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This chapter looks at how the federal government and private insurers began setting limits on the amount of money they were willing to pay for medical care. Under legislation enacted in 1983, hospitals began receiving a set fee for Medicare patients based on their diagnoses, regardless of how much it actually cost to treat them. Another challenging development was the rise of managed care. Under this system, third-party payers, such as employer-sponsored health insurance plans, attempted to reduce medical costs by limiting the number of hospitalizations and the use of specialists by member patients. These health care trends threatened New York Hospital, Cornell University Medical College, and by extension, Cornell University. As the New York Hospital–Cornell Medical Center struggled to handle these challenges throughout the 1980s, relations between the hospital and medical school continued to deteriorate.

This chapter explores how Cornell University Medical College (CUMC) joined with New York Hospital between 1928 and 1934 to construct a new medical center on the Upper East Side, creating a greater integration of clinical, research, and teaching activities. The medical center's cornerstone was set on June 12, 1930. In a volume of the student-run Cornell Daily Sun, G. Canby Robinson, director of the New York Hospital–Cornell Medical College Association, wrote in enthusiastic terms of the affiliation between CUMC and the New York Hospital. His idealism was not just confined to the expansive possibilities presented by the affiliation; much of his correspondence conveyed a deep-seated belief in the power of medicine, not just to heal bodies but also to inspire a love of mankind and of service to humanity.

This chapter explains that the term “malaise” is frequently used to describe the 1970s, a decade generally remembered for its economic and political woes. The United States was plunged into a deep recession in 1973. Medical schools, hospitals, and the health care system were certainly affected. Health care costs escalated rapidly, and the public became increasingly aware of factors that were contributing to a rise in chronic conditions. University medical schools like Cornell University Medical College were forced to tread a fine line between charting a socially responsive course and maintaining a commitment to academic scholarship. By the end of the decade, the situation at Cornell had turned dire. Serious reservations regarding the quality of its students and faculty had emerged, relations with New York Hospital had taken a turn for the worse, and financial problems appeared insurmountable.

There are whole districts in Manhattan, Brooklyn, and the Bronx that operate as medical cities at the highest level of biomedical research as well as clinical facilities for patients. Bellevue Hospital, New York Hospital, New York University School of Medicine, Sloan Kettering, Mount Sinai, Weill Cornell, the Bronx VA Medical Center, Albert Einstein College, SUNY Downstate Medical Center, New York Presbyterian/ Columbia Medical Center, and The Rockefeller University, just to mention some of the best known among them. They are all producers of new knowledge from basic biology to bedside medicine. Handling and eradicating illnesses of epidemiological scale are among their spectacular successes.

During the latter part of the nineteenth century, few changes occurred in drug therapy and the treatment of nonsurgical disorders, which comprised the bulk of medical practice. Major improvements occurred in the diagnosis and prevention of infectious diseases and in surgery, which was revolutionized by the discovery of anesthetics and antiseptic techniques. Dispensaries and hospitals continued to expand as providers of health care in urban areas, with dispensaries playing the larger role. Hospitals assumed a significant educational role. The number of physicians increased at a rate comparable to the growth in population in the latter part of the nineteenth century. The 55,055 physicians enumerated by the census in 1860 increased to 132,002 in 1900, about 175 physicians per 100,000 population at both dates. Medical schools graduated enough students to assure a reasonable supply of physicians in almost all towns and villages in the country, although urban areas continued to have more physicians per capita. The physician who began practice in a large city entered a highly competitive profession. He usually started by caring for the tenement population, perhaps augmenting his income by working as a dispensary or railroad physician or assisting another practitioner. His earnings were low and he had few regular patients. Eventually he found a neighborhood where he was able to attract enough patients to establish himself. Competition from other physicians and from pharmacists and dispensaries remained a problem throughout his career. A physician who chose a small town or rural area, where most of the population lived, had a different type of career. Rural families were poor and the physician’s services were low on their list of priorities. Professional relations reflected this fact. Established physicians often greeted the newcomer by sending him their nonpaying patients. Once the rural physician established a clientele, he had less difficulty keeping it than an urban physician. The stability of rural populations enabled him to retain the patronage of families from one generation to another. The rural physician worked longer hours than his urban counterpart and had to be more self-reliant because of the absence of specialists and hospitals.

During the early nineteenth century, medical practice became professionalized and medical treatment standardized as medical school training became more popular and medical societies and journals were organized. Dispensary and hospital care increased with the growth in urban populations. Medical students became dissatisfied with the theoretical training in medical schools and turned to private courses from individual physicians and clinical instruction at hospitals and dispensaries. By mid-century, private instruction had become almost as important as medical school training. Because little progress occurred in medical knowledge during the first half of the nineteenth century, the quality of medical care remained low, although it became more standardized due to the greater popularity of medical school training. Diagnosis continued to be unsystematic and superficial. The physical examination consisted of observing the patient’s pulse, skin color, manner of breathing, and the appearance of the urine. Physicians attributed many diseases to heredity and often attached as much credence to the patient’s emotions and surmises as the natural history of the illness. Although the invention of the stethoscope in France in 1819 led to the use of auscultation and percussion, the new diagnostic tools contributed little to medical care in the short run because more accurate diagnoses did not lead to better treatment. Few useful drugs existed in the materia medica and they were often misused. According to Dowling, the United States Pharmacopoeia of 1820 contained only 20 active drugs, including 3 specifics: quinine for malaria, mercury for syphilis, and ipecac for amebic dysentery. Alkaloid chemistry led to the isolation of morphine from opium in 1817 and quinine from cinchona bark in 1820. Morphine was prescribed with a casual indifference to its addictive properties and quinine was widely used in nonmalarial fevers, where it was ineffective and produced dangerous side effects. Strychnine, a poisonous alkaloid isolated in 1818, was popular as a tonic for decades, and colchine, another alkaloid discovered in 1819, was widely used for gout despite its harmful side effects. Purgatives and emetics remained the most widely used drugs, although mineral drugs replaced botanical ones among physicians trained in medical schools because their actions were more drastic and immediate.

Chapter 2 introduces the activists whose endeavors are the focus of the rest of the study. Future leaders of the empire of humanity, such as Caribbean-born Quaker John Coakley Lettsom, who lived his adult life in London, and the Edinburgh-educated Philadelphian Benjamin Rush, were born in the 1730s, ’40s, and ’50s. From their youth, they participated in the project of building a single, coherent Atlantic community. That orientation and their own personal experiences as they made their way around the Atlantic world for schooling, training, and jobs laid the foundation for all their later philanthropic activity. To provide the reader with an understanding of the base that the book’s subjects built on, the chapter surveys the charitable landscape of the urban British Atlantic world in the 1760s. It ends with a look at two charities that reveal tensions and bonds within the transatlantic community as the imperial crisis developed.

This chapter focuses on the deanship of Vernon W. Lippard, a Massachusetts native who had taken the five-year combined medical course in the Sheffield Scientific School, receiving his M.D. degree cum laude in 1929. One of five students elected to membership in the medical honor society, Alpha Omega Alpha, he was also awarded the Parker Prize, given annually to the graduating student “who has shown the best qualifications for a successful practitioner.” During his final year, the first issue of the Yale Journal of Biology and Medicine was published, and it contained two abstracts, based on articles by faculty members, signed “V.W.L.” After graduating, Lippard remained in New Haven for an internship in pediatrics with Grover Powers at the New Haven Hospital. He then went to Cornell for residency training and was the first chief resident when the Cornell Department of Pediatrics moved to the newly completed New York Hospital in 1932.

During the last half of the nineteenth century, medical schools grew significantly in number and enrollments, as did all institutions of higher education. Many medical schools added optional fall and spring sessions to compete with the private courses and provide additional training for their students. Faculty members were appointed in the clinical specialties, which led to the expansion of the curriculum to include courses in the specialties and the replacement of the repetitive course with a graded one. After the Civil War, enrollments in higher education grew significantly, especially in professional schools. The number of students enrolled in all institutions of higher education increased from 32,000 in 1860 to 256,000 in 1900. The 1860 enrollments, which consisted almost entirely of men, comprised 3.1 percent of the white male population between 18 and 21 years of age. The 1900 enrollments, which included many women in colleges and normal schools, comprised 5.0 percent of the white male and female population between 18 and 21 years of age. In 1860, 51 percent of the students were enrolled in colleges and universities, 44 percent in medical, law, and theological schools, and 6 percent in normal schools. In 1900, 41 percent were enrolled in colleges, 33 percent in professional schools, and 27 percent in normal schools. A higher standard of living and greater access to education led many students to enter college directly from secondary school, according to a study of 20,000 graduates of 11 well-established colleges. The study found that the median age at graduation, between 22 and 23 years, changed very little between the late eighteenth century and 1900, but that the range of ages became smaller over the period. This indicated that students had more preliminary education and were less likely to delay attending college. The admission standards of the colleges remained low. Most did not require a high school diploma. Entrance requirements included Latin and mathematics, plus Greek for admission to the classical course. Equivalents were widely accepted. Most students did not meet even these requirements.

During the first half of the twentieth century, both mortality rates and the incidence of infectious diseases declined, due primarily to public health measures and a higher standard of living. Developments in surgery and drug therapy improved medical care and increased the amount of specialization among physicians. On the other hand, fewer physicians were available to care for the sick because of a decline in the per capita number of medical school graduates. The urban poor continued to receive most of their care from outpatient departments in public and private hospitals, while a growing number of the middle classes became paying inpatients in private hospitals. Hospitals expanded their educational activities to include internships and residency programs. In the first half of the century, physicians became less accessible to much of the population. The number of physicians per capita decreased substantially from 1900 to 1930 and remained at that level until 1950. The greatest impact of this decline occurred in rural areas: between 1906 and 1923, communities of under 5,000 population experienced about a 25 percent reduction in the physician-population ratio, while cities of 50,000 or more experienced a decline of less than 8 percent. Young physicians especially preferred the cities. In 1906 in communities of fewer than 1,000 persons, the proportion of graduates from 1901 to 1905 who practiced in those communities exceeded the proportion of all physicians who practiced in those communities by a ratio of 1.17 to 1. By 1923 in the same size communities, the proportion of graduates of the classes of 1916 to 1920 who practiced there compared to the proportion of all physicians who practiced there dropped to a ratio of 0.58 to 1. Thus rural communities changed from locations preferred by younger physicians to locations avoided by them. The same ratio in cities of over 100,000 population increased from 0.99 to 1 in 1906 to 1.36 to 1 in 1923, which indicated the growing popularity of large cities for young physicians. Several factors accounted for the preference of physicians for towns and cities. Urban physicians earned more than rural ones and had greater opportunities to Specialize.

Medical care at the end of the eighteenth century, like that in any period, was determined by the state of medical knowledge and the available types of treatment. Some useful knowledge existed, but most of medical practice was characterized by scientific ignorance and ineffective or harmful treatments based largely on tradition. The empirical nature of medical practice made apprenticeship the dominant form of medical education. Toward the end of the century medical schools were established to provide the theoretical part of the student’s education, while apprenticeship continued to provide the practical part. The scientifically valid aspects of medical science in the late eighteenth century comprised gross anatomy, physiology, pathology, and the materia medica. Gross anatomy, the study of those parts of the human organism visible to the naked eye, had benefitted from the long history of dissection to become the best developed of the medical sciences. This enabled surgeons to undertake a larger variety of operations with greater expertise. Physiology, the study of how anatomical structures function in life, had developed at a far slower pace. The greatest physiological discovery up to that time, the circulation of the blood, had been made at the beginning of the seventeenth century and was still considered novel almost two centuries later. Physiology was a popular area for theorizing, and the numerous physiologically based theories of disease were, as a physician wrote in 1836, “mere assumptions of unproved, and as time has demonstrated, unprovable facts, or downright imaginations.” Pathology at that time was concerned with pathological or morbid anatomy, the study of the changes in gross anatomical structures due to disease and their relationship to clinical symptoms. The field was in its infancy and contributed little to medicine and medical practice. Materia medica was the study of drugs and drug preparation and use. Late eighteenth century American physicians had available to them a substantial armamentarium of drugs. Estes studied the ledgers of one New Hampshire physician from 1751 to 1787 (3,701 patient visits), and another from 1785 to 1791 (1,161 patient visits), one Boston physician from 1782 to 1795 (1,454 patient visits), and another from 1784 to 1791 (779 patient visits).

The professionalization of academic medicine occurred in the clinical as well as the basic science curriculum. Full-time clinical faculty members replaced part-time faculty members in the wealthier schools. Medical specialties, many of which were rare outside the medical school, dominated the clinical courses. Clinical teaching, which was improved by more student contact with patients, occurred primarily in hospitals, whose patients were atypical of those seen in community practice. The growing importance of hospitals in medical education led to the construction of university hospitals. Early in the century, some leading basic medical scientists called for full-time faculty members in the clinical fields. They noted that full-time faculty members in the basic sciences had produced great scientific discoveries in Europe and had improved American basic science departments. In 1907, William Welch proposed that “the heads of the principal clinical departments, particularly the medical and the surgical, should devote their main energies and time to their hospital work and to teaching and investigating without the necessity of seeking their livelihood in a busy outside practice” Few clinicians endorsed this proposal. They found the costs prohibitive and disliked the German system of medical research and education on which it was based. Medical research in Germany was carried on, not in medical schools, but in government research institutes headed by medical school professors and staffed by researchers without faculty appointments. All of the researchers were basic medical scientists who were interested in basic research, not practical problems like bacteriology. Although the institutes monopolized the available laboratory and hospital facilities, they were not affiliated with medical schools, had no educational programs, and did not formally train students, although much informal training occurred. For these reasons, their research findings were seldom integrated into the medical school curriculum, and German medical students were not trained to do research. German medical schools had three faculty ranks. Each discipline was headed by one professor, who was a salaried employee of the state and also earned substantial amounts from student fees. Most professors had no institute appointments and did little or no research.