned to the office of the surgeon general of the army in washington and in the fall of 1864 4 was appointed in charge of the library of that office soon to be located in ford's theatre the scene of the

Page  3 page 3 assassination of abraham lincoln this was the post that was to lead to friendship with sir wllliam and other great men of medicine of their time a keen reflection of their mutuality of interests and experiences is found in a few unpublished letters from sir william to dr billings 5 these letters show how books technical inventions and clinical medicine brought these men together at the close of the last century paramount among these interests was a love of books and the development of libraries the scholarly and perceptive dr osler had begun to exchange books and manuscripts with the national medical library as far back as 1883 when he was at ficglll he had discovered the enormous value of the index catalogue and the index medicus and was its champion wherever he went the following letter addressed to billings associate dr fletcher is characteristic of his attempts to acquire copies of these works for libraries throughout the world norfolk and norwich medical chirurgical society norwich sept 1st 1903 slide 3 dear dr fletcher i was sorry not to see in the excellent library the index catalogue could it not be sent here there is a collection of about 5,000 books and the young men use it very much the librarian mr quinton is a man after your own heart sincerely yours wm osler i sail on the 16th . hope you are very well

Page  4 page 4 osler used the surgeon general's library extensively his wit and great respect for the value of books is reflected in a delightful note which he sent to dr blllings inviting punishment for losing one of our library books probably left on the train between washington and baltimore slide 4 feb 18 1890 209 w monument street dear dr billings bring a club with you on your next visit and pummel me well what an aggravating devil i am yes do order the book and make me pay double for it if possible sincerely yours wm osler osler's high regard for billings is clearly evident in the form of two letters inviting blllings to take charge of the bodleian library slide 5 5a 13 norham gardens oxford nov 10th 10 i.e 1910 dear billings do you happen to have a spare copy of your pamphlet on medical education extracts from lectures before the johns hopkins university 1877-78 a commission is trying to reorganize education in london one great difficulty is in connection with medical education i am to give evidence and i would like to borrow some of your powder

Page  5 page 5 you will be sorry to hear that that unique character bodley's librarian is very seriously ill i wish you could take hold of the place for a year with mr carnegie's purse behind you we have our underground stack completed which will hold more than a million volumes sorry to have missed you this summer sincerely yours wm osler slide 6 my dear osler your note of november 10th is received i am sorry to say that i have not any copy of the pamphlet on medical education to which you refer it is possible you may find one in the library of the royal medical and chirurgical society very few copies were printed off only about enough for the use of the trustees i am sorry to hear of the illness of mr nicholson it would never do to have a man like myself in his place with best wishes yours very sincerely j s billings dr william osler regius professor of medicine 13 norham gardens oxford osler was not alone in his appreciation of billings' development of the index catalogue not long before his last

Page  6 page 6 illness dr william henry welch 1850-1934 paid a visit to the library of the surgeon general's office as it was known prior to 1928 he was one of the library's oldest friends and most constant users as he sat in the librarian's col edgar erskine hume office smoking one of his black cigars he fell into one of those reminiscent moods which his friends and pupils enjoyed he spoke of the foundation of the library of its growth of the place it occupied in the world of science and then said i have been asked on more than one occasion what have been the really great contributions of this country to medical knowledge i have given the subject some thought and think that four should be named 1 the discovery of anaesthesia 2 the discovery of insect transmission of disease 3 the development of the modern public health laboratory in all that the term implies 4 the army medical library and its index catalogue and he added slowly this library and its catalogue are the most important of the four the ghost of billings pervades the atmosphere of the national library of medicine in bethesda maryland indeed so do the shades of osler oliver wendell holmes william welch and many others who recognized and encouraged both the scholarly and pragmatic innovations which billings undertook in our library at that period of history 1865-1895 although billings will be remembered primarily for his development of the index catalogue

Page  7 page 7 and index medicus he made several lesser known innovations and contributions which i believe deserve further elaboration many have forgotten that it was dr john shaw billings who designed the johns hopkins hospital and the curriculum for the medical school it was he also who went to philadelphia where in less than several minutes he recruited dr osler to become the first professor of medicine at johns hopkins osler's own account of this event clearly reflects the characters of these two men of action an important interview i had with him illustrates the man and his methods early in the spring of 1889 he came to my rooms walnut street philadelphia we had heard a great deal about the johns hopkins hospital and knowing that he was virtually in charge it at once flashed across my mind that he had come in connection with it without sitting down he asked me abruptly will you take charge of the medical department of the johns hopkins hospital without a moment's hesitation i answered yes see welch about the details we are to open very soon i am very busy today good-morning and he was off having been in my room not more than a couple of minutes 7 dr william welch the first professor of pathology at johns hopkins had already been recruited by billings in 1884 after billings death in 1913 welch described the role which billings played in the development of johns hopkins as follows

Page  8 page 8 dr billings was one of the five eminent physicians selected by the trustees to prepare essays regarding the best plans to be adopted in the construction and organization of the hospital for which johns hopkins had provided the largest gift of money which had been made up to that time for such a purpose his essay was chosen as the best and from 1876 to the opening of the hospital in 1889 he acted as the highly efficient medical advisor of the trustees of the johns hopkins hospital whose confidence he enjoyed in the highest degree the building of the johns hopkins hospital with its admirable arrangement for heating ventilation isolation sanitary cleanliness and nursing and especially those for joining hands with the university as dr blllings expressed it in the work of medical education and discovery marked a new era in hospital construction for which dr billings deserves the chief credit 8 i find it necessary to point out however that cushing noted that billings made only scant provision for a medical library at hopkins 9 perhaps even less well known are the contributions made by billings to the field of vital statistics and to the technology

Page  9 page 9 of electric data processing the origin of vital statistics is recognized as an english contribution the first bills of mortality were prepared in 1532 and were issued from time to time until 1849 but received little attention not even from sydenham until 1662 when john graunt published his slender volume natural and political observations upon the bills of mortality in his book graunt extrapolated mortality and morbidity data for various diseases in different districts of london this modest author remarked of his own work there is much pleasure in deducing so many abstruse and unexpected inferences out of these poor despised bills of mortality and in building upon that ground which has lain waste these eighty years and there is pleasure in doing something new though never so little without pestering the world with voluminous transcrip tions 10 when the observations of graunt and his successors were finally put to use for the improved practice of public health and clinical medicine the need for an accurate and efficient device to handle masses of data became apparent although joseph marie jacquard in 1780 invented a machine in which perforated cards controlled the pattern of hoods and needles for use in weaving and the english mathematician charles babbage later 1828 tried to develop an analytical engine it was clearly hollerith and billings who developed the first operational device using perforated cards for

Page  10 page 10 statistical purposes the invention of the electrical tabulating machine using punched cards is properly attributed to herman hollerith a statistician who was working at that time for the united states census office from his own account and that of others it is clear however that it was dr john shaw billings who serving as consultant to the census office first suggested to hollerith that an electrical machine utilizing punch cards should be developed for use in the 1880 census the evidence for this has been recently reviewed by love hamilton and hellman in their publication tabulating equipment and army medical statistics -^ billings himself wrote in 1891 that the data collected by t invention of the electrical tabulating machine using punched cards is properly attributed to herman hollerith a statistician who was working at that time for the united states census office from his own account and that of others it is clear however that it was dr john shaw billings who serving as consultant to the census office first suggested to hollerith that an electrical machine utilizing punch cards should be developed for use in the 1880 census the evidence for this has been recently reviewed by love hamilton and hellman in their publication tabulating equipment and army medical statistics -^ billings himself wrote in 1891 that the data collected by the census for each living person or in systems of death invention of the electrical tabulating machine using punched cards is properly attributed to herman hollerith a statistician who was working at that time for the united states census office from his own account and that of others it is clear however that it was dr john shaw billings who serving as consultant to the census office first suggested to hollerith that an electrical machine utilizing punch cards should be developed for use in the 1880 census the evidence for this has been recently reviewed by love hamilton and hellman in their publication tabulating equipment and army medical statistics -^ billings himself wrote in 1891 that the data collected by the census for each living person or in systems of death registration for each decedent might be recorded on a single card or slip 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 grouping of these perforations was 12 first suggested by billings in 1880 finally we have hollerith's own statement while engaged in the 10th census that of 1880 my attention was called by dr billings to the need of some mechanical device for facilitating the compilation of population and similar statistics this led me to a consideration of the problems involved billings gave a brief description of the electric tabulator which reads in part

Page  11 page 11 the cards thus punched are passed through machines in which an electrical connection is made by the passage of a metal rod through the cards wherever a hole has been punched and the currents thus produced actuate a series of small dials on which the number of the data is recorded... the machine not only records certain groups of facts on the dials but has series of assorting boxes which also have electrical connections by means of which the cards as they pass through the machine can be assorted into groups on any system required as for instance into groups of ages into groups of birth place or according to birth-place of mother or accord ing to occupations etc 14 this electrical tabulating machine the forefunner of the modern computer was actually used in connection with the 1886 mortality records of the city of baltimore it was used also in the surgeon general's office for compiling and tabulating army health statistics in 1889 it handled massive amounts of data collected in the united states census of 1890 this tabulator made it possible to complete the population count of the united states in only six weeks a task which previously had taken more than a year when hand methods were employed a more comprehensive account of the machine is given in the publication of general love and others cited above it is of interest to note that hollerith first used tape presumably paper

Page  12 page 12 tape before adopting the suggestion of billings to use punched cards 5 osler was among the first to utilize machine-compiled vital statistics for application to medical research teaching and practice the following two letters show his eagerness to acquire data obtained by the 1890 census for these purposes slide 7 1502 walnut street phila, dear dr billings sept 6th sorry to trouble but i would like to know whether you think the pneumonia statistics of the last census reliable enough to draw the conclusion which they warrant that the mortality in this disease was enormously increased yours sincerely wm osler slide 8 baltimore july 20th dear dr billings sorry to worry a busy man but i would like very much to know when the vital statistics of the census of 1890 will be available i wish particularly to refer to such questions as tuberculosis among the indians yery sincerely yours wm osler p.s i suppose it would be possible if i send some one over to get the cards on trichiniasis i want to make a reference to the number of epidemics which have occurred in this country and the number of cases

Page  13 page 13 one might say that osler at this time modified his precept from from books to bedside and back to books again to from books to bedside and back to computers again although some consider alexander the great as the first formal patron of research for the large sums of money and resources he made available to aristotle for specimen collections and taxonomic research in our country at least it was dr billings who was responsible for the first federal grants made in support of medical research in 1880 while librarian of the surgeon general's office he also served as vice president of the national board of health a short-lived predecessor of the u.s public health service he justified the use of federally appropriated funds for support of special scientific investigations which in itself is noteworthy but more important he and his associates made a remarkable choice of subjects to be studied since many of these same problems remain important areas for study today these are reported in the annual report of the national board of health for the year 1880 16 among the research grants awarded were the following 1 the collection of information and advice from the principal sanitary organizations and sanitarians of the united states as to the best plans for a national public health organization 2 the investigation of yellow fever in the island of cuba by a commission of experts consisting of dr g m sternberg u.s.a and others

Page  14 page 14 3 an investigation as to the best method of determining the amount and character of organic matter in the air by prof ira remsen of johns hopkins univ 4 an investigation as to the effects of disinfecting agents upon the causes of the infectious diseases by dr c f folsom dr w s bigelow of boston dr h p bowditch professor of physiology and dr wood professor of chemistry in harvard university 5 an investigation into the adulterations of food in the united states by prof r m kedzie m.d president of the state board of health in michigan and by prof lewis diehl of louisville ky as to the adulterations of drugs 6 an investigation by prof j w mallet of the university of virginia on the best method of determining the amount of organic matter in potable water and its effect on the health of persons who drink such water thus billings the librarian medical bibliographer and hospital designer may also be considered to have been one of our nation's foremost medical statisticians and science administrators he was also the engineering consultant who designed the ventilation system for our nation's capitol the designer and librarian of the new york public library system a feat which he accomplished by charming five million dollars from andrew carnegie here then are a few vignettes of a friend of sir william osler which reinforce the ideas and views that books computers and medicine may be used together to improve and advance the state

Page  15 page 15 of man's health today the nlm uses modern high-speed electronic computers for the organization and publication of the index medicus and for the storage and retrieval of citations to the world's biomedical literature thousands of physicians now request information as did sir william osler seventy-five years ago computers are being applied also to manage laboratory and clinical records of hospitals and clinics they are used for rapid evaluation of electrocardiograms and other physiological measurements they will undoubtedly be used for many other logical functions in teaching research and the practice of medicine i look forward to the continued use of books and computers as an aid to man's memory and as an adjunct to his skills and talents let us not however fragment the unity of medicine by attempting to exploit these new modalities of information and communication technology without considering their effects upon the welfare of people individually and collectively and upon the purposes which medical teaching research and practice are dedicated osler and billings were men who knew how to combine the past with the present and concern themselves with the frailties of humanity unless their perspectives are retained the art of medicine may become a cool unfeeling science much to the discomfort of the patient and the practitioner

Page  16 references 1 address by sir william osler in new york public library memorial meeting in honor of the late dr john shaw billings april 25 1913 new york 1913 pp 8-10 p 8 2 cushing harvey the life of sir william osler oxford clarendon press 1925 vol 1 p 292 3 published in part in garrison fielding h john shaw billings a memoir new york putnams 1915 chapter ii pp 19-135 4 for the date see his who founded the national library of medicine med rec ny 1880 17 298-299 it would appear that the library began to move into fords theatre on or about 12 november 1866 see us department of the army office of the surgeon general the armed forces institute of pathology its first century 1862-1962 by robert s henty washington 1964 p 54 5 the osler-billings letters cited are from the collections of the national library of medicine or the new york public library 6 hume edgar erskine victories of army medicine philadelphia lippincott 1943 p45 dr j george adami of mcgill had written earlier i would go so far as to say that the outstanding service to medicine by the united states has been this library ie national library of medicine with its publications bull med lib assn, 1914 356-57 7 gushing op cit vol 1 p 297 8 address by dr william welch in new york public library memorial meeting in honor of the late dr john shaw billings april 25 1913 new york 1913 pp 10-13 p 11 9 cushing harvey medical career and other papers boston little 1940 p 167 10 graunt john natural and political observations mentioned in a following index and made upon the bills of mortality 2nd ed london roycroft 1662 p 67 11 u.s department of the army office of the surgeon general tabulating equipment and army medical statistics by albert g love eugene l hamilton and ida levin hellman washington 1958 chapter k development and description of electrical accounting machines p 36-51 the authors rely considerably upon pearl r some notes on the contributions of dr john shaw billings to the development of vital statistics1 bull bait 1938 6 387-93

Page  17 12 billings j.s mechanical methods used in compiling data of the 11th u.s census with an exhibition of a machine abstract med.rec n.y 1891,40,407-09 13 hollerith h the electrical tabulating machine, j roy statist soc , 1894,57,678-82 14 billings loc.cit p 407-08 15 love and others op.cit p 38 16 pp 4-6