Encyclopedia of Greater Philadelphia

Steven J. Peitzman

Dispensaries

Free clinics known as dispensaries served the “working poor” of European, British, and American cities from the eighteenth through the early twentieth centuries. Paid or volunteer physicians saw patients on site or at their homes in the dispensary’s district, caring for both minor ailments and more serious diseases. The Philadelphia Dispensary for the Medical Relief of the Poor, considered the nation’s first, opened in 1786. By the late nineteenth century, a disorganized assortment of dispensaries large and small served the Philadelphia region’s growing population of new immigrants.

[caption id="attachment_29126" align="alignright" width="300"]Photograph of Philadelphia Dispensary In 1801, the Philadelphia Dispensary opened a new building on Fifth Street between Chestnut and Walnut Streets, the middle building shown in this photograph taken in 1887. (Library Company of Philadelphia)[/caption]

The Philadelphia Dispensary opened in rented space but was able to erect a handsome building on Fifth Street between Chestnut and Walnut in 1801. Both Quaker and non-Quaker citizens supported the enterprise, originally headed by the admired Episcopal Bishop William White (1748-1836) and administered by other prominent Philadelphians, particularly members of the Wistar/Wister family. Benjamin Franklin (1706-90) headed the first subscribers, who could each list two persons for free care. Many prominent physicians served as regular dispensary doctors or consultants. An employed apothecary prepared the pills, tinctures, salves, and the like, which almost all patients received: the name “dispensary” well fit the function. The Philadelphia Dispensary also offered  inoculation against smallpox. In the early decades of the nineteenth century, the dispensary cared for large numbers of African Americans, and then Irish following their increasing immigration in midcentury.

[caption id="attachment_29116" align="alignright" width="296"] The Southern Dispensary for the Medical Relief of the Poor opened in 1816 on Shippen (Bainbridge) Street west of Third. The Renaissance Revival building dates from 1858. (Photograph by Steven J. Peitzman)[/caption]

Overwhelmed with clientele, the Philadelphia Dispensary in 1816 made loans to support the founding of the Northern Dispensary, serving the Northern Liberties into Kensington, and the Southern Dispensary (chartered in 1817) for Southwark, Moyamensing, and Passyunk. These functioned very much like the parent institution. Eventually, dispensaries could be found in the various townships and neighborhoods. For example, the Germantown Dispensary (later Germantown Dispensary and Hospital) opened modestly in one room in 1864, an initiative of the prominent physician James. E. Rhoads (1828-94). The Camden City Dispensary was founded in 1866, with members of New Jersey’s prominent Cooper family enrolling as “life members” (subscribers). Norristown Hospital and Dispensary was among facilities in the region to offer  both inpatient and outpatient services; founded in 1889, it soon changed its name to Charity Hospital, and later Montgomery Hospital.

Specialty Dispensaries

The evolution of Philadelphia’s various dispensaries reflected changes in the region’s population and in medicine. The Southern Dispensary in Philadelphia, for example, saw increasing numbers of immigrants from Eastern Europe and Italy as well as African American migrants from the South during the late nineteenth and early twentieth centuries. With the growth of specialization in medicine, specialty dispensaries arose for skin diseases, eye and ear problems, pediatrics, and for the ubiquitous and deadly tuberculosis. The older dispensaries organized their clinics by categories of disease. Nonetheless, the major dispensaries of Philadelphia remained mainstays of outpatient medicine for ailments such as coughs and catarrhs (colds), “rheumatism,” dyspepsia, and diarrhea and earaches among children. Dispensaries in industrial areas also looked after cuts, burns, and various injuries not needing hospitalization or major operations.

Something like a dispensary mania surged in the second half of the nineteenth century. The strong presence of the alternative therapeutic practice homeopathy in the city led to homeopathic dispensaries. The House of Industry and the College Settlement also offered dispensaries. Jewish anarchist physicians opened their Mt. Sinai Dispensary at 236 Pine Street in 1900. The major hospitals spawned dispensaries, as did some of the medical schools.

Medical education had played a major role at dispensaries from the beginning, since young doctors used them to gain experience. Alumnae of the Woman’s Medical College of Pennsylvania founded an outpost, the Barton Dispensary (named for a founder), on Third Street in South Philadelphia in 1895; it later moved, when the college did, to East Falls. The “Medical Society for Self-Supporting Women” for some years in the late 1880s conducted an evening dispensary for working women, with women physicians as staff.  In 1883 surgeon John B. Roberts (1852-1924) and others opened the Philadelphia Polyclinic and College for Graduates in Medicine at Thirteenth and Locust Streets. This “short course” school for those already holding the M.D. aimed at providing practical experience sometimes lacking in conventional medical schools. Instruction depended largely on the institution’s dispensary practice, although later, at Lombard Street between Eighteenth and Nineteenth, it added a hospital (later known as Graduate Hospital).  While many Philadelphia physicians practiced at a dispensary sometime in their careers, and some even founded one, other physicians thought the proliferation was getting out of hand. They suspected that persons capable of paying a fee to a private practitioner nonetheless would seek care at a dispensary–what was referred to as “dispensary abuse” or more broadly, “charity abuse.” This tension arose in other cities as well.

Clinics Evolve

Over the course of the twentieth century, other forms of free clinics gradually replaced dispensaries. A 1929 report on medical facilities in Philadelphia listed seventy-one dispensaries, almost all of them outpatient practices of hospitals, medical schools, or other organizations. Only the Northern Dispensary and the Southern survived as independent entities. The original Philadelphia Dispensary had merged with the outpatient services of Pennsylvania Hospital in 1922. By the 1940s, health clinics conducted by the Philadelphia Department of Health assumed some of the work once done by the city’s dispensaries. Outpatient departments of hospitals and medical schools expanded (and eventually could gain reimbursement with the advent of Medicare and Medicaid in 1966). Nonprofit agencies such as the Public Health Management Corporation also opened free-standing clinics, including the Mary Howard Health Center, managed by nurses and serving Philadelphia’s homeless population. Into the 1980s and 1990s, community-minded medical students and faculty physicians at Hahnemann Medical College and the Medical College of Pennsylvania (the former Woman’s Medical College of Pennsylvania, coeducational as of 1970) reinvented the free neighborhood night clinic. Surprisingly, the term “dispensary” resurfaced in 2017 with a novel connotation—the place to go for medical marijuana.

Philadelphia’s dispensaries of the nineteenth and early twentieth centuries, including the nation’s first such institution, served basic health needs of the poor, particularly first-generation immigrants, though their educational function may have been at times exploitive. Various free or low-cost clinics continued to operate in the early twenty-first century, demonstrating a persistent need despite the availability of health insurance and the federal Medicare, and Medicaid programs.

Steven J. Peitzman is Professor of Medicine at Drexel University College of Medicine. His historical work includes the book  A New and Untried Course: Woman’s Medical College and Medical College of Pennsylvania, 1850–1998 (Rutgers University Press, 2000) and articles about medicine and medical education in Philadelphia and Germantown. (Information current at date of publication.)

Typhoid Fever and Filtered Water

[caption id="attachment_20547" align="alignright" width="285"]This editorial cartoon by Fred Morgan, published in the Philadelphia Inquirer on April 6, 1899, shows William Penn balking at the idea of drinking the "mixed drink" offered him. This editorial cartoon by Fred Morgan, published in the Philadelphia Inquirer on April 6, 1899, shows William Penn balking at the idea of drinking the "mixed drink" offered him, a cocktail of runoff from upstream communities. (Philadelphia Water Historical Collection/Adam Levine)[/caption]

Philadelphia in the late nineteenth century stood shamefully high among large American cities in rates of death from typhoid fever (also known as enteric fever). Caused by a type of Salmonella bacterium, the disease had become common in Philadelphia and other cities with crowded populations, inadequate disposal of human waste, and lack of water treatment. Local outbreaks and the knowledge that they might be prevented by improving the water supply spurred physicians, activists, and organizations to press Philadelphia’s city government to improve water quality with a filtering system. After a decade of delay and fumbling, a massive apparatus installed between 1900 and 1910 largely ended deaths from typhoid fever.

By the last decades of the nineteenth century, the Philadelphia region no longer suffered from massive epidemics of yellow fever, cholera, or smallpox—though the horrific influenza pandemic of 1918 lay in the future. Typhoid fever, meanwhile, had become both endemic (common) and given to outbreaks or local epidemics. Philadelphia endured outbreaks in 1876 (probably relating to the crowds coming to the city for the Centennial Exhibition), 1888-1889, 1899, and 1906–but the disease was always present. During the 1890s, more than 5,400 deaths from typhoid fever occurred. More died from tuberculosis, but the means existed to prevent typhoid. The symptoms of typhoid include high fever, headaches, a subtle rash, vomiting, and sometimes diarrhea; complications such as bowel perforation or hemorrhage can cause death. The microbe spreads through the “fecal-oral” route, meaning contaminated milk, asymptomatic carriers, and most importantly, impure water. Before antibiotics, treatment consisted of a “mild” diet (milk, eggs, beef broth), bed rest, and cold baths, the last much loathed by patients. Surgery could occasionally save patients who had bowel perforations.

[caption id="attachment_20549" align="alignright" width="259"]Two bottle of water, one before filtration and one after. This photograph from 1903 shows bottles of water, the one at left unfiltered, the one at right after filtering. (PhillyHistory.org)[/caption]

In a time of industrial growth and population increase, typhoid was a regional problem, but no regional framework existed to deal with it. In the nineteenth century, as in the twenty-first, Philadelphia drew its water from the Schuylkill and the Delaware Rivers, into which both the city and upstream districts discharged all manner of industrial and human waste. The creation of Fairmount Park in the nineteenth century lessened the city’s contribution to the Schuylkill’s considerable defilement. But Manayunk within the city and upstream industrial towns such as Norristown, Pottstown, and Reading created pollution “as diversified as the occupation of the people: sewerage, chemical, wool-washing, dye stuff, butcher and brewery refuse–there is almost nothing lacking,” according to the 1883 Annual Report of the Philadelphia Bureau of Water. In addition to the ills and pollution caused by industrial waste, matter added by latrines and flush toilets could disseminate typhoid. A similar situation, though perhaps less dire, befouled the Delaware.

Larger Reservoirs

As one response to this menace, in the 1880s the Bureau of Water built an “interceptor sewer,” a sort of bypass channel that drained waste from Roxborough, Manayunk, and Falls of Schuylkill (East Falls), diverting it from the river. The city also created larger reservoirs to allow water more time to settle, so that gravity could lead to sedimentation of particulate contamination. The rate of deaths from typhoid declined into the early 1890s, but still amounted to a persistent loss of life of young and old Philadelphians, which was generally recognized as preventable. More seemed to be needed. In 1889, influential Germantown physician and author Henry Hartshorne (1823-97) argued for filtration of the water supply in a pamphlet titled Our Water Supply: What it is and What it Should Be, published on behalf of a committee of citizens. Hartshorne cited recent experience in Europe, where cleansing of municipal water through “slow” filters of layers of sand and crushed coal had become an accepted technique. The method had recently been introduced into the United States and became more widely known through an important book published in 1895, The Filtration of Public Water-Supplies, by engineer Allen Hazen (1869-1930).

[caption id="attachment_20548" align="alignright" width="300"]Construction on the lower Roxborough filter plant in 1901. The lower Roxborough filter plant was under construction when this photograph was taken in 1901. (PhillyHistory.org)[/caption]

Into the 1890s, a variety of lay and medical groups in Philadelphia campaigned for clean water and particularly for a system of filters. These included the Women’s Health Protective Association (founded in 1893), the College of Physicians of Philadelphia, the Civic Club, and beginning in 1896 a broadly-based Citizens’ Organizations Filtration Committee. The City Councils (then bicameral) took up the issue, but political factionalism, unclear authority to borrow large funds, and an extreme diversity of opinion delayed approval of funding. For example, while some members of Council favored filtration, Thomas Meehan (1826-1901), the “dean of American horticulturists” and a locally prominent Germantown resident, dismissed its value and may have doubted the germ theory of infectious disease. In addition, the chief of the Bureau of Water, a capable engineer named John Cresson Trautwine (1850-1924), deplored the waste of water more than the waste in it, and so persistently urged the metering of water (then not in effect) more than the filtering of it. In addition, several proposals to bring pure water from either the Pine Barrens of New Jersey (suggested in 1891) or from unpolluted realms of the upper Schuylkill (1889, 1897) episodically competed for attention.

A particularly vicious outbreak in 1898-99 (which some alleged related to the movement of soldiers into the city at the time of the Spanish-American War) resulted in 948 deaths in 1899 and finally provoked progress. The City Councils approved the request of Mayor Samuel Ashbridge (1849?-1906) for a $12 million bond issue to build the system of sand filter beds. Construction began in 1901 and 1902 at the reservoirs and pump stations in Roxborough (“upper” and “lower”), West Philadelphia (Belmont), and Torresdale. The end of the decade saw the last filter beds completed, at the Queen Lane location. Numerous photographs made by the city show the enormity of these vast undertakings, probably then the largest municipal projects in Philadelphia’s history. The plan included laying massive pipes interconnecting the several water facilities. The entire effort ended up costing an estimated $26 million to $28 million.

Typhoid Declines

[caption id="attachment_20551" align="alignright" width="249"]An Editorial cartoon from 1909 depicting William Penn celebrating filtered drinking water supply in Philadelphia. In this 1909 editorial cartoon, a William Penn character, anticipating the filtration of the entire city water supply a few days later, raises a glass of filtered water to the departing devil, whose suitcase reeks with the germs of typhoid, diphtheria, and scarlet fever. (Philadelphia Water Historical Collection/Adam Levine)[/caption]

Typhoid fever rates eventually fell by more than 90 percent with the advent of filtered drinking water–which was also, at least sometimes, clear and free of odor, something new to Philadelphians. A serious outbreak occurred in 1906, but it was mainly limited to areas not yet receiving filtered water. In 1909 chlorination was added to further combat water-borne bacteria. In the 1910s and 1920s typhoid immunization came into wide use. Occasional small epidemics still occurred; one in 1911 resulted from a rupture of a large main supplying the Roxborough plant. Until immunization made most of the population resistant to the disease, some outbreaks could be traced to a picnic mishap or other tainted food. Into the 1920s and 1930s, the city’s public health officials rightly or wrongly deemed most cases to have been acquired outside the city, particularly at the New Jersey shore during the summer. Enough cases continued to occur, however, to induce the closing of the popular springs throughout Fairmount Park, though these likely did not spread typhoid to any great extent. By 1935, rarely did a Philadelphian die from typhoid fever.

Steven J. Peitzman is Professor of Medicine at Drexel University College of Medicine. His historical work includes the book  A New and Untried Course: Woman’s Medical College and Medical College of Pennsylvania, 1850 – 1998 (Rutgers University Press, 2000) and articles about medicine and medical education in Philadelphia and Germantown. He also has published on the history of his clinical area, kidney disease.

[caption id="attachment_20767" align="alignright" width="575"]1898 map showing deaths per 100, with Philadelphia in the 30 to 40 range.This This map, based on 1890 census data, shows the death rate attributed to typhoid fever in the Mid-Atlantic region, with the Philadelphia area showing thirty to forty deaths per thousand residents. Typhoid was common in the late nineteenth century, and Philadelphia endured outbreaks in 1876, 1888-1889, and 1899. (David Rumsey Historical Map Collection)[/caption]

City of Medicine

In 1843, a student at the “med school of the University of Pennsylvania,” as he called it in a letter to a friend in Boston, declared Philadelphia “decidedly the city of the Union for doctors, the facilities for study making it a perfect little Paris.” The comparison reflected the renown of the French capital at that time for bedside teaching and anatomical dissection. By that point in the mid-nineteenth century, Philadelphia had become the country’s pre-eminent medical city, known particularly for its wealth of opportunity for medical education. Although the city lost its edge in the early 1900s, it recovered later in the century to become a growing center of health care, research, and education.  Medical care and education remained integral factors in the social and economic fabric of the city.

[caption id="attachment_12090" align="alignright" width="300"]In 1752 Pennsylvania Hospital received its first patients in rented quarters on Market Street. By 1804 it had completed the handsome set of structures now known as the Pine Street Building. Though long supported by many Quakers, the Hospital has always cared for all Philadelphians. It has as well continuously provided valued clinical instruction. (Photograph by Steven J. Peitzman) In 1752 Pennsylvania Hospital received its first patients in rented quarters on Market Street. By 1804 it had completed the handsome set of structures now known as the Pine Street Building. Though long supported by many Quakers, the Hospital has always cared for all Philadelphians. It has as well continuously provided valued clinical instruction. (Photograph by Steven J. Peitzman)[/caption]

Philadelphia gained its early reputation as a city of medicine through the development of hospitals and medical schools. The founding of Pennsylvania Hospital in 1751 (America's first general hospital) was an indication that by the mid-eighteenth century, Philadelphia had grown into a substantial urban complex with needs for services beyond what family and church could provide. Founded by physician Thomas Bond (1712-84) and Benjamin Franklin (1706-90), the nation’s first hospital joined a movement—rooted in Enlightenment thought, then underway in Britain—to create “voluntary hospitals” to care for “strangers” and the “worthy poor,” funded and conducted by private philanthropy. From the outset, the hospital contributed to the city’s allure in medical education. Its Wednesday and Saturday morning demonstration “clinics” drew crowds of nineteenth-century medical students.

[caption id="attachment_12095" align="alignright" width="278"]The Southern Dispensary for the Medical Relief of the Poor opened in 1816 on then Shippen, now Bainbridge Street west of Third. The Renaissance Revival building still standing (318-320) dates from the 1858. Most row-house Philadelphians went to family doctors in their neighborhood (or the doctor came to them). Free dispensaries (clinics) served the poor and working poor; the Southern particularly cared for the immigrants of South Philadelphia. Young physicians and trainees valued the experience gained at such dispensaries. (Photograph by Steven J. Peitzman) The Southern Dispensary for the Medical Relief of the Poor opened in 1816 on then Shippen, now Bainbridge Street west of Third. The Renaissance Revival building still standing (318-320) dates from the 1858. Most row-house Philadelphians went to family doctors in their neighborhood (or the doctor came to them). Free dispensaries (clinics) served the poor and working poor; the Southern particularly cared for the immigrants of South Philadelphia. Young physicians and trainees valued the experience gained at such dispensaries. (Photograph by Steven J. Peitzman)[/caption]

Numerous hospitals subsequently arose within neighborhoods and nearby townships, supported by religious denominations or particular segments of the citizenry, such as African Americans or women. The city opened Blockley Almshouse in 1732, which later became Philadelphia General Hospital; and the origins of the Municipal Hospital for Contagious and Infectious Diseases can be traced to before 1818.  Specialty hospitals arose for care of the eyes, children, and maternity work. Reflecting the Quakers’ concern for those “deprived of reason,” Pennsylvania Hospital spawned a progressive Hospital for the Insane (1841) on then-rural grounds west of the city; a Friends Asylum (1817) was founded in the Frankford countryside. With other Quaker women, in 1862 pioneer woman doctor Ann Preston (1813-72) founded Woman’s Hospital of Philadelphia to provide clinical training for women medical students and nurses. Temporary hospitals, some immense, were thrown up throughout the city to care for soldiers during the Civil War, the Satterlee in West Philadelphia being the best known. Eventually the city’s medical schools established their own hospitals.

The numerous hospitals served as objects of neighborhood pride and philanthropy, particularly service by women. In addition, their accident wards supported the city’s vast industrial growth in the nineteenth century.

Philadelphia’s place as a center of medical education can be traced to 1762 when William Shippen Jr. (1736-1808), son of a physician and educated in England and Edinburgh, initiated some lectures on anatomy and midwifery on Walnut Street near Third. Also a product of Edinburgh and European experience, the energetic John Morgan (1735-89) in 1765 proposed an enlightened plan for medical education, and with Shippen, inaugurated lectures at the College of Philadelphia intended as part of a course of study leading to a degree in medicine. From 1789 through 1791, both the revived College of Philadelphia and the newly chartered “University of the State of Pennsylvania” offered medical lectures, by feuding faculties (Philadelphia’s early teaching physicians were a notably feisty bunch). The factions united as the forerunner of the University of Pennsylvania School of Medicine, America’s first. It won standing during the nineteenth century as one of the strongest in the nation, though strong in a stolid sort of way.

Perceiving room for another medical school in Philadelphia, if not an actual need, surgeon George McClellan (1796-1847) and some collaborators opened Jefferson Medical College in 1824. Both Penn and Jefferson welcomed huge classes, and so produced a high proportion of early American doctors. Jefferson’s faculty came to rival Penn’s in national reputation.

[caption id="attachment_12082" align="alignright" width="300"]This posed photograph of the dissection laboratory of the Woman’s Medical College of Pennsylvania (WMCP) from the 1910 yearbook conveyed the reassuring idea that the study of medicine, even anatomy, could be orderly and lady-like. The opening of Quaker-supported WMCP in 1850 and founding of Woman’s Hospital of Philadelphia (1861) made Philadelphia the home of many early women physicians and surgeons. (Legacy Center Archives, Drexel University College of Medicine) This posed photograph of the dissection laboratory of the Woman’s Medical College of Pennsylvania (WMCP) from the 1910 yearbook conveyed the reassuring idea that the study of medicine, even anatomy, could be orderly and lady-like. The opening of Quaker-supported WMCP in 1850 and founding of Woman’s Hospital of Philadelphia (1861) made Philadelphia the home of many early women physicians and surgeons. (Legacy Center Archives, Drexel University College of Medicine)[/caption]

Beginning in the 1840s and 1850s, in Philadelphia (and elsewhere in the United States), the making of new medical colleges swelled into a kind of mania. Those after Penn and Jefferson that endured into the twentieth century included Hahnemann Medical College (1848); the Woman’s Medical College of Pennsylvania (1850; the first of its kind in the world); the Medico-Chirurgical College (1881); the Philadelphia Polyclinic and College for Graduates in Medicine (1883); and the Philadelphia College and Infirmary of Osteopathy (1899). Other schools, ranging from fully creditable to entirely fraudulent, came and went. Extinct schools included (among many) the co-educational Penn Medical University (1853), which had nothing to do with William Penn and was surely not a university. Lastly, the Medical Department of Temple College, later Temple University School of Medicine, opened in 1901. The availability of strong medical education for women, and the presence of several women’s hospitals, fostered growth of a sizeable community of women physicians and surgeons who practiced and taught here. Hahnemann Medical College taught the therapeutic system of German physician Samuel Hahnemann (1745-1843) called homeopathy, which flourished in Philadelphia. 

By 1890, about 2,000 names appeared in the city’s medical directories, for a population of approximately one million. Most were doctors in the neighborhoods—serviceable, often hard-working. They saw patients in their homes and during office hours, and some attended at a hospital. They looked after illnesses severe and trivial, delivered babies, vaccinated, repaired fractures and lacerations, gave advice; and, more or less successfully, made a living.

[caption id="attachment_12080" align="alignright" width="233"]A fully expressed product of the Enlightenment, Benjamin Rush (1746-1813)  became America’s fist internationally recognized physician, though a controversial one. His fervid belief in the arterial localization of disease led to intensive use of bleeding and calomel (mercurous chloride)  during the yellow fever epidemics of the 1790s. As doctor and citizen, Rush served the Revolution, advocated for abolition, embraced temperance, and offered ideas for the development of education in the new republic. (Engraving after painting by Thomas Sully, National Library of Medicine) A fully expressed product of the Enlightenment, Benjamin Rush (1746-1813) became America’s fist internationally recognized physician, though a controversial one. His fervid belief in the arterial localization of disease led to intensive use of bleeding and calomel (mercurous chloride) during the yellow fever epidemics of the 1790s. As doctor and citizen, Rush served the Revolution, advocated for abolition, embraced temperance, and offered ideas for the development of education in the new republic. (Engraving after painting by Thomas Sully, National Library of Medicine)[/caption]

But it was the downtown physicians and surgeons, most with senior faculty positions at Penn or Jefferson, who built Philadelphia’s reputation as the nation’s medical capital. Among the early figures were Benjamin Rush (1749-1813), a reformer interested in everything, concerned with better care of the insane, and signer of the Declaration, recalled (unfortunately) for his ferocious use of mercury and bleeding for yellow fever; Philip Syng Physick (1768-1837), “father of American surgery”; and editor and ophthalmologist Isaac Hays (1796-1879). Later in the nineteenth century came anatomist and brilliant polymath Joseph Leidy (1823-91); master teacher of internal medicine Jacob Mendez Da Costa (1833-1900); physiologist, neurologist, psychiatrist, and popular novelist S. (Silas) Weir Mitchell (1829-1914); internationally known surgeons Samuel D. Gross (1805-84), and W.W. (William Williams) Keen (1837-32), the latter very much a progressive mind and a teacher at Woman’s Medical, Jefferson, and the Pennsylvania Academy of the Fine Arts (anatomy). Gynecologists included Washington L. Atlee (1808-78), among the first to remove uterine fibroids, and Emeline Horton Cleveland (1829-78), one of the earliest women to perform abdominal surgery. Others gained repute through specialty practice centered on disorders of the eye, ear and throat, skin, nervous system, and mind. Active as well were oddballs and dissidents--followers of arcane sectarian systems, or the radical Quakers from Bucks, Montgomery, and Chester Counties who upheld the right of women to study medicine.

[caption id="attachment_12084" align="alignright" width="224"]Progressive surgeon W[illiam] W[illiams] Keen (1837-1932), a graduate of Central High School,  taught at the Woman’s Medical College of Pennsylvania and later at his medical alma mater, Jefferson Medical College. He advocated laboratory research and accepted the germ theory. Keen also counts as a pioneer in neurological surgery and collaborated with S. Weir Mitchell (1829-1914) in studies of nerve injury acquired during the Civil War. He also taught anatomy at the Pennsylvania Academy of the Fine Arts. (National Library of Medicine) Progressive surgeon W[illiam] W[illiams] Keen (1837-1932), a graduate of Central High School, taught at the Woman’s Medical College of Pennsylvania and later at his medical alma mater, Jefferson Medical College. He advocated laboratory research and accepted the germ theory. Keen also counts as a pioneer in neurological surgery and collaborated with S. Weir Mitchell (1829-1914) in studies of nerve injury acquired during the Civil War. He also taught anatomy at the Pennsylvania Academy of the Fine Arts. (National Library of Medicine)[/caption]

Some Philadelphia doctors strayed well beyond medicine. In addition to the novelist S. Weir Mitchell, physician and pathologist William Pepper (1843-98) led the founding of the Free Library of Philadelphia and two museums. Philadelphia can claim two physicians who found fame as Arctic explorers—the erratically adventurous Elisha Kent Kane (1820-57) and Isaac Israel Hayes (1832-81). James E. Rhoads (1828-95) gave up an exhausting practice in Germantown for Quaker work in service to the freedman and Indian, and he later served as president of Bryn Mawr College.

It was not, of course, novels or Arctic ice that established the stature of Philadelphia doctors in the nineteenth century. What then? One can extrapolate from what the distinguished anatomist and historian George W. Corner (1889-1981) wrote about the senior faculty at Penn: “The University’s medical teachers had always been superb clinicians—masters of diagnosis and treatment and polished expositors.” That is, they brought comprehensive knowledge and experience to their practices and teaching (and many were broadly erudite beyond their professional expertise).

For most of the nineteenth century, medical practice drew upon the foundational sciences of anatomy and morbid anatomy (pathology, the study of structural change in organs caused by disease). Philadelphia’s skilled anatomists dissected, taught, and wrote books that added to the city’s reputation as a city of medicine. Several brought back the ideas and methods they had studied in Paris. The reputations of Philadelphia’s doctors spread through their participation in national organizations, consulting or teaching visits out of town, and the praise of their students. They benefited from Philadelphia’s centrality in medical publishing: its enormous production of medical books in the nineteenth century far exceeded that of New York or Boston. Philadelphia physicians readily fed the publishers’ demands for new textbooks and manuals (including homeopathic). For more than 100 years, the American Journal of the Medical Sciences, edited and published in Philadelphia, prevailed as the country’s leading such periodical.

In the early twentieth century, however, Philadelphia lost its edge. Significantly, the influence of Philadelphia’s American Journal of the Medial Sciences declined, while the New England Journal of Medicine, published in Boston, gained scriptural standing. Not only Boston but also New York and Baltimore challenged Philadelphia for medical leadership of the United States, and in some ways won. The destabilizing factor was experimental laboratory research—or, unhappily for the Quaker City, the paucity of it in the city’s medical colleges. The decisive factor was philanthropy—or the paucity of it for Philadelphia’s medical colleges.

[caption id="attachment_12086" align="alignright" width="300"]Medical Hall (later Logan Hall, Claudia Cohen Hall) opened in 1874 soon after the University of Pennsylvania moved to its campus in West Philadelphia. A Gothic design by the professor of architecture Thomas Webb Richards (1836-1911), it is the oldest extant medical school structure in the city. (Photograph by Steven J. Peitzman) Medical Hall (later Logan Hall, Claudia Cohen Hall) opened in 1874 soon after the University of Pennsylvania moved to its campus in West Philadelphia. A Gothic design by the professor of architecture Thomas Webb Richards (1836-1911), it is the oldest extant medical school structure in the city. (Photograph by Steven J. Peitzman)[/caption]

By the 1880s and 1890s the center of advance in medical science had shifted from the hospital wards and autopsy rooms of Paris to the universities and laboratories of Germany. Beginning in the 1860s and 1870s, the acceptance of microbes as the cause of many diseases leant enormous luster to the laboratory and its workers. Physiology, the study of function, seemed a promising field. A handful of young American medical graduates worked under German scientists in the 1880s and 1890s, then returned home to seek a place to do original laboratory research. The only likely locus in Philadelphia in this period was Penn, but it was not to be. One of these German-trained men, Simon Flexner (1863-1946), came to the university in 1899 but left in 1903, disappointed by the lack of interest and resources for investigation. He went to New York to head the new Rockefeller Institute for Medical Research. In a history of Penn’s medical school, George W. Corner wrote that in this period its leaders failed to recognize that “for a generation and more to come, the advance of medicine was going to depend on discoveries in biology and biochemistry that would rapidly alter the physician’s whole outlook.” Corner might have added physiology and bacteriology. It was indicative of local inertia that neither Jefferson nor Penn required course work in bacteriology until ten years after Robert Koch (1843-1910) in Germany announced the discovery of the microbe causing tuberculosis.

Aware of the need to move forward, progressive leaders at the Penn medical school in 1910 effected a reform program (really a coup), which promoted David Edsall (1869-1945), an alumnus and faculty member with sound credentials in both laboratory and clinical work. The insurrection displaced several senior professors and brought in promising researchers from outside the city. Regrettably, the “old guard” among faculty managed a counter-revolution: Edsall left Penn and soon guided the rise of Harvard University Medical School to pre-eminence.

Perhaps these events reflected the larger intellectual outlook of Philadelphia in the nineteenth century. Never as overtly concerned with pure knowledge as Bostonians, Philadelphians excelled in the realm of the useful and tangible: mechanical innovation and making things well, illustration and lithography, architecture and building, and the practice of medicine and surgery. Unlike at Harvard and Yale, at Penn the science, engineering, and medical schools occupied most of the space. Of course erudition and scholarship could be easily found in the city, but for the most part, the practical prevailed. The leading nineteenth-century physicians and surgeons of Philadelphia did publish a great deal that was new—careful anatomical and pathological observations, discerning descriptions of diseases, novel procedures and remedies. But animal experimentation in the laboratory seemed foreign.

As medical science advanced in Boston under Edsall, several accidents of philanthropy favored the ascent of Baltimore and New York City as national centers of medical education and research. In the nineteenth century, Americans saw medicine as practical work and a source of livelihood and thus not as an object of charitable support. Neither government nor individuals subsidized medical research. Few Philadelphians made donations to the city’s medical schools. (A modest exception was the Woman’s Medical College, embraced by its Quaker friends.)  Nor did this usually occur elsewhere. But in Baltimore, Quaker businessman Johns Hopkins unexpectedly bequeathed his immense fortune to the founding of a hospital and a university. The early trustees chose to build the university on the German research model, including a medical school linked to the hospital. The Johns Hopkins Medical School opened in 1893—with former Philadelphian William Osler (1849-1919) as one of its prized founding faculty.

In 1910 the Carnegie Foundation for the Advancement of Teaching, founded in 1905, in conjunction with the Council on Medical Education of the American Medical Association, engaged educator Abraham Flexner (1866-1959), Simon’s brother, to carry out an inspection of North American medical schools. Flexner’s famous report of 1910, Medical Education in the United States and Canada, furthered a process already underway to raise standards and close marginal, or worse, schools. Subsequently, Flexner directed the distribution of grants from the Rockefeller General Education Board to the stronger schools. Dogmatic and sometimes arrogant, Flexner insisted on the “full-time plan” (essentially, that medical school teachers be on salary, not mainly in private practice); nurturing of research; and assured access to hospital teaching beds. His vision also demanded a continued reduction in the number of medical schools in the United States, with no more than one school, fully part of a university, in each metropolis.

Neither “full-time” for clinical faculty nor the giving up of schools much appealed to medical Philadelphia, where at each older institution a distinct personality and heritage had evolved, upheld by alumni, faculty, and even students. For a time, however, Penn and Jefferson diligently worked towards a merger, or at least an awkward sort of coupling that would perhaps look like a merger to Flexner, but still preserve individual identities. The press touted the plan: “Philadelphia is now in a fair way to become a contender for the title of the medical center of America” said the Philadelphia Press on June 3, 1916—tacitly admitting that the city already had lost such status (other newspapers agreed). The unlikely merger plan dissolved in 1917, and with it, the expectations for major foundation funding. By 1920, the Carnegie and Rockefeller philanthropies had contributed approximately $80 million for the development and endowment of American medical schools. None of this money came to Philadelphia.

Although some meaningful local gifts aided the city’s medical schools in this period and Philadelphia surely had wealth, no one in the city matched John D. Rockefeller. The largest single act of philanthropy aimed at education was by banker Anthony J. Drexel (1826-93), whose admirable creation of the Drexel Institute for Art, Science and Industry (now Drexel University) in 1893 centered for the most part on providing affordable practical education matched to the industrial needs of the city and the age. An assessment of Philadelphia philanthropy from 1893 praised Drexel, while declaring that the city’s millionaires tended to send their dollars far away--to “famine stricken Russians,” the “red man on the frontier,” and, generally, to “the dark and hidden places of the earth.”

A sampling of the leading journals of experimental work in medicine in the mid-1920s reveals that although Philadelphia sent forth a few papers, Boston, Baltimore, and New York generated substantially more. The earliest American medical scientists to win Nobel prizes in physiology or medicine included researchers at the Rockefeller Institute in New York and Harvard Medical School in Boston, but none from Philadelphia. Of course, the city’s medical fabric was not entirely dormant. Sound scientific work developed in microbiology and in some of the stronger “basic science” departments of the medical schools. In the early 1920s, A. Newton Richards (1876-1976) at Penn, who as a young imported pharmacologist-physiologist managed to survive the counter-revolution of 1910, carried out with colleagues brilliant studies of the function of the kidney. In doing so, he attracted some of the city’s earliest research support from a foundation, the Commonwealth Fund.

[caption id="attachment_12088" align="alignright" width="300"]The Alfred Newton Richards Medical Research Building of the University of Pennsylvania, built between 1957 and 1964, was certainly not Philadelphia’s first space for biomedical research. It is, however, the most widely known, being one of the most acclaimed designs of  notable modernist architect Louis Kahn, himself a Philadelphian. It symbolizes the increase in laboratory science in the city which occurred in the 1950s and 1960s. (Photograph by Steven J. Peitzman) The Alfred Newton Richards Medical Research Building of the University of Pennsylvania, built between 1957 and 1964, was certainly not Philadelphia’s first space for biomedical research. It is, however, the most widely known, being one of the most acclaimed designs of notable modernist architect Louis Kahn, himself a Philadelphian. It symbolizes the increase in laboratory science in the city which occurred in the 1950s and 1960s. (Photograph by Steven J. Peitzman)[/caption]

Philadelphia’s opportunity for a medical revival came in the 1950s. A flood of research support which appeared from the National Institutes of Health (and other governmental funding) led to, if not a leveling, at least considerable opportunity for all of Philadelphia’s medical schools, and some hospitals, to expand their clinical services and increase research productivity. Soon the schools swelled into “academic medical centers,” keenly competing with each other while looking more and more like each other. Woman’s Medical admitted men, and Hahnemann ejected Samuel Hahnemann’s homeopathy, as it made an astonishing transformation from minute doses (a tenet of this practice) to a skyscraper stacked high with intensive care units. In the absence rational planning based on needs of the citizens, many of the old neighborhood hospitals became poor and closed, while a corridor of high-tech clinical centers—Pennsylvania Hospital, Jefferson, Hahnemann/Drexel, Penn, Presbyterian—formed an imposing east-west alignment downtown. Temple to the north struggled valiantly with the burdens of caring for the sick and shot-up poor, as did the surviving hospitals in deteriorating districts. Beyond the city’s borders, some of the larger community hospitals, such as Lankenau and Abington in the suburbs and Cooper in Camden, expanded their educational functions and established successful research programs. All of this growth created jobs for nurses, physicians, scientists, technicians, billers and coders, and more, and required the ceaseless construction of buildings and additions. The United States Bureau of Labor Statistics documented “education and health services” (combined in its statistics) as the region’s largest employment supersector. 

Even in the period of decline in the early decades of the twentieth century, Philadelphia’s medical institutions never lost their reputation for the highest quality training of medical students, residents, nurses, and pharmacists; in fact, the attraction grew as the major centers expanded.  By the later decades of the twentieth century, “health care” and health-care education became the region’s dominant industry. White coats, short and long, continued as an enduring visible attribute of the city and region.

 

Steven J. Peitzman is Professor of Medicine at Drexel University College of Medicine. His historical work includes the book  A New and Untried Course: Woman’s Medical College and Medical College of Pennsylvania, 1850 – 1998 (New Brunswick: Rutgers University Press, 2000), and articles about medicine and medical education in Philadelphia and Germantown.

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