Adventures in Medical Education: A Personal Narrative of the Great Advance of American Medicine [Reprint 2014 ed.] 9780674369153, 9780674369085

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ADVENTURES IN MEDICAL

EDUCATION

A Personal Narrative of the Great Advance of American Medicine

GEORGE CANBY ROBINSON From the portrait by Thomas C. Corner, 1937

ADVENTURES IN MEDICAL EDUCATION A Personal Narrative of the Great Advance of American Medicine G. CANBY ROBINSON, M.D., L.L.D., Sc.D.

Published

for

THE COMMONWEALTH FUND BY HARVARD UNIVERSITY PRESS Cambridge,

Massachusetts

· 1957

©

19B7 B Y T H E

COMMONWEALTH

FUND

Published for The Commonwealth Fund By Harvard University Press Cambridge, Massachusetts For approximately a quarter of a century T H E COMMONWEALTH FUND, through its Division of Publications, sponsored, edited, produced, and distributed books and pamphlets germane to its purposes and operations as a philanthropic foundation. On July 1, 1951, the Fund entered into an arrangement by which HARVARD UNIVERSITY PRESS became the publisher of Commonwealth Fund books, assuming responsibility for their production and distribution. The Fund continues to sponsor and edit its books, and cooperates with the Press in all phases of manufacture and distribution. Distributed in Great Britain By Oxford University Press, London

LIBRARY OF CONGRESS CATALOG CARD NO.

57-14698

MANUFACTURED I N T H E UNITED STATES OF AMERICA

TO MARION

BOISE

ROBINSON

Stalwart Adventurer, Boon Companion Wise Counsellor

PREFACE

HE Johns Hopkins University was two years old when I was born in Baltimore on November 4, 1878. We grew up together, and I had the good fortune to have a direct educational path leading through its college into the Johns Hopkins Medical School when it was in its youthful vigor. The date of my birth was the first of many favorable circumstances that have shaped my medical career. I began to study medicine just when its great advance was gathering momentum and when fundamental changes in medical education were taking place. I was on what might be called the ground floor when these changes began and was in a position to go along with their development almost from the beginning. The purpose of this book is to give an account of the projects in which I have participated and of the people with whom I have been associated during this period of progress. I have had the opportunity to take part in events of much importance in the recent growth of medicine which exemplify the fundamental occurrences in medical education during this period. As these developments are an integral part of the social history of the United States, an effort has been made to give an accurate account of them by drawing on official sources such as medical school catalogues and printed reports, as well as on my own records and memory. In order to assure accuracy, the various chapters have been submitted to friends who have shared my experiences, and I am grateful for their corrections, confirmations, and encouragement. The first two chapters, which deal with the early growth of medical education and the development of the Johns Hopkins Medical School, were read by Dr. William W. Francis. We attended the medical school at the same time, and as librarian of the Osier Library at McGill University, he has done more than anyone else to keep alive the Osier tradition. The chapter on hospital days was read by Dr. Edward B. Krumbhaar. We were vii

PREFACE

together as residents in the Pennsylvania Hospital, and he has since become a leader in American medicine and its history. The account of the Hospital of the Rockefeller Institute has been reviewed by Dr. Rufus Cole, its original director, and by Dr. F. Peyton Rous, for many years a member of the institute and particularly familiar with the history of its early days. The chapter on the Washington University Medical School has been read by Dr. Philip A. Shaffer, as well as by Dr. Robert J. Terry and Dr. Joseph Erlanger, all of whom participated in the school's reorganization. The Vanderbilt University chapter was reviewed by Dr. C. Sidney Burwell, who was my valued colleague there and who remained at Vanderbilt as professor of medicine for some years after I left. Dr. Joseph C. Hinsey read the chapter on the New York Hospital-Cornell Medical Center, of which he is at present director, and Mr. Henry R. Shepley reviewed that chapter and the one on Vanderbilt. He and I worked together on building the plant of each of these schools. The chapter on the Peiping Union Medical College was read by Dr. Franklin C. McLean, its first director and professor of medicine, as well as by Dr. Hinsey, now president of the China Medical Board. Dr. Alan M. Chesney reviewed the chapter on the Johns Hopkins studies of the social aspects of medicine. As dean of the medical school at that time he took an active part in the inauguration of this work in 1936. It is a pleasure to express my gratitude to all of these old friends who have given their help and approval of what has been written about the projects in which they have taken prominent parts. Great assistance in writing this book has come from Miss Margaret G. Boise, my sister-in-law, who has edited and typed my writing and has given me the advantage of her years of experience as the literary secretary in the department of surgery of the New York Hospital-Cornell Medical Center under Dr. George J. Heuer. Her patience and tireless cooperation are greatly appreciated. I wish to express my appreciation of the encouragement given by The Commonwealth Fund and of its cooperation in publishing this book. Greenport, viii

Long Island May 1957

CONTENTS Preface

Vll

Introduction

xi 1

I.

The Growth of American Medical Education

II.

The Johns Hopkins University School of Medicine (1899-1903)

27

III.

Hospital Days (1903-1910)

63

IV.

The Hospital of the Rockefeller Institute (1910-1913)

81

The Washington University School of Medicine (1913-1920)

101

The Vanderbilt University School of Medicine (1920-1928)

145

V. VI. VII.

The New York Hospital-Cornell Medical College Association (1928-1934)

189

VIII.

The Peiping Union Medical College (1934-1935)

229

IX.

The Social Aspects of Medicine (1936-1941)

253

X.

War Service andPost-War Activities (1941-1955)

281

XI.

Half a Century of Progress in Medicine

301

Index

323 ix

INTRODUCTION HE history of medical education is an integral part of the social history of America. It reflects the efforts to provide one of the essential components of society—the physician, trained to relieve suffering and anxiety and to combat death, the man set apart throughout human history to render to individuals and to society a service for which there was always an urgent human need. It is therefore of interest to trace the progress of medical education from the days of the pioneers through the era of great expansion of this country up to the time when medical science began to dominate the training and practice of the doctor. There are four periods in this story. In the first, beginning in colonial days, doctors were trained as apprentices; the young aspirants to the profession worked for a few years under preceptors until the fledglings were able to fly alone. The second period begins with the first organized medical schools, initiated toward the end of the eighteenth century by a few courageous young men, most of whom had acquired their own medical training in Europe and returned to establish similar institutions in this country. In the third period, covering most of the nineteenth century, this light from abroad was dimmed and almost extinguished when the rapid expansion of American settlement and population called for many more doctors than the few good medical schools could supply. During this period American medical education endured its dark ages. Doctors banded together in all parts of the country to teach medicine as best they could, forming schools without enlightened educational methods or academic standards, depending on students' fees for their support. Under these conditions rivalry and competition developed between these proprietary schools; the spirit of commercialism lowered standards of admission and graduation, and stimulated efforts to attract students by promises that often could not be fulfilled. xi

INTRODUCTION

While medical education was at a low level, the school of experience was open to almost anyone who wanted to practice medicine. Out of this unguided and free school came illustrious physicians and surgeons and noteworthy pioneers of medical science. Among them were a few much concerned with the status of medical education, who made efforts to keep alive the educational ideals being realized in Europe, and who fought for the elevation of medical education. They were the men who led the movement during the last quarter of the nineteenth century which succeeded in incorporating into universities a few medical schools that were then struggling toward higher scholarship and scientific research. The development of medical education as a serious responsibility of universities represents the fourth period, culminating in the founding of the medical school of the Johns Hopkins University. The opening of this school in 1893 initiated what has been called "The Heroic Age of American Medicine." There, for the first time in this country medicine was taught at a true university level to students who were college graduates with special training in the natural sciences and modern languages. I began the study of medicine at Johns Hopkins in 1899, at the beginning of the great awakening in medicine in this country, and from that time on this book becomes autobiographical. It relates the story of a number of important developments in the new American medicine in which I had the opportunity to participate. Although this book is by no means a complete history of medical education in America, it describes how medical research developed, and how modern medicine based on science was spread to the Middle West and to the South, expanded in New York City, and developed in China. My experiences in the study of the social aspects of medicine at Johns Hopkins are described, and my war-time and post-war activities are included to round out the autobiography. In conclusion some basic principles and present-day problems of American medical education are discussed.

xii

CHAPTER

I

THE GROWTH OF AMERICAN MEDICAL EDUCATION AN has been conscious of a difference between good health and sickness throughout recorded history, and the fear of death has always been a fundamental human emotion. Men have been distinguished even in the crudest civilization for their skill in treating sickness, repairing injuries, and combatting death. In all ages there have been physicians or healers dedicated to the alleviation of human suffering, who have also felt the compelling call to teach their art and to train youthful followers in order to transmit their skill and experience to coming generations. The spirit of the teacher has always pervaded the calling of medicine. It has been the motive power that has perpetuated and developed the art of medicine and that, since the sixteenth century, has stimulated the accumulation and organization of knowledge that have created medical science. The obligation of the physician to teach his art was first clearly set forth in the fifth century B.C. in the Oath of Hippocrates, the pronouncement which has had the greatest influence on the ethics and practice of medicine. Hippocrates, the father of medicine, born on the island of Cos about 460 B.C., was the wisest and greatest physician of the Golden Age of Greece. For twenty-five centuries the Oath of Hippocrates has been the credo of the medical profession and is still in many universities what Osier called "the formula with which men are admitted to the doctorate." It sets forth the relations of teacher and pupil and binds the physician to teach the art of medicine in the following words: "I swear by Apollo the physician, and Aesculapius, and Hygeia, and Panacea, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and 1

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this stipulation—to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others." Medical Teaching in the Colonies

That the physician has always been imbued with a sense of obligation to teach and to develop the profession of medicine was of great importance in the society that evolved in the American colonies. A sense of duty led the doctors who established themselves in this country to take an active part in building up the profession of medicine. There were several doctors who came across the sea to care for the early settlers. The first was Thomas Wotton, who sailed from England on December 19, 1606, with Captain John Smith, to found the first permanent colony at Jamestown, Virginia. In 1608 the life of John Smith was saved by Dr. Walter Russell, who had just arrived in Jamestown and who treated successfully a sharp wound inflicted by a stingray, which had brought the indomitable leader of the colony so low that his funeral was being arranged. This was, perhaps, the first time that medicine shaped the course of history in the New World. Deacon Samuel Fuller, who came on the Mayflower in 1620, was the first practitioner of medicine in the Plymouth Colony, although it is said that he had no medical degree but had studied medicine at Leyden when the Pilgrims had foregathered there. Two surgeons were sent to the Massachusetts Bay Colony in 1628, but much of the medical care was given by the clergymen, who were the best educated among the settlers. Later in the colonial period a few European-trained physicians came to practice in America. During the French and Indian War the doctors serving with the British troops spread some knowledge of medicine among those colonists who did their best to alleviate suffering and to bolster up the morale of the people living under trying conditions. Medical remedies were often improvised from folklore, just as all the problems of living had to be met by using anything that was at hand. As the pioneers 2

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pushed out into the great country toward the West, their crude and perilous lives were protected by anyone willing to take the responsibility of treating the sick or injured, or by those who took advantage of the situation by practicing quackery. Medical education throughout the colonial period and well into the nineteenth century was conducted under the preceptorial system. Students were apprenticed to practicing physicians, who served as their preceptors, usually for three or four years. The students often lived in the homes of their teachers and did menial chores about the house and stable while they learned to make pills and potions, visited patients with the doctors, helped in the office, and read what medical books the doctors might have. They began to practice medicine on their own whenever they or their preceptors decided they were ready, for there were no legal restrictions on medical practice during that period, and medical "diplomas" were sometimes issued by the preceptors when their students "graduated." The preceptorial system was continued long after medical schools were established in this country and was for many years the principal method by which students obtained clinical experience to supplement the lectures they attended in a medical school. In fact, teaching outside of medical colleges continued up to recent times and evolved into the so-called "quiz classes," popular especially in New York, where they were conducted by some of the leading physicians and surgeons even after the beginning of the twentieth century. The Early

Medical

Schools

By the middle of the eighteenth century, brilliant and ambitious young men began to go abroad to study medicine in Paris, London, and especially in Edinburgh, then the leading European center of medical education. It was through the efforts and talents of these young men that the first schools of medicine were organized in this country. The pioneer in organized medical education was John Morgan, the first of a line of prophets who pointed the way education and research should lead American medicine toward the high place it has attained in the world today. John Morgan was born in Philadelphia in 1735; studied there under John Redman, the foremost preceptor of his time; and served for a year as the apothecary in the Pennsylvania Hospital. In 1760 he went abroad to study in Edinburgh, London, and 3

ADVENTURES

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EDUCATION

Paris. While visiting Italy he received from Giovanni Battista Morgagni, the father of pathology, a copy of the latter's book on the sites and causes of disease, published in 1761. Morgan studied under the Monros, the leaders of the new and celebrated Edinburgh school, as well as under William Cullen and William and John Hunter. He was granted an M.D. degree by the University of Edinburgh in 1763 and, while still abroad, was made a Fellow of the Royal Society at London and a Licentiate of the Royal Colleges of Physicians in Edinburgh and in London—high honors for a young man from the colonies. On his return to America in 1765, Morgan was appointed professor of medicine by the trustees of the College of Philadelphia, the institution that became the University of Pennsylvania in 1779. His was the first academic appointment in America. At the commencement exercises of the college on May 30 and 31, 1765, Morgan delivered a discourse on medical education, written while he was abroad. The discourse, which required two sessions for delivery, is an American medical classic.* Morgan set forth a plan of medical education so sound and thorough and so much in accord with present-day principles of university teaching that he was indeed prophetic. At the beginning of his address he discussed the various branches of knowledge which are the basis of the science of medicine, and with much the same emphasis as is given them today. "Medical Science," he said, "is one whole, of which all the branches I have enumerated are the several parts. They may be considered as the links of a chain that have a mutual connection with one another. . . . The great extent of medical science, which comprehends under it so many different branches, makes it impossible to learn it thoroughly without we follow a certain order." He enlarged on the idea that medicine must be learned by the study of progressive courses until all branches of medical science have been comprehended in an orderly plan. This basic principle of education was generally neglected for over ninety years by the medical schools of this country. Morgan's clear conception of research was expressed in the following words: "The knowledge of the more intricate and hidden truths of science are to be developed by degrees. We can only arrive at them by the assistance of other more obvious * Morgan's Discourse upon the Institution of Medical Schools in was reprinted in 1937 by the Johns Hopkins Press. 4

America

THE GROWTH

OF AMERICAN

MEDICAL

EDUCATION

truths, which they are connected with, and which lead us to them by a certain chain of facts, observations, and just deductions in a train of strict reasoning. . . . Observation and physical experiments should blend their light to dissipate obscurity from medicine." Later on in his discourse he made an eloquent plea to students of medicine which he closed by saying: "Inspired by a love of science, your diligent inquiry into natural causes and effects must produce discoveries; and these discoveries prompt you with fresh alacrity to new researches; an employment as delightful and honourable as it is advantageous." Morgan advocated a thorough liberal education in preparation for the study of medicine by saying that "young men ought to come well prepared for the study of Medicine, by having their minds enriched with all the aids they can receive from the languages and the liberal arts." He pointed out the advantages of having a medical school joined to a college and, after reviewing the essential subjects of premedical studies, he said: "Happy are we to have all these taught in such perfection in this place." He discussed the advantages, in contrast to the prevailing apprentice system, of having each subject taught by a group of specially-trained teachers who form a cooperating faculty; he emphasized the value of the Pennsylvania Hospital as part of the medical school and the need for a medical library. He advocated that medical education be promoted in an established institution "under those who are patrons of science, and under the authority and direction of men incorporated for the improvement of literature," and pointed out the advantages of giving degrees for real merit and of graduate study abroad. In his plea to the trustees of the college, this youthful, vigorous orator showed his enthusiasm and deep concern for the future of American medicine. "Under your patronage," he said, "we may hope that Medicine will put on the form of a regular science, and be cultivated with ardor and success." He closed his discourse with the following eloquent and ornate peroration: "Oh! let it never be said in this city, or in this province, so happy in its climate, and its soil, where commerce has long flourished and plenty smiled, that science, the amiable daughter of liberty and sister of opulence, droops her languid head, or follows behind with a slow unequal pace. I pronounce with confidence this shall not be the case; but, under your protection, every useful kind of learning shall here fix a favorite seat, and shine forth 5

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in meridian splendor. To accomplish which may every heart and every hand be firmly united." Morgan's plan of education, based upon the school of Edinburgh, included high standards of liberal education for admission to a medical school conducted by a faculty composed of teachers well prepared to offer a graded, progressive course of study in all the sciences and art of medicine, with a hospital and medical library as essential teaching facilities. The medical school was to be controlled by the trustees of the university of which it was an integral part, and the cultivation of scientific research was strongly advocated. The remarkable foresight of John Morgan projected a concept of medical education which remained as the American ideal but which was not fully realized until the Johns Hopkins Medical School was opened more than a century later. In the introduction to the reprint of Morgan's Discourse Abraham Flexner wrote that "it was not long before his wise words were forgotten and the country entered upon an era of medical education upon which we can look back only with regret and shame." The medical school of the College of Philadelphia was opened in September 1765 when Morgan was joined by William Shippen, Jr., also a graduate of Edinburgh, who had returned to Philadelphia in 1762 and had begun private and public instruction in anatomy and obstetrics. Shippen brought with him from abroad a number of anatomical drawings and casts that had been presented to the Pennsylvania Hospital by Dr. John Fothergill, a distinguished Quaker physician in London who was much interested in the development of medical education in the colonies. This contribution played an important role in the beginning of medical teaching in the Pennsylvania Hospital, the cradle of clinical instruction in America. It was there that I had my hospital training, and this collection of drawings and casts comes into my story later on. The faculty of the medical school of the College of Philadelphia made a promising start under Morgan's leadership in association with Shippen. Adam Kuhn was appointed to the staff in 1768 as professor of botany and materia medica, and in 1769 Benjamin Rush became the fourth member of the faculty. Kuhn, the son of a Germantown physician, had studied botany with Linnaeus in Sweden and had then gone to London and to Edinburgh, where he graduated in 1767. Rush, who graduated from 6

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MEDICAL

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Edinburgh in 1768, was appointed professor of chemistry at the age of twenty-three and became the most distinguished American physician of his time. He was also a signer of the Declaration of Independence. The medical school was closely affiliated with the Pennsylvania Hospital where in 1767 Thomas Bond was formally authorized by the managers of the hospital to conduct clinical lectures. In the same year the College of Philadelphia required each candidate for a medical degree to attend the Pennsylvania Hospital for one year. Three other medical schools were successfully launched in America during the eighteenth century—all by outstanding, well-educated physicians and all connected with well-established colleges. In New York medical teaching was started at King's College in 1767 by a group of doctors who had studied in Dublin, Leyden, and particularly in Edinburgh. Although no comprehensive medical teaching program comparable with Morgan's was set forth, the commencement address of Samuel Bard in 1769 inaugurated a movement of important and lasting consequences. Bard, who had studied medicine at the London Hospital as well as at Edinburgh, where he obtained his medical degree, was the professor of the practice of medicine at King's College and the leader of the new medical school. At the graduation of two students in Trinity Church in New York, he eloquently urged the community to meet the crying need for a general hospital, not only for the care and relief of the sick, but also as the only satisfactory means of instructing students properly in the practice of medicine.* This address, delivered before a notable company including the Governor, Sir Henry Moore, stimulated much public interest and started the movement that culminated in the foundation of the New York Hospital, chartered in 1771, which became one of the leading centers of medical education in the United States. The King's College medical school eventually became the College of Physicians and Surgeons of Columbia University. In Boston organized medical instruction had not progressed before the Revolutionary War. Joseph Warren was the first physician to offer apprenticed students lectures in various fields * For a discussion of Bard's address, see Edward W. Sheldon, President of the Society of the New York Hospital. Address commemorating the 150th anniversary of the hospital, 1921.

7

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of medicine, but his career was cut short when he was killed in the Battle of Bunker Hill at the age of thirty-four. His younger brother, John Warren, took up the torch and in 1780 began lectures on medicine which attracted wide attention and which were attended by some of Boston's intellectual leaders, including President Willard of Harvard. John Warren, who was attached at this time to the military hospital in Boston, submitted a plan for a medical department to the corporation of Harvard College. The plan was accepted, and Warren, although he was a home product trained in the preceptorial system and had no medical degree, was appointed professor of anatomy and surgery. Soon thereafter, Benjamin Waterhouse, who had studied at Leyden and Edinburgh and who was the first physician to practice vaccination successfully in America, was made professor of the theory and practice of physic. These two men formed the beginnings of the Harvard Medical School. The school was hampered by lack of clinical facilities—a deficiency soon recognized by the faculty but not overcome satisfactorily until 1821 when the Massachusetts General Hospital was opened. The fourth medical school organized in the eighteenth century was the medical department of Dartmouth College, established in Hanover, New Hampshire, in 1797. It came into being through the leadership of Nathan Smith, one of the most distinguished physicians in the annals of American medical education. This was the first medical school established at a distance from a large city and it had great influence on early medical education in New England. Smith, born in 1762, was a gifted, enthusiastic, and far-seeing young man. After two years under his preceptor, Dr. Goodhue of Ludlow, Vermont, he began to practice but, disturbed by his lack of knowledge, he attended the Harvard Medical School and in 1790 was its seventh graduate. Still discontented with the available opportunities for the study of medicine in New England, he persuaded President Wheelock of Dartmouth to support his proposal for a medical department at Dartmouth College. Although the trustees favored the proposal, they held back, probably because Nathan Smith was young and inexperienced as well as because of lack of funds. Undaunted, Smith gave up his practice, left his family, and went to Britain to work for nine months in the University of Edinburgh and in London where the Hunterian school of experimental medicine prevailed. He returned in 1797 with books and apparatus for the new school, 8

THE GROWTH OF AMERICAN

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even though it had not yet been endorsed by the trustees. The school was established, and Smith was elected professor of medical subjects with the stipulation that he could employ assistants at his own expense. Up to 1810 his only assistant was one of his students, Lyman Spaulding, who became distinguished as the founder of the United States Pharmacopoeia. The medical school prospered, and in 1803 Smith managed to raise funds for a separate building to house it. Nathan Smith was appointed professor of the theory and practice of surgery and obstetrics when the Medical Institute of Yale College was founded in 1812. There he served with enthusiastic leadership until his death in 1829. He had also encouraged and directed the establishment of the Medical School of Maine of Bowdoin College in 1820 and had lectured there from 1821 to 1825, when he resigned because of pressing duties at Yale. He was declared to have done more to improve physic and surgery in New England than any other man. The story of the medical schools founded in the eighteenth century is a fascinating chapter in American history.* The influence of the European universities, especially that of Edinburgh, was great, and was brought to this country by a remarkable group of young and vigorous men who performed a valuable service during America's struggle with its newly won independence by giving medical education a fine quality at its start. They were individualists, carried forward by the impelling idea that medical education was of fundamental importance in our politically chaotic society. In spite of all the difficulties they faced, these pioneers in organized schools for medical teaching created the first era of lofty ideals and sound philosophy of medical education, in sharp contrast to the situation in the first half of the nineteenth century. The Dark Age of Medical Education

Not long after the United States began its rapid growth and expansion, a new era in medical teaching started in an effort to train doctors to meet the growing needs of a society culturally as well as politically cut off from Europe except by ever-swelling * For a study of this subject (from which I have drawn many details), see William Frederick Norwood. Medical Education in the United States before the Civil War. Philadelphia: University of Pennsylvania Press, 1944.

9

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waves of emigrants among whom there were only a few highly educated people. Medical education during the first half of the nineteenth century sank to a low level. The preceptorial system of instruction continued, but medical schools were formed rapidly throughout the country. Only a brief summary can be given here of the dark era of medical education which held sway until well into the present century. The main cause of this situation was the establishment by groups of doctors of a great many medical schools on a proprietary and independent basis, sometimes in communities hardly larger than villages. In the first half of the nineteenth century a veritable race in chartering medical schools took place, which Norwood aptly characterized as "an enlightening exhibition of the life and work of professional men, undisciplined within and unregulated from without, while they attempted to give medical care to a rapidly expanding democracy in which ingenuity was unhampered and personal liberty was glorified." Abraham Flexner reported in 1910 that forty-two medical schools had been started from time to time in Missouri alone, and that twelve were then in existence. Conditions were created by this multiplicity of unregulated schools which were bound to shatter educational standards. Practically none of the schools had endowments; there was great rivalry among them; and a commercial spirit was rampant. The success of the schools, from the points of view of reputation and perhaps especially of financial returns to the professors, was generally judged by the number of students attracted to them by hook or by crook. Extravagant and misleading statements were often published, but facilities for clinical teaching were usually almost nonexistent. Scandals often arose from the way bodies were obtained for dissection—an ancient problem of medical education which was described by the master pen of Robert Louis Stevenson as prevailing in London and Edinburgh before the passage in 1832 of the Warburton Anatomy Act, which legalized the use of unclaimed bodies for anatomical study. In The Body Snatcher, Robert Louis Stevenson wrote: "The Resurrection Man—to use a by-name of the period—was not to be deterred by any of the sanctities of customary piety. It was part of his trade to despise and desecrate the scrolls and trumpets of old tombs, the paths worn by the feet of worshippers and mourners, and the offerings 10

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and the inscriptions of bereaved affection. To rustic neighbourhoods, where love is more than commonly tenacious, and where some bonds of blood or fellowship unite the entire society of a parish, the body-snatcher, far from being repelled by natural respect, was attracted by the ease and safety of the task. To bodies that had been laid in earth, in joyful expectation of a far different awakening, there came that hasty, lamp-lit, terror-haunted resurrection of the spade and mattock. The coffin was forced, the cerements torn, and the melancholy relics, clad in sackcloth, after being rattled for hours on moonless by-ways, were at length exposed to uttermost indignities before a class of gaping boys." Episodes such as Stevenson so skillfully describes continued in this country long after they had been prevented in England by the lawful provision of bodies for anatomical study. I recall old William, a pensioner in the Vanderbilt University Medical School, who used slyly to tell of the shot he still carried in his body— a souvenir of the days when he did his lowly part in promoting the study of anatomy. During the first part of the century, the medical colleges were coordinated with the prevailing preceptorial system, and it was common practice for the better students to attend the schools while working with their preceptors. They were required to take courses of lectures for four or five months during two years, listening to the same lecturers each year giving the same lectures, before they were granted the M.D. degree. Many of the schools sought and obtained connections with existing colleges which were no more than nominal, and although the schools were often known as medical departments of universities or colleges, they were neither controlled nor supported by the trustees of the institutions under whose names they sought academic respectability. In fact, the connection was so loose that the medical school and the college sometimes were not even in the same state. The rivalry among medical schools was often intense, especially among those located in the same city. This led not only to a scramble to enroll students—accompanied by an ever-lowering standard of admission—but to personal feuds as well. There are stormy chapters in the medical story of these times. I have heard that at times pistols were on the desks at faculty meetings when there was more heat than light in these gatherings. One story that did not go back very far was told to show the rivalry bell

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tween schools. A prominent professor told his colleagues, with a gleam in his eye, that he had recently shaken hands with the leading professor in a rival school and while so doing had felt the rival's radial pulse and found the artery as hard as a pipestem. It was not necessary to explain to his medical colleagues that their rival had but a short time to live, and this news seemed to give general satisfaction. The state of medical education caused dissatisfaction among the more enlightened of the professors and brought forth criticism and protests, most of which seemed to go unheeded. One of the reformers who was to have an influence on the future progress of American medicine far greater than anyone at the time realized was Patrick Macaulay, who delivered the annual discourse of the Medical and Chirurgical Faculty of Maryland in 1823. This discourse entitled Medical Improvement was published during the following year and undoubtedly fell into the hands of a great future benefactor of medical education and, we believe, directed his attention to the essential need for a hospital for medical teaching. To create such a hospital he left half of his large fortune. It is because the wise, well-educated, and forward-looking Patrick Macaulay wrote a discourse which was undoubtedly read and taken to heart by his friend Johns Hopkins that this now obscure physician deserves a place among the prophets of American medicine.* Macaulay's main theme was that improvement of medical education is "the means likely to give increase and perpetuity to our medical character." He advocated three improvements: "1. We must be encouraging young men of science and abilities to study medicine, by which the interests of humanity will be promoted, the science advanced, and its dignity more effectively supported. 2. By extending the time and increasing the course of studies in our medical schools before we confer honors or grant diplomas. 3. The character and dignity of the profession of medicine will be advanced by protecting native talent and guarding every avenue to the honors of medicine against those whose moral and intellectual attainments do not fit them for its responsible and delicate duties." That these reforms were needed in 1823 is emphasized by * For a discussion of this occurrence, see John C. French. "Mr. Johns Hopkins and Dr. Macaulay's 'Medical Improvement.'" Bulletin of the History of Medicine 27:662, 1953. 12

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Macaulay's description of the requirements for a medical diploma at that time: "A young gentleman enters a physician's office, he reads twelve months, repairs to some medical college, and after an attendance at most on two courses of lectures, receives a diploma; now during that time he may not have seen ten important cases of disease." He compared the medical education of his day, in which he gave little credit to the preceptorial method of instruction, with the five to seven years of study required in Europe, and set forth a truly modern medical curriculum embracing five principal subjects, as follows: "1. An intimate acquaintance with anatomy, chemistry, and physiology. These give an insight into the operations of the animal economy. "2. The study of the materia medica, pharmacy and botany. Chemistry is the basis upon which we must learn these branches. "3. The study of the states of the system in its departure from health to disease, the causes and symptoms. This presents the most important field for speculative inquiry [research]. It is embraced under what is properly termed the institutes of medicine, physiology, pathology and therapeutics. "4. The study of practical medicine and surgery. This presupposes an intimate knowledge with all the other branches which we have stated as necessary to be studied. With it is essentially connected a course of clinical medicine, or the application of our knowledge at the bedside. There is nothing more important to the student, for here it is that he is to test his knowledge and acquirements, and supply from the active sources of his own genius whatever is wanting. "5. The preservation of the body in a state of health. This has been termed Hygiene. It is fixed in a knowledge of the operations of the living healthy economy, and the causes which produce derangement. Here we study the effects of climate, habit, dress, etc. These are all indispensable to the attainment of a proper medical education." His plan of medical education resembles in scope and method that advocated by John Morgan over half a century before, which had fallen into obscurity. Morgan could include in his plan the Pennsylvania Hospital, where clinical instruction had already been inaugurated, while Macaulay had to plead for hospital teaching facilities; with particular insight in doing so he sowed the seeds that brought forth a rich harvest. In declaring a hospital to 13

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be essential for medical education, Macaulay said: "You must all be convinced on a moment's reflection how important it is for a student, before he enters on the extensive field of practice, to have previously had an opportunity of seeing and prescribing for diseases in the wards of an hospital or almshouse. So extensively are these great benefits appreciated in the European capitals, that every large hospital has become a medical school, in which lectures are delivered and diseases illustrated at the bedsides of the patients. It is true that the want of these large establishments in our country deprives us of the like advantages which the student can enjoy in Paris, London, or Vienna; but there is still daily an increasing necessity for supplying the deficiency by our opening as many avenues to practical instruction as the state of our cities and their institutions will admit." Macaulay not only advocated improvements in instruction as essential for advancing the status of the medical profession, but he looked ahead and saw a plan of education in which the hospital would play an integral part. This idea did not begin to be realized for another half century, but his influence, we believe, was a potent factor in bringing about this important reform, as will be subsequently discussed. West of the Allegheny Mountains medical education was first organized in 1816 at Transylvania University in Lexington, Kentucky, though the medical department had been "instituted" by its trustees in 1799. In 1816 it was expected that Lexington would be the metropolis of the Ohio Valley, and the Transylvania Medical School had an illustrious career for over thirty years. It was well supported by state funds from public lands, by the city of Lexington, and by private gifts; in 1841 it was said to be the best endowed medical school in America. On several occasions collections of medical books were purchased in Europe, giving Transylvania a medical library of unique value. There were a number of brilliant teachers on its faculty, and except for lack of adequate material for anatomical study and facilities for clinical teaching, it deserves to be ranked with the famous schools started in the Eastern cities in the eighteenth century. The school began to decline about 1846 and was obliged to close in 1857 when the advent of railroad and especially steamboat travel diverted the march of prosperity, transplanting the centers of commerce and of population of this region to Cincinnati and Louisville. 14

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The development of medical education in the Ohio Valley followed the course it took in the country as a whole, and after the organization of numberless unendowed schools, the area became a veritable hotbed of medical rivalry and feuds. The belligerent pattern was exemplified at the very beginning in Transylvania by a duel in 1816 between the professor of surgery (the head of the school) and the professor of obstetrics, which would have proved fatal for the latter had his antagonist not rendered immediate first aid. The early history of the medical schools of the Ohio Valley, especially those of Cincinnati, is confusing, as faculties, teachers, and names of institutions shifted in a kaleidoscopic fashion hard to follow. However, it serves as an example of the beginnings of medical education throughout the United States. In Cincinnati we find a great leader in the teaching of medicine, several nationally renowned medical educators, and a medical graduate who became one of the most illustrious medical men in our history. The great educational leader was Daniel Drake, and among the famous teachers were Samuel D. Gross, Willard Parker, and Nathan Ryno Smith, the son of Nathan Smith of New England fame. All these men were later to shine as distinguished medical leaders and teachers in Philadelphia, New York, and Baltimore. The illustrious graduate was John Shaw Billings, of whom much will be said later. The influence of the Ohio Valley schools reached out to St. Louis and Nashville and affected the formation of the first medical schools in those cities, where our story later leads us. The stormy and influential career of Daniel Drake is one of the most interesting in American medicine. Born in New Jersey in 1785, he was taken at the age of three to Mayslick, Kentucky, where he grew up in poverty as a member of a frontier family. He was almost entirely self-educated. Eventually he became a scholarly writer, an accomplished speaker, and a great leader of men, although many controversies and personal feuds disturbed his career. His early life resembles that of Abraham Lincoln. Although he turned to medicine instead of to law, his accomplishments in medicine are justly comparable with those of Lincoln in politics. In 1800, at the age of fifteen, Daniel Drake went to Cincinnati to study medicine under the preceptorship of Dr. William Goforth, receiving in 1805 the first medical diploma granted west of the Allegheny Mountains. He then went to Philadelphia, where 15

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he studied medicine for five months at the University of Pennsylvania under Benjamin Rush, Caspar Wistar, James Woodhouse, and Philip Syng Physick, leading American teachers of his time. After practicing medicine in Cincinnati for nine years, he returned to Philadelphia, received his M.D. degree at the University of Pennsylvania in 1816, and a year later began his teaching career on the first faculty of Transylvania University as professor of materia medica and botany. Here the first of his many controversies occurred, and in 1818 he returned to Cincinnati, where he was joined by Dr. Coleman Rogers and Rev. Elijah Slack, a chemist, and together they gave systematic lectures to medical students. Out of this venture came the Medical College of Ohio, opened in 1820, the second medical school in the Midwest. During this year, largely through Drake's efforts, the Commercial Hospital was opened in Cincinnati as a facility for teaching clinical medicine—the first important step in this country toward establishing hospitals controlled by medical teachers. Drake was forced out of the Medical College of Ohio in 1822 by the votes of the other two members of the faculty following a disagreement, in accordance with the provision of the charter Drake himself had devised. This action has been designated by a local medical historian as the beginning of the thirty years' war. The battles of this period waged by Drake and his colleagues were characterized not only by vituperative oratory and occasional fistic encounters, but by lengthy arguments in the newspapers, which often excited and amused the public. In these days everyone either loved a fight or seldom showed hesitancy in battle. Drake soon returned to the Transylvania Medical School where he served as professor of medicine for three years, resigning in 1827. In 1830 he accepted the professorship of medicine in the Jefferson Medical College in Philadelphia—a signal honor for the boy who grew up on the Western frontier. However, he returned in one year to Cincinnati, again as a teacher in the Medical College of Ohio, where he continued a conflict begun in 1824 with the professor of surgery, John Moorhead, an Irishman from Edinburgh. This conflict seems to have stimulated Drake to found a rival school in 1835, the medical department of Cincinnati College, which subsequently became the University of 16

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Cincinnati. Here Drake brought together the most distinguished faculty of his time, including Samuel D. Gross, Willard Parker, and Joseph McDowell, who in 1842 started one of the first two medical schools in St. Louis. Drake's very promising venture failed in 1839 for lack of funds and equipment. He then went to the Louisville Medical Institute, an offshoot of Transylvania opened in 1837, which became the medical department of the University of Louisville in 1845. Drake remained at Louisville for ten years as professor of clinical medicine and pathological anatomy and, after 1849, divided his time between teaching there and lecturing again in the Medical College of Ohio. He died quite suddenly in November 1852 at the age of sixty-seven. This rather bewildering account of Drake's teaching career shows the unstable and unsatisfactory state of medical education characteristic of this country during most of the nineteenth century. According to Garrison,* one of our leading medical historians, Daniel Drake was described by his colleague, Samuel D. Gross, as being a tall, commanding figure, simple and dignified in manner, always well dressed, and as a lecturer having a splendid voice and fiery eloquence "causing him at times to sway to and fro like a tree in a storm. He was gentle, fond of children, hating coarseness, and had a genuine poetic side, writing very creditable verses." He never went to Europe as he thought his origin and early chances would place him at a disadvantage in meeting eminent people. Drake's apparent restlessness, his genius for controversy, and his leadership in medical education are not the reasons for his high place in the annals of American medicine. It is the books he left behind that are of lasting significance. In 1826 he founded the Western Journal of the Medical and Physical Sciences, then the most important medical journal of the Midwest, and at the end of his life he published a monumental work on The Diseases of the Interior Valley of North America, an American classic on which he worked for thirty years. The book that sets him apart as a prophet in American medical education, however, is a little volume published in 1832, entitled Practical Essays on Medical Education and the Medical * Fielding H. Garrison. An Introduction to the History of Medicine (4th edition). Philadelphia: Saunders, 1929. 17

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Profession of the United States.* Garrison wrote that these seven essays are "far and away, the most important contributions ever made to the subject in this country"—an opinion in which I concur. The first essay, "Selection and Preparatory Education of Pupils," was directed toward fathers who want their sons to become doctors. Drake pointed out the various pitfalls in the existing preceptorial system and discussed the reasons why young men of genius are attracted to or repelled from the profession of medicine. Regarding the inferior quality of the profession he said: "The root of this great evil is planted in society itself. Some persons are too dull to discriminate among the members of the profession, others allow themselves to be captivated by pleasant manners, and not a few call for cheap doctoring, all of which tend directly to elevate false pretensions and depress real merit." The second essay was on "Private Pupilage," and here Drake discussed the qualifications of a preceptor and gave advice to those preparing to enter this system of medical education, of which he wrote: ". . . our system of private tuition is essentially bad. But, in truth, we have no system; and it would be more correct to say, that in the United States a good system of private pupilage is imperiously required." This statement may be interpreted to mean that at that time there were almost no adequate facilities for clinical teaching in hospitals and that the study of patients was only possible in the practice of the physicians serving as preceptors. He made a strong plea for a good liberal education, including the study of French, as preparation for medical training, and outlined a graded course of medical study requiring three years for completion as a much needed educational reform. He finally stated the responsibilities a preceptor should assume for his apprentice and how these responsibilities should be met. In his third essay on "Medical Colleges" Drake made the following comments concerning the disastrous effects on educational standards of the large number of medical schools being chartered at that time. "This extraordinary increase may be ascribed, in part, to the great number of state sovereignties * The book was reprinted by the Johns Hopkins Press in 1952 with a biographical introduction by Dr. David H. Tucker, Jr., from which I have freely drawn. 18

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which make up our confederacy, each of which, instead of the federal government, grants college and university charters; and is ambitious to rival its neighbors in the number, if not the excellence of its institutions. But another cause is equally operative. This is the want of due care in the selection of professors; by which the standard of professorial excellence is depressed to a level, that brings the office within the reach of unqualified aspirants; and offers to mediocrity of talents, a degree of encouragement which no age or nation ever before held out." Drake's reference to the federal government as the authority that should charter medical schools might raise the cry of "socialized medicine" in some quarters today. He foresaw the problem raised by the disturbing distinction between practitioners and teachers, which caused resentment in Baltimore, St. Louis, Nashville, and New York in my own experience—a form of town and gown controversy which still exists in some medical school localities. Drake criticized the educational programs and principles of his day with the same directness and with almost the same words used by Abraham Flexner in his famous report on medical education in 1910, seventy-eight years later. Drake's fourth essay was on "Studies, Duties, and Interests of Young Physicians"; the fifth on "Causes of Error in the Medical and Physical Sciences"; the sixth on "Legislative Enactments" ; and the seventh on "Professional Quarrels." Although these last four essays were not as directly concerned as are the first three with the education of the student, they set forth and repeatedly emphasized the idea that the life of the physician is a prolonged school and that, upon graduation, the doctor of medicine must begin immediately to improve and expand his education. He advised the young physician "to write much and publish little" and gave very wise advice on all phases of the doctor's life. He set forth what he called a declamation of some of the factors which oppose the progress of medical science in the United States, discussing nine categories which included forming conclusions while we should still be observing, vividness of fancy, impatience, excessive deference to authority, defective love of truth as related to self-interest and self-love, and defective ambition. Drake gave a sound and comprehensive discussion of the propriety of putting medical schools under the supervision of the law and giving the sovereign states the power to govern them with 19

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liberality, vigilance, and wisdom. After enumerating the essentials which a medical school should be required to fulfill before it is granted a charter—specifications just as sound today as they were in Drake's time—he declared that the conduct of a medical institute on the principles he expressed would elevate and purify the practice of medicine, and that "if the fountain of supply be pure, the stream will seldom be tainted, and its waters will require but little clarification"—a philosophy that motivates the best of medical education today. Drake discussed at some length the important question of state licensure for medical practice and described the situation of his time by saying: "More than half the states of the Union, have laws to regulate the practice of medicine; but I am by no means convinced, that they have ever done any real good to the profession or society." In his last essay, "Professional Quarrels," a subject he was so well qualified to discuss, Drake wrote: "I propose, briefly to lay open some of the causes, which generate differences and discord in the profession, as I have either observed or felt their operation." He took up ten causes of discord, among them the dissatisfaction aroused by the establishment of medical schools from which some of the profession are barred. He said that teachers on the faculty and non-teachers who felt as well qualified as those appointed to the staff, form two classes that "stand in a relation to each other, which predisposes them to hostility. Such is the law of human nature. . . . If the professors withdrew from practice on being appointed, they would be viewed with very different feelings, by their brethren. But a professorship is a passport to business; and the increase that follows an appointment, is of course at the expense of those who surround the school; an effect, under which, although pride or prudence may keep them quiet, they cannot be expected to cherish the most friendly or pacific sentiments." This was perhaps the first time an argument for full-time clinical teachers—a problem of medical education that was to be debated with much heat nearly a century later—was advanced in this country. Drake's essays are beautifully written and deserve a high place in American literature. A fine quality of wisdom pervades them, and they could be read today with much profit and interest by every teacher of medicine. The original edition is a very rare book, and it is regrettable that the 1952 reprint is also hard to 20

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come by because of its limited edition. The essays give the impression that the many controversies and conflicts in which Drake was involved had their origin in his dissatisfaction with his colleagues' failure to maintain the high intellectual and spiritual standards that his own belief and conscience demanded, and that this dissatisfaction stimulated his impetuosity. His indomitable spirit urged Drake on to action as well as to words, and at a meeting of the Medical Convention of Ohio in 1838 he presented an eight-point plan for reform of medical schools, specifying longer sessions, more professors, a graded curriculum, stricter admission requirements, and at least four years of study, two of which would be with a preceptor. In order to create a national movement for improvement, a convention on medical education to include representatives of all medical schools in the United States was proposed, and a copy of the proceedings of the meeting was sent to each school. Although no tangible results were immediately apparent, this was an important step toward the eventual formation of the American Medical Association, which grew out of a meeting in New York in 1846, organized by the ardent young advocate of educational reform, Nathan Smith Davis of Chicago. This meeting, called the National Medical Convention, was primarily concerned with the improvement of medical education and had much the same objectives as those presented by Drake in Ohio eight years previously. In 1848, at the Convention in Baltimore, the gathering was officially named the American Medical Association. It formed the strong national organization which has exerted great influence on medical education, legal control of medical practice, and the regulation of medical ethics, both by educational and advisory methods throughout the nation and by efforts to stimulate the conscience of the profession. The Beginning

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The widespread recognition of the parlous state of our medical schools began to have effects. When the University of Michigan opened its medical school in 1850, it specified advanced requirements for admission and graduation and, what was then unique, remuneration of the members of the medical faculty by salaries from the university on the same basis as the professors in the arts and sciences. The teachers of medicine were therefore released from dependency on students' fees for their financial sup21

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port. Although it lacked adequate clinical facilities until 1877 when the first hospital directly connected with an American medical school was built, the University of Michigan was an important leader toward true university standards in medical education. It was an outstanding university medical school at the beginning of this century, but seems to have been unduly overshadowed by the more spectacular development of the Johns Hopkins school, which drew into its original faculty several professors who had had their early opportunities at Michigan. Another noteworthy event occurring before the Civil War was the establishment of the medical school of Lind University in 1859 in Chicago under the leadership of Nathan Smith Davis, founder of the American Medical Association. Here, for the first time in this country, a three-year, graded curriculum was inaugurated, the courses of study being divided into three groups each covering one year. The faculty consisted of twelve professors; lecture rooms, laboratory, dissecting room, library, museum, and unusually good clinical facilities were provided. In 1864, financial losses caused by the Civil War brought an end to Lind University, but the medical school eventually became the medical department of Northwestern University. This was a noble experiment which set a fine example for the future. Lasting reforms in American medical education began soon after 1869 when Charles W. Eliot was elected president of Harvard University. He surprised the members of its medical faculty by attending their meetings and by reminding them that Harvard had a new president who considered the medical school to be an integral part of the university. Eliot not only inaugurated a much-needed educational principle of university responsibility for medical education, but he also initiated a movement to raise entrance requirements, to grade the curriculum, to lengthen the course to three years, and to provide better facilities for clinical and laboratory teaching. However, the serious problems of limiting the number of students admitted and of requiring that they have college training were not solved for a number of years. One of my friends recently told me that there were two hundred students in his class entering the Harvard Medical School in 1894, of whom only fourteen were college graduates. Other university medical schools responded to the stimulation of medical and educational leaders during the last quarter of 22

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the nineteenth century. At the University of Pennsylvania definite improvements were brought about under the leadership of William Pepper, who followed his father as professor of medicine in its medical school and in 1881 became the provost of the university. In 1874 he founded the University Hospital in Philadelphia, an important step in the development of clinical teaching; and in 1877 he delivered an address which is a guidepost marking a significant turn and a new direction in medical education. He began by commenting on the complacency that had settled down and the smooth and uniform course of medical education that had not for many years been disturbed even by suggestions for important changes. He deplored the lack of cultural and educational progress in the midst of the great material progress observed at the Centennial Exposition held in Philadelphia in 1876. He said the troubles of the medical profession had been advancing and increasing for at least fifty years, and he considered the decline of the Pennsylvania Medical School from the high standards established by Morgan and Shippen to be disgraceful. He pointed out that the European medical schools required examinations for admission, five to seven years of study, personal training, graded courses, and impartial achievement examinations—all of which were lacking in American schools. He made a violent attack on the commercial spirit of our medical schools and their rivalry to obtain students for the sake of fees. He considered that the first of the evils damaging the medical profession arose from the degraded system of education which caused the enormous overproduction of medical men and led to unprincipled competition. He condemned the establishment of free dispensaries to get clinical material and named as the three obstacles to earning a proper living in medicine excessive overstocking of the profession, unchecked quackery, and abuse of medical charities. Pepper declared that reform of medical education was being demanded both by the profession and by the public and advocated further development and strengthening of state boards of licensure as the only practical means of correction. He said that the medical schools must reform themselves and recommended the introduction of preparatory examinations for admission, the lengthening of the medical course to three years, the careful grading of courses, the practical instruction of each student at the bedside and in the laboratories, and the radical change of 23

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paying fixed salaries to professors so that they would have no pecuniary interest in the size of their classes. Credit was given to Harvard as having taken these steps in 1871 under the leadership of President Eliot, and to the University of Pennsylvania which had taken all except the requirement of an entrance examination in May 1877. As Pepper had foreseen, the lack of rigid entrance requirements weakened not only the medical school of the University of Pennsylvania but practically all other schools in this country until 1893, when Johns Hopkins broke sharply with tradition by demanding the possession of a bachelor's degree and other specific requirements for admission. In 1893, the year before he retired as provost of the university, William Pepper delivered another address in which he reviewed with evident pride the changes in the medical school made in 1877 to which he attached much importance. He gave reasons why high admission standards had to be introduced slowly. The fact that the medical course had been lengthened to four years of eight months each in 1891, was referred to as a basic advance, and Pepper said that "the broad basis of modern medical education is the careful training of the individual student at the bedside and in the laboratory."* In his 1877 address Pepper named as other reformed medical schools, Harvard, Chicago Medical College, the University of Michigan, and Syracuse University. The forward steps taken by a few schools with financial backing and university standards of education widened the gap between them and the many schools without endowment or educational leadership that depended on students' fees for their support. Pepper recognized this situation in 1893 when he said that the increasing endowments and the constantly improving equipment of the great schools would eventually make it impossible to operate poor, commercial, unendowed medical schools. Another important factor in separating the good and the poor medical schools was the influence of the advanced students returning to this country from the German universities toward the end of the nineteenth century. The training and the scientific ideals to which they had been exposed in Europe made them seek * This address, which sets forth the modern point of view of medical education, was published in 1894, together with the address of 1877, under the title Higher Medical Education. The True Interest of the Public and the Profession. Philadelphia: Lippincott. 24

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university positions, and at that time there were a few universitymedical schools anxious to have well-trained scholars on their faculties. It was this marked discrepancy of standards between the university and the proprietary schools that set the stage for the veritable revolution in medical education that was soon to follow. It is interesting to note how American students were attracted at different times to various European medical centers and how, on their return, they influenced the development of medical education in this country. In colonial times a few students had studied at Leyden, which had the highest standards of medical education during the lifetime of the great teacher Hermann Boerhaave; but as his death occurred in 1735, it is unlikely that any Americans studied directly under him. Boerhaave, however, trained illustrious teachers who became the leaders of medical education in Edinburgh, in Vienna, and in several of the German universities, and his influence was felt through his disciples, especially in Edinburgh. As has been noted, the Edinburgh school greatly influenced the first medical schools in this country. Many of the early American doctors also studied in London, where they were encouraged by a number of leading physicians who were interested in furthering the development of medicine in the colonies. Soon after the turn of the nineteenth century a number of very able Americans were attracted to Paris where PierreCharles-Alexandre Louis, the father of medical statistics, was the outstanding teacher. After the middle of the century, the German universities predominated in medicine and were most influential in the development of the medical sciences, sending back to this country a group of well-trained medical scientists and teachers who brought a new spirit into the medical schools of the American universities. Many American doctors went to Vienna at this time, especially for training as medical specialists, and that city continued for many years to be the center for graduate courses in clinical medicine. The outstanding scientific leaders in the German universities gave the American students the scientific training and the stimulus for research which prepared them for the development of the true university spirit in America and paved the way for the far-reaching reform in medical education that took place during the first decades of the present century. This reform, strongly stimulated by the 25

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founding of the Johns Hopkins University Medical School and the Johns Hopkins Hospital, marked the beginning of a new era in American medical education. Summary

The history of medicine in America during the three centuries between the arrival of the first settlers and our own time is a story of human struggle to meet a fundamental need of a society progressing from the crude conditions of the pioneers to the comparatively well-ordered and luxurious living which existed at the beginning of the twentieth century. Only a few events of this story have been told, but enough, perhaps, to indicate the fine beginning of medical education in the eighteenth century under the leadership of a few brilliant medical men with European training and the decline of educational standards when a great many medical schools emerged without restrictions, endowment, or general educational leadership. Throughout this period, however, a few men appeared who knew how medical education should be developed, and illustrious practitioners of medicine and surgery arose in spite of their meagre educational opportunities. Outstanding natural ability often showed itself under the freedom of pioneer life, and the history of American medical education before the dawn of the present era had its bright and heroic episodes as well as its dark and sometimes shameful periods.

26

CHAPTER

II

THE JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE -< 1 8 9 9 - 1 9 0 3

>-

HE great ordeal of the Civil War created tremendous stress and strain on the political, economic, and social structure of the United States, and left behind cultural and spiritual wounds which took many years to heal. The postwar history of this country is filled with great events, some to our discredit and others that have shown the sterling qualities of all Americans and have given to the world magnificent evidence of the vision without which people perish. An outstanding example of this vision and faith was the decision of Johns Hopkins to devote his fortune to founding a university and a hospital in Baltimore. He thus created, on the line where the North and the South had been cruelly divided, institutions of great significance in healing the wounds of war and in reuniting a vast country which had been so violently torn apart. This decision was reached in 1867, only two years after the war had ceased.

T

The Founders and Planners Johns Hopkins, a Quaker, was born in 1795 into a family which, because of religious convictions, freed its slaves in 1807. This momentous response to a Quaker "concern" when Johns was only twelve years old, greatly reduced the earnings of the family plantation in Anne Arundel County, south of Baltimore, and made it necessary for him to go to the city to seek his fortune at the age of seventeen. In Baltimore his successful career began in his uncle's wholesale grocery and commission business. He 27

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prospered greatly through his own ability and business acumen as a merchant and financier, and in 1867, a bachelor with a large fortune, he reached the decision to endow a university and a hospital. His initial step was to select two boards of trustees, one for the university and one for the hospital. A number of the trustees were, like himself, members of the Society of Friends. There were twelve men on each board, of whom ten served on both boards, thus assuring the close relations between the two institutions that was to prove so significant in the future. Johns Hopkins laid down no instructions regarding the university, but he wrote an important letter to the trustees of the hospital in 1873 when he turned over to them the land he had purchased for the building. This letter is very significant because it set forth not only Hopkins' clear conception of the hospital as part of the university's medical school, which he had also endowed, but also the high standards he directed the trustees to follow in its construction and management. This letter directed the trustees to provide a hospital "which shall.. . compare favorably with any other institution of like character in this country or in Europe. It will therefore be your duty to obtain the advice and assistance of those at home or abroad who have achieved the greatest success in the construction and management of hospitals. I cannot press this injunction too strongly upon you, because the usefulness of this charity will greatly depend upon the plan which you may adopt for the construction and arrangement of the buildings." The letter continued: "It will be your especial duty to secure for the service of the hospital, surgeons and physicians of the highest character and of the greatest skill. I desire you to establish, in connection with the hospital, a training school for female nurses. This provision will secure the services of women competent to care for the sick in the hospital wards, and will enable you to benefit the whole community by supplying it with a class of trained and experienced nurses." The last instruction in this remarkable letter is particularly noteworthy: "In all your arrangements in relation to this hospital, you will bear constantly in mind that it is my wish and purpose that the institution should ultimately form a part of the medical school of that university for which I have made ample provision by my will."* * This letter is quoted by Chesney in his book, which has been an important source from which the following account is drawn. See Alan M. 28

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There has been much speculation as to the source of the farsighted conception expressed in this letter by a financier who had travelled from Baltimore no further than to Cape May, New Jersey. This question seems to have been successfully answered by my friend, John C. French, former librarian of the Johns Hopkins University, who discovered a copy of Patrick Macaulay's Medical Improvement. French* recognized the possible relation of the discourse to the instructions laid down by Johns Hopkins and he made an extensive search into the history of Macaulay. He was unable to unearth certain important documents, such as Macaulay's will, but he established the facts that Johns Hopkins and Macaulay had served together as directors of the Baltimore and Ohio Railroad for two years and that they had had summer homes about four miles apart in Baltimore County. The most important evidence that Johns Hopkins had read Macaulay's Medical Improvement is that he acquired part of Macaulay's library. A number of books marked with Macaulay's bookplate are still in the Johns Hopkins Hospital. After a careful study of the available material, French concluded that it cannot be doubted that Johns Hopkins was aware of Macaulay's views on medical education. We believe that Macaulay's strong pleaf for the provision of hospitals similar to those in Europe for the teaching of medicine, guided Johns Hopkins in formulating his instructions regarding the hospital. Johns Hopkins died late in 1873 leaving $7,000,000 to be divided equally between the university and the hospital. This gift is said to be the largest ever given up to that time by a single donor to a public institution. Jacob H. Hollander, the Johns Hopkins professor of political economy, calculated that on the basis of the purchasing power of the dollar in 1928, this bequest would have equalled about $100,000,000 in that year. The board of trustees of the Johns Hopkins University, on the independent advice of the presidents of Harvard, Cornell, and Michigan, appointed Daniel Coit Gilman as president of the university in 1875. Gilman's great contribution to the advanceChesney. The Johns Hopkins Hospital and the Johns Hopkins University School of Medicine: A Chronicle. Volume I. Baltimore: The Johns Hopkins Press, 1943. * John C. French. "Mr. Johns Hopkins and Dr. Macaulay's 'Medical Improvement.' " Bulletin of the History of Medicine 27:562, 1953. t Quoted in the previous chapter. 29

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ment of learning through the development of the first true university graduate school in this country is well known. His interest in medical education and his efforts to raise it to the same high academic level are not so generally recognized. In his inaugural address at the ceremonies on February 22, 1876, which marked the establishment of the university, he sharply criticized the educational standards of the existing medical schools and then said: ". . . we need not fear that the day is distant, we may rather rejoice that the morning has dawned, which will see endowments for medical science as munificent as those now provided for any branch of learning, and schools as good as those now provided in any other land." He continued: "It will doubtless be long, after the opening of the university, before the opening of the hospital; and this interval may be spent in forming plans for the department of medicine. But in the meantime we have an excellent opportunity to provide instruction antecedent to the professional study of medicine." He then discussed a course of undergraduate study "which shall train the eye, the hand and the brain for the later study of medicine." In 1878 he presented a report prescribing a premedical course which included the study of chemistry, biology and physics, modern and ancient languages, and other subjects leading to a bachelor of arts degree, and which was far in advance of the admission requirements of existing medical schools. His report is especially significant as the course of study he set forth is essentially the same as that now required for admission to all medical schools of first rank in this country. The trustees of the university gave evidence of their wholehearted support of the establishment of a medical school by purchasing land in 1876 adjacent to the hospital site. On this land the future laboratories of the medical school were to be constructed, but it was eighteen years before the first building was erected for this purpose. The trustees of the Johns Hopkins Hospital, mindful of the instruction of the donor to obtain advice and assistance on the construction and management of hospitals, requested five prominent men to present their views on how the hospital should be built. The essay submitted by John Shaw Billings, brevet lieutenant colonel and assistant surgeon in the United States Army, was considered the best plan. The essay showed remarkable insight into the relation of the hospital to medical education, and 30

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it was indeed fortunate that Billings was available to accept the appointment offered him by the trustees on July 1, 1876, to supervise the construction of the hospital. John Shaw Billings was born in 1838 in Indiana and graduated in medicine in 1860 from the Medical College of Ohio in Cincinnati. He had been a superior student in the school founded by Drake, who no doubt strongly influenced Billings' concepts of medical education. In his paper, A Review on Higher Medical Education, published in 1878, Billings placed the remarkable essays of Drake at the top of a list of twelve outstanding publications on medical education by American and European authors. At the beginning of the Civil War, soon after Billings graduated in medicine, he entered the medical corps of the United States Army and saw active service throughout the war. In 1864 he was assigned to the office of the Surgeon General in Washington where for ten years he was engaged in studies on military hygiene and on hospital construction and organization. He wrote a number of valuable reports on his studies and during those ten years must have given penetrating thought to medical education and research. He was thoroughly prepared to offer wise solutions to the problems presented by the endowment of Johns Hopkins. Gilman and Billings conceived the basic principles on which a great university and a great hospital and medical school were created. They worked together with deep appreciation of the unique opportunity that lay before them to bring about improvements in scientific work, to advance higher education, and to establish coordinated institutions that were to raise the standard of science and of medical education in this country to a new level. Gilman's outstanding contributions to American education and scholarship have received general acclaim, but Billings' role in the development of the Johns Hopkins University Medical School and indeed his influence on medical education generally in this country have not been widely acknowledged, although he is often referred to as the designer of the Johns Hopkins Hospital. Perhaps it is because these contributions have been overshadowed by his later achievements as a bibliographer; as the founder of the Surgeon General's Library and of the Index Catalogue and the Index Medicus; and as the organizer of the New York Public Library. He ranked high as a leader in the development of the science of vital statistics and in the field of public health, as 31

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an eminent historian and a great organizer. Garrison,* his biographer, considers him perhaps the greatest medical man this country has produced. Billings' concept of the Johns Hopkins Hospital, as expressed in his original essay, was that the hospital should be the clinical center of a university school of medicine. He conceived facilities for clinical teaching far ahead of any then existing in this country and, as Garrison observed, far ahead of his own personal experience. When he wrote his essay for the hospital trustees, he had not been abroad; yet he proposed to provide facilities for teaching and research as well as for the care of patients which were comparable with, and in some respects superior to, any available in the European hospitals of that day. He wrote: "This Hospital should advance our knowledge of the causes, symptoms and pathology of disease, and methods of treatment, so that its good work shall not be confined to the city of Baltimore or the State of Maryland, but shall in part consist in furnishing more knowledge of disease and more power to control it, for the benefit of the sick and afflicted of all countries and of all future time." He envisaged a medical school which should attempt to provide teaching of superior quality and which should have as one of its objectives the training of men to become original investigators. No medical school in the United States had such a purpose at that time. Billings advocated a plan of clinical instruction which would be limited to small classes of twenty-five students a year, carefully selected by rigid entrance examinations. The senior students were to live in the hospital and assume actual charge of patients. To meet this last provision, his hospital plans provided ample living quarters for these students in a dignified setting in the front building of the hospital. In 1877, after Billings had visited hospitals and medical schools in Europe, he gave a series of twenty lectures at the Johns Hopkins University on the history of medicine, legal legislation, and medical education. In two of these lectures he gave his answer to the question: "In view of the present condition of medical education in this country, how should the Johns Hopkins University organize its medical department?" These two lectures were printed privately by the university trustees in 1878 •Fielding H. Garrison. John Shaw Billings: Putnam, 1915. 32

A Memoir. New York:

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under the title Suggestions on Medical Education. This publication may be considered the "Declaration of Independence" of modern American medical education. It sets forth a comprehensive program based on true university standards, an ideal from which American medical education has not basically deviated.* Billings' Suggestions on Medical Education is comparable with the writings of John Morgan, Patrick Macaulay, and Daniel Drake, brought up to date after a broad and comprehensive study of the subject by a student of medical education who saw before him an opportunity to put his plans and principles into immediate operation. Billings advocated a new type of medical school dedicated primarily to graduating practitioners of medicine "better trained and more skilful than those of other schools, but still practitioners." He therefore considered clinical instruction, the study of the living subject, as its first objective. "The second existing demand [was] for the promotion of original research and discovery in Medicine," which should include adequate provision for the publication of scientific papers. He presented convincing arguments for a research-centered medical school and summed them up in these words: "What is desired is that the Medical Faculty shall increase knowledge,—and shall fit its students to increase knowledge,—and that its attempts to do this shall not be restricted or limited by the fact that a part of its work is to teach the practical applications of this knowledge. Let this last be the secondary and not the primary object, and by so doing, we shall be free to do, and shall have the means to do, work which is not only highly desirable, but which cannot be done elsewhere." Thus did Billings express the same ideals for the medical department that Gilman had for the university as a whole. He formulated the concepts of a true university medical school that were influential in attracting to its faculty the new type of American scholar then being trained in the German universities. These concepts were of great significance in directing the future course of medical education. He emphasized the necessity of thorough preparation of students to be admitted to such a school * This important contribution to American medical education was reprinted by Chesney in 1938. Apparently it had been virtually forgotten, as only three copies could be found at that time. See Alan M. Chesney. "Two Papers by John Shaw Billings on Medical Education." Bulletin of the Institute of the History of Medicine 6:285, 1938.

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and advocated that the baccalaureate degree be made an indispensable prerequisite for the degree of doctor of medicine, which should confer the right to teach as well as to practice medicine. He envisaged the student body as a relatively small number of well-educated men, constituting a privileged group of scholars. Billings' discussion of the curriculum of the future school is a masterpiece of medical pedagogy and presents a plan of study which is followed even today by the best American medical schools. He recommended that the first two years be devoted to the medical sciences and set forth a plan of clinical teaching, to occupy the two following years, that is at the present time carried out in principle by our best teaching clinics. He thus advocated a four-year medical course—one year longer than the course prescribed by the best schools and two years longer than the course in most schools in 1877. Among other features of teaching, Billings included visits by students to patients' homes, a method recently introduced as an innovation in some of our present-day schools. He appreciated the value of the investigative spirit in the study of patients, for, as he wrote: ". . . nature's experiments on the human body cannot be repeated at will, like those in comparative Physiology, and the phenomena must be observed as they chance to occur or not at all." He gave an excellent discourse on how the medical specialties should be organized and taught, emphasizing public health, preventive medicine, medical jurisprudence, and psychiatry. In fact, he presented a teaching program so broad and comprehensive that even today it has not been completely developed in most of our medical schools. The Builders

Gilman was as deeply concerned as Billings with the problem of finding men capable of carrying out the ideals which both cherished for the new school of medicine. "After we have got our good men," Billings wrote, "we want to keep them good. For our purposes there is no such thing as a man who 'knows enough.' They are to improve steadily, to grow mentally, and for this growth we must provide nutriment and space. . . ." He considered the training of original investigators to be a primary function of the medical school, ". . . to bring [men] face to face with the innumerable problems relating to life, disease and death, which are yet to be solved; to inspire them with the desire 34

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to investigate these questions; and to give them the training of the special senses, of manual dexterity, and, above all, of clearness and logical scientific precision of thought, which are required to fit them to be explorers in this field." Gilman and Billings worked together to find the men to create the new medical school and to direct the services of the new hospital. It was fortunate that at that time there were a number of Americans, trained for the most part by the scientific and clinical leaders in the German universities, who were not only wellprepared, but young, vigorous, and hopefully looking for just the sort of opportunity the new Johns Hopkins was to provide. Before the medical faculty was recruited, however, the university gave official sanction to the ideas that had been developed. In 1883 the trustees resolved that "the President of the University, the Professors of Chemistry, Hygiene and Physiology, and the Professor of Pathology (to be hereafter designated), and such other professors as this Board may appoint, constitute a Faculty of Medicine." This faculty was to serve until the opening of the Johns Hopkins Hospital and consisted of Gilman as president, Ira Remsen as professor of chemistry, Henry Newell Martin as professor of physiology, and Billings as professor of hygiene. Billings was unable to accept the professorship because of his position in the Surgeon General's office, but he served on the faculty for thirty years as lecturer on the history of medicine, an appointment he had received in 1876. Ira Remsen was a graduate of the College of Physicians and Surgeons in New York, but instead of entering the medical profession he had gone abroad to study chemistry, had received his Ph.D. degree at the University of Göttingen, and had served as an assistant to the illustrious chemist Liebig at Tübingen. Newell Martin was a medical graduate of the University College of London and after being associated closely with the eminent English physiologist, Michael Foster, had been called to Johns Hopkins as its first professor of biology. The original medical faculty held three meetings in January 1884, and the minutes of these meetings are of much significance in the history of medical education. Special attention was given to premedical education, to the requirements for admission, and to the curriculum of the future medical school. These meetings formally set the educational standards that were to be followed. It was decided that although the curriculum should not be formu35

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lated until the future staff of the Johns Hopkins Hospital could be consulted, the university would begin at once to work for the advancement of the medical sciences. The broad foundations for the Johns Hopkins Medical School in cooperation with the hospital were laid down. This set the stage for the group of illustrious men who were to carry out with distinction its actual creation. The first professor to be added to the original faculty was William Henry Welch, appointed professor of pathology in April 1884. Welch had graduated from the College of Physicians and Surgeons in New York and, after a hospital internship, had gone abroad to study pathology, remaining two years in German universities under von Recklinghausen, Cohnheim, and Ludwig. Immediately after accepting the Johns Hopkins appointment, he returned to Germany to study the then-young science of bacteriology. He entered on his professional duties well prepared not only for teaching science, but also for leadership in developing a research-centered medical school and hospital along the lines and with the high standards of scholarship advocated by Billings. The appointment of Welch was destined to have great influence on the development of the new era of medical education and research in America. The life of William H. Welch presents a record of achievement unsurpassed in American medicine and too well known to need recounting here. His great accomplishments have been set forth with thoroughness, skill, and affection by two of his ablest followers, Simon Flexner and his son James Thomas Flexner, whose biography recounts the great influence of Welch in what they call "The Heroic Age of American Medicine." One of Welch's early activities was his graduate teaching in pathology which began in 1886 and had an important influence on the development of the medical school. As soon as the pathological laboratory was built (the first hospital building to be completed), Welch began to attract the sort of men Gilman and Billings had had in mind as the primary asset of the university. They came to work with him as graduate students in pathology and bacteriology, and among them were eight who subsequently became professors in the medical school. They were William S. Halsted, Simon Flexner, Franklin P. Mall, Lewellys F. Barker, William S. Thayer, J. Whitridge Williams, Thomas S. Cullen, and Henry M. Thomas. This was the first opportunity in this country for study and re36

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search in the medical sciences at the university level and was particularly significant as it initiated the intellectual achievements for which the Johns Hopkins University Medical School and Hospital became famous. The Johns Hopkins Hospital was completed in 1889 after thirteen years of planning and construction, financed largely by the income from its endowment. Previous to its opening, serious thought was given to finding the men qualified to organize and conduct the hospital services and to teach in the future medical school. This search among the medical men of Great Britain and America was carried on by Gilman, Billings, and Welch. It led to the appointment of William Osier in 1888 and of William Stewart Halsted and Howard Atwood Kelly in 1889, as the chiefs of medicine, surgery, and gynecology and obstetrics. All were young men under forty years of age. Osier had been on the faculty of his alma mater, McGill University, and of the University of Pennsylvania, and had studied in London, Berlin, and Vienna. Halsted had spent two years in various German university clinics and in Vienna in the clinic of the preeminent surgeon, Billroth. Kelly had not been abroad, but at the age of thirty-one had made a brilliant record in Philadelphia, where he attracted Osier's attention and gained his admiration. He had served as associate professor of obstetrics at the University of Pennsylvania for one year before his Hopkins appointment. These three chiefs of the hospital services and William H. Welch, its pathologist, have been known as "The Big Four" of the Johns Hopkins Hospital. They entered on their hospital duties with high hopes, ready to foster the ideals of the great new teaching hospital and eager to participate in this unique American opportunity. Their subsequent accomplishments in medical practice, in teaching, in research, and in the training of men are well known throughout the medical world, and their appointment was an outstanding accomplishment in the selection of men. Billings had been offered the appointment of director of the hospital in 1888 following his formulation of plans of administration which were, with a few minor changes, subsequently adopted. He was, however, unable to accept this offer, and in January 1889 President Gilman became the director of the hospital, dividing his time between it and the university until Henry M. Hurd assumed the post of hospital superintendent on August 1, 37

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1889. This episode in Gilman's career served as another link between the hospital and the university, and gave the president of the university an intimate insight into medical organization which was of much value to the future school of medicine. The development of the resident staff under the leadership of Osier was a significant step in the organization of the hospital and had a far-reaching influence on American medicine. Billings' plans provided dignified living quarters in the administration building of the hospital, not only for an unusually large resident staff, but also for twenty-four senior medical students. His plan of having the members of the senior class reside in the hospital was never carried out, but the space provided for them was added to that available for the graduate house staff. These facilities made it possible for a relatively large number of carefully selected medical graduates to live in the hospital and obtain long periods of training, giving them opportunities nowhere else available. These opportunities have always been much prized by the students of the medical school because of their unique advantages for postgraduate training, and winning these privileges has always been a great stimulus to high scholastic standing in the medical school. As the long period of resident training was unique in its early days, many of those who completed the five or more years of resident service were immediately appointed to teaching positions (sometimes as full professors) in the improving medical schools in all parts of the country. The development of the resident system under the leadership of Osier was an important factor in spreading the fame and standards of Johns Hopkins throughout this country, and it was an outstanding contribution of the hospital for which Osier deserves great credit. It was one of many conspicuous improvements that he made in medical teaching and ranks in importance with his introduction of the students into the hospital wards as clinical clerks. The opening of the Johns Hopkins Medical School was delayed until 1893 because the university funds for its support were inadequate. However, in 1890 a movement was started by a group of Baltimore women headed by Miss M. Carey Thomas and Miss Mary E. Garrett, daughters of original trustees, to raise funds to finance the medical school on condition that women be admitted on the same terms as men. The Women's Fund Committee spread to other cities, and early in 1893 it had raised 38

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$500,000 (a great portion of which had been given by Miss Garrett), the full sum needed to finance the medical school. In February of that year it was announced that the school would open in the fall. The university was then faced with the problem of securing a staff and providing facilities for the teaching of the medical sciences. The medical school was to make its beginning in improvised facilities, using existing university laboratories and building an addition to the pathological laboratory on the hospital grounds. Finding professors of anatomy, physiology, pharmacology, and physiological chemistry was a more serious problem than the provision of buildings. However, three young, welltrained men were found for these posts—Mall, Abel, and Howell, all of whom subsequently added renown to the school and won dominant places in their respective fields of science. Franklin P. Mall had gone to Germany after graduating in medicine from the University of Michigan in 1883 and had spent three years in the laboratories of the embryologist, His, and with the physiologist, Carl Ludwig. He entered Welch's laboratory in 1886 as the first Johns Hopkins Fellow in Pathology and worked there for three years before going to Clark University for a brief period and then to the University of Chicago as professor of anatomy. From Chicago he was called to Johns Hopkins at the age of thirty-one. John J. Abel was professor of materia medica and therapeutics at the University of Michigan when he accepted the call to the Hopkins in 1893 to teach physiological chemistry and pharmacology. Abel had spent seven years in various German universities studying with several outstanding men in the medical sciences and working in university clinics. William H. Howell was appointed professor of physiology at the age of thirty-three. He was a native Baltimorean, had received his Ph.D. degree in physiology under Newell Martin in 1884, and had taught at the University of Michigan and at Harvard University, where he was a member of the medical faculty when called back to Baltimore. Gilman, Welch, Osler, Halsted, Kelly, and Hurd (who was professor of psychiatry as well as superintendent of the hospital) , were joined by Mall, Abel, and Howell to form the faculty that launched the Johns Hopkins Medical School in October 1893, four years after the hospital was opened. Welch was appointed dean, and this group was designated by the trustees of the university as the advisory board. The school opened with fifteen 39

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students, all college graduates meeting the special requirements in science and modern languages that had been prescribed. The first medical building to be erected by the university, the laboratory of anatomy, was completed in 1894 on the ground purchased by the university eighteen years before. It was soon followed by the building for the departments of physiology, pharmacology, and physiological chemistry. The additional stories added to the pathological laboratory on the hospital grounds provided facilities for the department of pathology and bacteriology. Soon after its opening, the medical school had adequate laboratories and was integrated with the Johns Hopkins Hospital, all directed by enthusiastic, highly trained teachers and investigators. At last the vision of John Morgan expressed one hundred and thirty years before in Philadelphia had become a reality. At that time he had prophesied that "Medicine will put on the form of a regular science, and be cultivated with ardor and success," and he had closed his eloquent address with words that expressed the ideal of the new school in Baltimore: ". . . every useful kind of learning shall here fix a favorite seat, and shine forth in meridian splendor. To accomplish which may every heart and every hand be firmly united." A Student's View of the Medical

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I entered the Johns Hopkins Medical School as a first-year student in the fall of 1899, at the beginning of its seventh year. During this brief period the organization of teaching and research had been perfected. The original heads of departments were relatively young and in their prime, and the spirit of youth was in the air. The medical school was in its best and most influential period. I believe that it is therefore of historic interest to give an account of the school of that day from a student's enthusiastic point of view, and to recall the leading figures who participated in inaugurating the school that was strongly influential in elevating the standards of medical education in this country. There were fifty students from all parts of the United States in my class, and, as from time immemorial, the study of human anatomy was our starting point. We began with one of the most emotional experiences of a medical student—to unwrap and become acquainted with the first dead human body we were to know intimately in the dissecting room. Our first months were 40

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devoted to studying the names and forms of bones, examining under the microscope and making drawings of sections of various parts of the body, and carefully dissecting and studying the human body. Franklin P. Mall, the professor of anatomy, was one of the most brilliant contributors to anatomy and embryology this country has produced. He believed that anatomy can be learned only by the efforts of the student and that the duty of the teacher is to give him the opportunity to work out his own anatomical salvation. He gave independence and responsibility to his students, treating them as mature and well-trained college graduates. He would occasionally visit the dissecting rooms and walk about with a detached manner, making remarks here and there while casually looking over our dissections. These remarks were often more philosophical than anatomical, and I recall that on one occasion, after a glance at my dissection, he quietly remarked: "Anatomy must be studied according to the Aristotelian form of thought." Although these words remained in my memory, they were not understood for several years. In spite of Mall's infrequent appearances as a teacher, the students were not left alone. The splendid group of young men, several of them recent graduates of the school who were beginning their careers in anatomy under Mall, helped us in the spirit of advanced students rather than didactic instructors. The senior of this group was Ross Harrison, who had a long and brilliant career as professor of comparative anatomy at Yale and who was then working on his fundamental studies on the growth of nerve cells. He was in charge of the course in microscopic anatomy, officially called histology and histogenesis. Another in this group was Charles R. Bardeen, later professor of anatomy at the University of Wisconsin where as dean of the medical school he organized one of the first university medical schools in the Midwest and was a leader in medical education throughout his career. Others were Henry McE. Knower, who became professor of anatomy at the University of Cincinnati, and Mervin T. Sudler, later professor of surgery and dean of the medical school at the University of Kansas. There was also a graduate student, Abram T. Kerr, who was carrying on research in the distribution of the nerves of the skin, and who asked the students to make special dissections and charts of the nerves of the bodies they were studying. The slight part I played in his research opened the 41

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way to a position in his department for a short period after my graduation when he was professor of anatomy in the medical department of Cornell at Ithaca. The dissecting rooms in Mall's department set a new style. The light, airy, adjoining rooms on the top floor of the anatomical laboratory in which eight to twelve students worked together in well-ordered and clean surroundings were in striking contrast to the usual dissecting halls of that time, where indignities were often played on the social outcasts who ended their terrestrial sojourn in dissecting rooms. Only once was the academic tone of our dissecting room disturbed. It was on a spring day when an Italian organ grinder took his stand beneath the open windows of our room. An unmusical classmate, either annoyed by the organ music or just looking for some fun, came to our table and took the spleen from our "body" and threw it down at the organ grinder. Unfortunately, an unnoticed policeman was standing nearby and picked up the spleen that had missed its mark. He brought it into Professor Mall with the complaint that someone had thrown a "kidney" out of the window. After being assured by the professor that no "kidney" had been thrown out, he left, but Mall came immediately to the dissecting room with more than usual to say, and ordered those involved in the episode from which the policeman's lack of anatomical knowledge had given a way out, to report immediately to his office. The thrower and his partner, my partner, and I, who had abetted the act, went together to his office to diffuse the blame, and received a scholarly discourse on proper behavior in a dissecting room, on public decency, and on the responsibility of scientists. And that was all. However, the student who threw the spleen was one of two students dropped from the class at the end of the year, not because of this episode but because it was a symptom of a crude personality which marked him off from the rest of his classmates. Physiology and physiological chemistry were the other subjects of the first year. Our study of physiology began in January with a fine, well-organized course of lectures and demonstrations by Professor William H. Howell supplemented by work in the laboratory where we performed experiments demonstrating some of the important activities of the animal body. Howell, a quiet, sympathetic man with an orderly mind, was a fine teacher who had the respect and esteem of all the students. He served as dean of the school from 1899 to 1911, and in 1917, when the school 42

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of hygiene and public health was established under the direction of William H. Welch, Howell became the assistant director, and in 1926 the director. His textbook of physiology was for many years widely used in this country, going through fourteen editions. Howell had an unusually long career in research. I recall the stirring report of his work on the coagulation of the blood which he presented to the Johns Hopkins Medical Society in 1938, sixty years after he entered the university as a college student, and he was still actively studying blood coagulation when he died in 1945 at the age of eighty-four. In the department of physiology George P. Dryer, who soon became professor of physiology at the University of Illinois, was the senior instructor, while the young men starting in physiology —recent graduates of the medical school—were Percy M. Dawson, later professor at the University of Wisconsin, Alfred B. Herrick, Percy G. Stiles, and Joseph Erlanger. Erlanger had a distinguished career as professor of physiology at Washington University, St. Louis, where we shall meet him again. These young men, all engaged in research, gave lectures occasionally on subjects of their special interest and worked with us as instructors in the laboratory. Physiological chemistry, as biochemistry was then called, began in March and continued to June. It was taught by Walter Jones, then a young associate professor, who later became the head of the department when physiological chemistry was given independent status. Jones was a spirited and, on occasions, a dramatic talker. He gave us an idea of the vehemence a scientific controversy could arouse, as he was at that time in the midst of a polemic with a professor in a German university and his arguments bubbled over in his lectures, giving them life and interest. One of our classmates, Arthur Loevenhart, was an advanced student of biochemistry and later became professor of biochemistry in the medical school of the University of Wisconsin. When the subject of his previous research fitted into the course, Jones asked him to lecture to the class—an example of the comradeship that existed among students and teachers in the medical school. The second year began with further studies in anatomy and physiology and with the course in bacteriology, taught by Norman MacL. Harris in the department of pathology, which took up our afternoons until January. For two weeks or so the labora43

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tory was converted into a kitchen, as the first step in bacteriology was the preparation of the various culture media on which bacteria were to be grown for study and differentiation. Through lectures and actual work with bacteria we learned about those that caused disease and how to carry out the then-standard procedures of bacteriology. In January we began to meet disease face to face in the course in pathology, attending post-mortem examinations in the hospital and studying specimens and microscopic sections in the laboratory. William H. Welch conducted what was no doubt at that time the finest course in pathology being given in this country. He was then in his early fifties and full of interest in his teaching, not only giving us superb lectures but spending much time in the laboratory discussing the specimens being studied by individual students. At the end of the course in June, Welch called each student into his office and went over with him the microscopic sections he had described and diagnosed as part of his final examination. I clearly remember this experience. Welch singled out one specimen of mine and expressed enthusiasm that it had been well described and understood. His interest and praise gave me an exalted feeling of achievement, and I left the room with the determination to do my best in medicine if only to show Dr. Welch that I was worthy of his praise. I have often thought of this experience as an example of the best sort of teaching and of the value of encouragement as a means of inspiring students to do their best. Dr. Welch was a great teacher and attracted many young men into the field of pathology. During the year I was taking the course William G. MacCallum, Eugene L. Opie, and Harry T. Marshall—all graduates of the Johns Hopkins school—were the young instructors. MacCallum rose to the rank of professor of physiological pathology at Johns Hopkins and in 1909 was called to Columbia University as professor of pathology, returning in 1917 to be Welch's successor at Johns Hopkins. Opie joined the staff of the newly organized Rockefeller Institute in 1904. He was called from there in 1910 to be professor of pathology at Washington University in St. Louis when its medical school was completely reorganized. Later, as dean, he took a leading part in that outstanding development of university medical education. In 1923 he became professor of experimental pathology 44

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at the University of Pennsylvania, as well as director of the laboratories of the Henry Phipps Institute for the study of tuberculosis. With the reorganization of the Cornell University Medical College in 1932, he was appointed professor of pathology there and pathologist at the New York Hospital. Marshall was soon called to the University of Virginia, where he had a long and successful career as professor of pathology. As spring approached, Harry Marshall asked my partner Louis Haskell and me to assist him in giving a course to physicians during June, which we gladly consented to do. During that month I spent most of my time in the pathological laboratory and was assigned my first "Arbeit" by MacCallum. He gave me a specimen of an unusual tumor that had been removed from the neck of a recently autopsied subject, suggesting that I describe it, study it microscopically, and make drawings of it. I devoted many hours to this task, including efforts to make sketches of the specimen. When I had done my best as an artist, I took my drawing to Max Brodel, who even then was recognized as one of the greatest medical artists. He viewed my drawing from various angles, upside down and sideways, and then said: "What is this, a hunting scene?" In spite of this initial discouragement, my crude first attempt as an illustrator was, with his help, made presentable. MacCallum assisted me in reviewing the foreign literature, and it was found that the tumor was a cyst originating from the thyroglossal duct, of which only one case had been fully described in Germany. This little piece of work was published, with the drawings, in the Bulletin of the Johns Hopkins Hospital in 1902 as my first medical publication. Pathology was the study that especially awakened my interest in medicine, and it was a great privilege to have had William H. Welch and his brilliant associates as my teachers. The last of the laboratory courses of the second year was pharmacology and toxicology, in which we studied the effects of drugs and poisons under John J. Abel. Abel was primarily a chemical investigator. He had a warm, outgiving personality and was a striking contrast to the methodical Howell, whose life, thought, and teaching seemed so orderly. Abel lectured in a reminiscent style, referring now and then to his unique seven years of wandering study with the leading medical scientists in various German universities. Neither his lectures nor his laboratory course was conducted systematically, but his personality, 45

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his enthusiasm, and his intensity of interest in his field of research made a strong impression on the students who were sensitive to this unique teacher. Abel was the first professor of pharmacology in America, this subject having been newly imported from the German universities, and he was one of the most respected American medical scientists of his time. He took a leading part in establishing and editing three important scientific journals and left behind a series of fundamentally important contributions to medical science. In January of our second year we began the study of living human beings, for which all that had gone before seemed prelude. At last we attached ourselves to that particular outward sign of the doctor, the stethoscope, feeling that we were putting on medical long trousers after having worn knee breeches up to that time. The start was made in physical diagnosis under William S. Thayer, Osier's right-hand man, a highly cultured and learned physician who was later to become professor of medicine, and who was an ideal man to direct the first contacts of the students with patients. We began by learning how to examine patients. By practicing at first on each other, we learned how to observe and how to use palpation, percussion, and auscultation. Then the class was divided into groups of six or eight students, each with its own instructor. We examined patients and learned how to recognize abnormal physical signs and to evaluate them in terms of disease. My group was directed in the outpatient department and hospital wards by Henry Barton Jacobs, who was especially interested in tuberculosis and who served as the first secretary of the National Tuberculosis Association when it was organized in 1904. We also had, in the spring, an introductory course in surgery under John Μ. T. Finney, who became one of the most beloved doctors in Baltimore and took a leading part in the community, not only as its most highly esteemed surgeon but also as a citizen rendering conspicuous public service in many ways. He and Thayer were a splendid pair to guide the emotions and shape the attitude toward patients of impressionable students at the threshold of their clinical training. Our first lesson in bandaging is memorable because of its emotional significance. At the end of the lesson on a Saturday morning, we were given a roll of bandage with which to practice on a bedpost or on a willing victim. I had the bandage in my pocket in the afternoon when 46

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I went to the Greenspring Valley Hunt Club to see a steeplechase in which my older brother was to ride. I was standing beside a fence as the horses jumped and I saw my brother fall. My hand went immediately to my first bandage with the thought: "I now shall really practice bandaging." Fortunately, there were no wounds and no injuries except a mild cerebral concussion, but the episode left the lasting impression that a doctor must always be prepared for an emergency. At the beginning of the third year we moved into the Johns Hopkins Hospital, where I spent the next two years studying under Osler, Halsted, and Kelly, who, with Welch, made up the famous physicians of the Johns Hopkins Hospital commemorated in the painting by John Singer Sargent that today hangs in the Welch Library. Besides them, J. Whitridge Williams had recently been appointed professor of obstetrics to complete a remarkable group of clinical teachers. During the mornings of this year, groups of students worked in the various clinics of the outpatient department under able and enthusiastic instructors and attended the general clinics given in medicine and surgery by Osier and Halsted for third- and fourth-year students. Only in obstetrics did we have systematic lectures. The most memorable experience of the third year was Osier's teaching in the dispensary. Three times a week he would meet the class at twelve o'clock for an informal discussion of patients which he called the "observation clinic." The students would line up on two rows of chairs, a couch for the patient between them. Osier would come into the room in buoyant spirits and sit at the head of the couch, and a student would present the history of the case he had studied during the morning under the guidance of an instructor. The patient would then be examined by Osier and the student, the primary object being to teach the beginners how to look at, feel, and listen to a patient, and how to observe the manifestations of disease. This would lead to a general discussion by Osier and the students of the lesson each case presented, including the diagnosis and treatment of the patient. Although the primary object was observation of the patient, the students perhaps unconsciously learned much from watching the great physician—how he put the patient at ease with kindly words and jests, his delightful sense of humor, his keen analysis, and his literary and historical allusions. We learned from a master at the start of our work with patients the 47

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best sort of doctor-patient relation—a most important lesson never to be forgotten. This was our introduction to one of the greatest teachers of medicine of modern times. Arnold Klebs' delightful description of Osier in the outpatient clinic is quoted by Garrison:* "Never can one forget the scenes in the out-patient department, where he stood, surrounded by his boys, helping them as a friend in their struggles with some difficult case. He would go to one, put his arm around his shoulder, and then begin a friendly inquiry, interspersed with humorous remarks, and allusions to the work done by special students on a given subject. Urging, encouraging, inspiring, so we saw him, exact always, dogmatic never, and when the humorous and friendly fire kindled in his eyes we could not help but love him and with him the task we had cliosen as our lifework." Klebs speaks of Osier as one of those "making apostles and missionaries in the great cause of scientific medicine." In Osier's department of medicine there was then a group of young men who exemplified his great influence in making missionaries of scientific medicine. These were William S. Thayer, Henry M. Thomas, Thomas B. Futcher, Thomas R. Brown, and Louis P. Hamberger, all of whom continued for many years as important members of the Johns Hopkins faculty. Serving on the resident hospital staff were Thomas McCrae, who became the professor of medicine in the Jefferson Medical College; Rufus Cole, who organized and directed the Hospital of the Rockefeller Institute; Charles P. Emerson, subsequently professor of medicine and dean of the University of Indiana Medical School; and Campbell P. Howard, who filled the professorship of medicine first at Iowa and later at McGill, where his father had been Osier's influential teacher. For a third of the year, the class had practical instruction in the surgical outpatient department under John Finney and a group of enthusiastic young surgeons. The weekly nonoperative clinics given by Halsted tended to be over our heads, and Halsted was a somewhat indistinct figure to most of the third-year students. His greatest distinction was his teaching of advanced students, especially those he selected for his resident staff, from whom he developed many eminent surgeons and teachers. The afternoons of the third year were largely taken up by * Fielding H. Garrison. An Introduction to the History of Medicine (4th edition). Philadelphia: Saunders, 1929. 48

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two laboratory courses, clinical microscopy conducted by Charles P. Emerson and surgical pathology given by Joseph C. Bloodgood, a pioneer in developing this field under Halsted's direction. We also attended a few clinics and lectures on the surgical specialties, including orthopedic surgery and ophthalmology. At the end of the afternoons we had special lectures by distinguished scholars from other cities—Alexander C. Abbott of the University of Pennsylvania on hygiene, Robert Fletcher of the Surgeon General's Library on medical jurisprudence, and Charles W. Stiles, the discoverer of the hookworm, on medical zoology. Lectures on the history of medicine were of special significance as they were given by John Shaw Billings, the greatest medical bibliographer America has produced, who played such an important role in developing the medical school and hospital. During the fourth year of the medical course most of our time was devoted to work as clinical clerks on the hospital wards. The class was divided into three groups that rotated through medicine, surgery, and obstetrics and gynecology. The clinical clerks were an integral part of the hospital organization and had specific duties, such as taking patients' histories, making physical examinations, doing the simpler laboratory tests, and helping with surgical dressings. We were made to feel that we had medical responsibilities which we carried out under supervision. The assignment of students to clerkships on the wards was a significant innovation in medical education for which Osier deserves the credit. It brought a new spirit into clinical teaching and revived the best features of the student-teacher relationship in the old preceptor system. While on the medical service, the students attended the ward rounds usually made each morning at nine o'clock by the chief, Dr. Osier. At that time students presented new cases assigned to them and participated in discussions of diagnosis and treatment. We spent the entire day on the wards, either with the patients or in the laboratories, except when we attended the few general clinics or were present at autopsies on patients we had studied during their last illnesses. One of the most vividly remembered lessons I learned on the wards was the value of persistent diligence in the examination of patients. A young girl was thought to have pulmonary tuberculosis, but the tubercle bacilli had not been found in her sputum. It was put up to me to verify the diagnosis by finding the or49

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ganism. This meant daily collection of sputum, preparation of microscopic slides, and long, tedious examination under the microscope. The tubercle bacilli were found and demonstrated to McCrae, the resident physician, on the twenty-first day of my search. This is an example of the freedom and responsibility we were given in our work with patients and indicates the value of the training we had under Osier's clinical clerkship plan of teaching. Osier devoted every Saturday evening to his students. The group on the medical wards was invited to his house at 1 West Franklin Street, and at eight o'clock, seventeen of us would gather around his dining-room table and listen to his unsurpassed talk on medical history. After an hour or so, light refreshments would be brought in and the conversation would turn to our patients on the hospital wards, as Osier went around the table inquiring how our work was going and suggesting further studies we might make. He talked to us for several evenings about the famous London physicians of the eighteenth and early nineteenth centuries who had carried in succession the famous Gold-Headed Cane, and one memorable evening he talked about his favorite book, Sir Thomas Browne's Religio Medici, and showed us over sixty editions of this book in his library. The fact that Osier gave up one evening every week from his busy life to these gatherings shows his devotion to his students and his strong desire to give them spiritual nourishment and to plant seeds of medical culture from his abundant store in their minds. This was another mark of his greatness as a teacher. On the surgical service the same principle of work on the hospital wards was followed, but Halsted seldom made the morning rounds himself. Our ward work was supplemented by attendance at operations in which we took part as assistants when patients assigned to us were operated upon. Among the staff members was Harvey Cushing, who had recently returned from a year of European study and who conducted afternoon courses in surgical anatomy and in operative surgery on dogs. Hugh H. Young, then a beginner in genito-urinary surgery, instructed us in his specialty, and we had a few lectures and demonstrations in other surgical specialties—otolaryngology, ophthalmology, and dermatology. In the trimester devoted to obstetrics and gynecology we were again assigned to ward patients, but gave less time to them. 50

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The delivery of babies in the homes of poor patients was an outstanding experience, as it was our initiation into medical practice in the outside world. Two students were on call night and day to accompany a doctor and a nurse to the home of the immediately expectant mother, each student assisting in six deliveries as his required quota. These visits, often in the night, to the homes of poor people were valuable experiences, not only because they made us feel that we were actually practicing medicine, but also because they gave us insight into the turmoil created in some of these poorly equipped homes when a baby arrives or sickness strikes. On the gynecology service we watched the skillful Howard Kelly operate and listened to his enthusiastic commentary, though he had little to say to us at other times. A course of lectures on gynecology was given by William W. Russell, and a course in gynecological pathology was conducted by Thomas S. Cullen, both very able men trained by Kelly. Cullen was his successor as professor of gynecology. Our instruction in pediatrics consisted of a few lectures by William D. Booker, who demonstrated cases of some of the contagious diseases of childhood. A course of lectures on psychiatry was given by Henry M. Hurd, and toward the end of the fourth year a few clinics were conducted by Henry J. Berkley at the Baltimore City Bay View Asylum. This review of the medical course at the Hopkins at the beginning of this century presents a striking contrast to the overcrowded curriculum of today. The medical school was characterized by quality rather than quantity, and there was a remarkable lack of external pressure on the staff and students. However, everyone felt much internal pressure—a drive toward high achievement and much hard work—that was propelled by the general spirit of the place and maintained by the interplay known as teamwork, between like-minded and like-feeling people of high quality. The medical school had the social and intellectual spirit of a true university graduate school. Students were treated as mature men and women, and the teaching staff helped them to get the best medical education that each was capable of acquiring largely through his own efforts. We were stimulated by splendid opportunities and surrounded by men with fine scientific training and great proficiency in medicine. As I look back over the years, I 51

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still think that when I was a student, the Johns Hopkins Medical School was at its most influential period and was playing an important· role as the leader of educational reform in American medicine. The heads of the four clinical departments of the medical school and hospital—Osler, Halsted, Kelly, and Williams—had characteristics that distinguished them strikingly from one another. William Osier was certainly the outstanding clinical teacher and had great influence on the students. Much has been written about his life and work, the long list being headed by the masterful biography by Harvey Cushing. Wilburt C. Davison read and summarized 440 articles about Osier in preparing a recent paper on his influence on modern medicine, and no medical man of our time has received greater praise as a teacher and as a friend. I shall, therefore, give only a brief description of Osier as I remember him. His characteristics and attainments that made him one of the greatest teachers of all time were his vivid, blithe, attractive personality; his extensive and well-organized knowledge of medicine, of medical history, and of books; his skill and wisdom as a physician; his warmth of feeling and interest in his patients, in his students, and in his fellow man; his sense of humor; and his remarkable ability as a writer and speaker. He had the g i f t of leaving behind vivid memories of everything he said and did; he had a rare combination of personal charm and intellectual vigor that blended to make him a conspicuous figure. Many students, of whom I was one, thought of him as the ideal physician whom they wished to emulate. His textbook, The Principles and Practice of Medicine, first published in 1892, had undoubtedly through its many editions greater influence on the teaching of medicine in this country than any other book. I was fortunate to be in time to have Osier as my teacher; two years after I graduated in 1903, he accepted one of the highest posts in British medicine and left f o r Oxford in 1905 to become the regius professor of medicine. There, until his death in 1919, he had an even wider sphere of influence than in Baltimore. The remarkable breadth of Osier's influence was expressed in a charming tribute by Sir Thomas Clifford Allbutt, Osier's contemporary as regius professor of medicine at Cambridge University. Speaking at a memorial service for Osier in 1920, Allbutt paid an eloquent tribute to the wide range of Osier's 52

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intellect and the singular charm of his personality. He then spoke of Osier's international reputation and his binding influence on the medical profession in many lands, his love of peace and good will, and "the extraordinary power he exerted in diffusing without diluting friendship." I was happy to have this diffused but undiluted friendship of Sir William Osier and to receive from time to time brief letters from him, as did hundreds of friends, many of whom had been his students. It was a great loss to Johns Hopkins and to American medicine that Osier was enticed to Oxford, the fountainhead of British culture, where in his latter years he had a life rich in literary and historical pursuits and associations, while his great talents as a teacher had a more restricted outlet. William S. Halsted, professor of surgery, was a philosopher, investigator, and master surgeon. Although his contacts with students were much less personal than those of Osier, he was, in a broad sense, a great teacher and created a new school of surgery in America not only through his own teaching and scientific contributions, but also through the many outstanding surgical teachers he trained. He broke away from the rapid and spectacular methods of operating in which he had been adept as a young man and developed an operative technique which gave great consideration to the care of body tissues and to the avoidance of excessive loss of blood. By slow and careful procedures, he diminished the shock of operations and improved the healing of wounds. Halsted exemplified the best German university professors. His life was devoted to thinking, to putting ideas to experimental tests, and to applying those that seemed sound to surgical practice. He made important advances in the cure of hernia, in the surgery of the thyroid gland, in the operative treatment of cancer of the breast, in surgery of the intestines and gallbladder, and in a number of other fields, while his revolution in operative technique had a wide and beneficial influence on the technical aspects of American surgery. His mind was always concerned with widening the boundaries of surgery, which he succeeded in doing by developing men who used his experimental approach. Among the men trained in his department who were pioneers in new fields were Cushing and Dandy in brain surgery, Young in genito-urinary surgery, Baer in orthopedics, Crowe in otolaryngology, and Baetjer in radiology. A large group of men went out from his department to become 53

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leading surgeons and eminent surgical teachers throughout the country. Howard A. Kelly was appointed professor of both gynecology and obstetrics in 1889 when he was thirty-one years old and came nearer to being a genius than any other man on the medical faculty. He had an extraordinary range of interests and, besides being a brilliant surgeon almost from the day he finished his internship in the Episcopal Hospital in Philadelphia, his avocations included botany, mycology, astronomy, geology, and the study of reptiles. He was a remarkable linguist, speaking, reading, and writing German, French, and Spanish; speaking modern Greek; and reading the Scriptures in Greek and Hebrew. He was a man of great energy and vigor as illustrated by a story that went around among the students. It was said that he rode a motorcycle to the hospital and, to save time, had arranged with the proprietor of a grocery store on his route that when he rode by with a shout, the grocer would telephone to instruct the hospital to start giving ether to the first patient to be operated upon, for Dr. Kelly was on his way. His lively interests went beyond medicine and the natural sciences. He was an enthusiastic religious worker and preacher, and took an active part in social reforms, sometimes of the more violent kind. Once he was a watcher at the polls in a Baltimore election that promised to be unusually rough and corrupt. The occasion lived up to expectation. The brave Kelly's watchfulness was ended by the severe beating he received at the hands of thugs representing the ward heelers. This account gives some idea of Kelly's personality and explains why he did not give much time and thought to the teaching of medical students. However, a long succession of highly trained gynecologists were developed under his direction. He was a prodigious worker, had written 485 books and journal articles by the time he was sixty-one, and had taken a leading part in developing medical illustration through the work of Brodel and other skillful medical artists whom he brought from Germany and supported for years. He was a pioneer in the use of radium in the treatment of cancer and invented a number of new instruments, raising gynecology to a new level in this country. Welch said, on Kelly's seventy-fifth birthday, that he had done more than any of the others to extend the fame of the Johns Hopkins University to distant lands. Kelly might have 54

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reversed this remark and given Welch that honor, but it showed how highly Dr. Kelly was esteemed by his colleagues. In 1899 J. Whitridge Williams was appointed professor of obstetrics. At that time Kelly retired from obstetrics, and it was then organized as a separate department. Williams was the first Baltimorean to be appointed head of a clinical department in the medical school and chief of an independent service in the Johns Hopkins Hospital. This appointment was the first that deviated from the university's policy of searching widely for potential leaders for appointment to the medical faculty instead of appointing native sons, the custom usually followed elsewhere. This policy was of great significance when Johns Hopkins was organized, although it created local resentment. Williams was an excellent teacher and published a textbook on obstetrics in 1903 which, with numerous revised editions, was widely used for many years throughout America. He had qualities of leadership, serving as dean of the medical school from 1911 to 1923, and he developed a strong department from which came a fine quality of research and a number of men who became professors of obstetrics throughout the country. The professors of the clinical subjects in the Johns Hopkins Medical School had advantages that had never before been available in this country. Not only did they have a relatively small number of well-trained and carefully selected students, but they had superior hospital facilities entirely under their individual professional direction. The Influence

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The hospital and teaching staff was greatly strengthened by the large hospital resident staff, for which living quarters were provided. This staff comprised a group of men who underwent intensive medical training for six or seven years in preparation for academic posts throughout the country. The development of a hospital resident system in the university atmosphere of the medical school and hospital was a significant innovation and was undoubtedly an important factor in making Johns Hopkins a strong influence in American medicine. First the hospital and then the medical school with superior endowment, program, faculty, and facilities for educating doctors not only to practice but also to teach, came into being just at the right time in the cultural, economic, and scientific growth of the United States. The 55

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opening of the medical school was part of a great awakening with which came the realization that medical education would have to be improved and that doctors with superior training were needed for this purpose. In the early days of the medical school, Hopkins men began to fill important teaching posts all over the country and had much influence in spreading the university spirit to many medical schools and hospitals. The influence of Johns Hopkins on the great changes in medical education at the turn of the twentieth century was largely owing to the leadership of two men—one the statesman, the other his ambassador—William H. Welch and Abraham Flexner. Dr. Welch earned the nickname of "Popsy" in the early days of the Johns Hopkins Medical School, as he was generally recognized as the father of the community as well as the dean of the medical faculty, but before his career ended he was "Popsy" to the entire medical America. No medical man has ever been given such world-wide acclaim as that given to "Popsy" Welch on his eightieth birthday. This acclaim was not centered around his career as a scientist or as a practitioner of medicine, but as "our greatest statesman in the field of public health," as President Herbert Hoover declared him to be. His great contributions were to American society as a whole, for, more than any one else, he stimulated the public's appreciation of medicine through his wise leadership in medical education, public health, and medical organization. He was most influential in raising the quality of American medicine and in improving its relations with the public. The citation written anonymously for Welch's eightieth birthday celebration, said to be by Harvey Cushing, sums up in beautiful language the meaning of his life: "To have stepped, in the prime of life, into a position of acknowledged intellectual leadership in the profession of his choice; to have occupied that position, albeit unconsciously, for those forty years which have seen the most rapid strides in medical progress of all time; to have had such influence in the furtherance of the medical sciences in this country as to turn the tide of students seeking opportunities for higher education from the Old World to the New; to have been as ready in countless unrecorded ways to share his time and thought with those who were inconspicuous as with those who sat in high places; to have been no less universally respected for his great learning than beloved for his personal charm and companionability; to have stood knee-deep in honors unsought and 56

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to have remained seemingly unaware of them; to have rounded out with distinction two successive university positions and, with enthusiasm undimmed, to be now well launched on a third which he is no less certain to adorn—to have done so much, in so many ways, for so many years, and to have aroused no shadow of envy or enmity on the way, betokens not only unselfishness of purpose but that fineness of character which always has been and always will be an inspiration to mankind." Dr. Welch's national significance is indicated by his election to the presidency of no less than fifteen important national associations, including the American Medical Association, the National Academy of Sciences, the Association for the Advancement of Science, and the Association of American Physicians. For many years Welch was called as adviser, counsellor, stimulator, and statesman in almost every advancement, reorganization, or development of medical schools in this country. He was sought as the principal speaker on innumerable occasions and carried the message of university medical education as developed at Johns Hopkins to all parts of the country. In medical education Welch was in reality the champion of the ideas formulated by Billings on the foundations created by Gilman. He not only developed these ideas over the years in Baltimore, but more than any one else he explained their meaning and encouraged their adoption throughout the United States. The influence of Johns Hopkins was further extended by Abraham Flexner. Flexner looked upon Dr. Welch as the high priest of the temple of medical learning. He took the Johns Hopkins Medical School as the standard of excellence by which all others should be measured when he made the study of American medical schools on which his famous report was based. This report played such an important part in reforming medical education in this country that it deserves more than passing notice. The report* had a tremendous effect on medical education and it is often spoken of as initiating the modern era. The Flexner

Report

In 1908 when Flexner was asked by Henry S. Pritchett, president of the Carnegie Foundation, to undertake the study of * Abraham Flexner. Medical Education in the United States and Canada. Bulletin Number Four. New York: The Carnegie Foundation for the Advancement of Teaching, 1910. 57

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American medical schools he had had no training in medicine, but had studied extensively the principles and practice of education. Pritchett was concerned primarily with the educational status of medical schools and their correlation with the general program of American education, and for the study of this problem Flexner was eminently well qualified. He had been a college student in the Johns Hopkins University and had great admiration for Gilman and Welch; his brother Simon had been a member of the Hopkins medical faculty. It was therefore natural that Flexner should first go to the Hopkins to learn what a medical school looked like from the inside. The report, with its farreaching results, was the culminating event of an educational revolution in medicine never before witnessed in American education. The effects of the report were manifested not only by the elimination of innumerable medical schools too poor to stand the light Flexner turned upon them, but by the marked improvements in the schools able to survive. Flexner not only criticized, but also presented a comprehensive plan for the development of medical education to meet the demands of American society for good physicians and to provide for the teaching of the rapidly expanding medical sciences that overwhelmed the old proprietary schools. In so doing he demonstrated the urgent need for greater financial support of medical instruction and research and called the attention of a number of potential benefactors to the advantages of philanthropic investments in the support of medicine. Up to the beginning of the present century this thought had not been presented to benefactors, and the movement initiated by Flexner and Welch was so effective that over $500,000,000 were given to medical education and research by private donors during the twenty-five years following 1910. Flexner may be said to have been a remarkable salesman of the goods which Welch had to offer, and as such he had an enormous influence in pointing out the way medicine should be led by education and research. An introduction by Henry S. Pritchett to the Flexner report summarizes the findings and defines the hoped-for results. The study was undertaken by the Carnegie Foundation to clarify the situation that existed in 1908 regarding the relation of medical schools to colleges and universities. It was primarily an educational problem to be studied by an educator. Medical knowledge was increasing rapidly, and the existing schools were as a rule unable to cope with its fast development. Therefore, the study 58

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was urgently needed, and no effort was spared to produce accurate and detailed information as to the facilities, resources, and methods of instruction in 155 medical schools in the United States and Canada which Flexner visited. The condition of medical education tended "not only to commercialize the process of education itself, but also to obscure in the minds of the public any discrimination between the well-trained physician and the physician who has had no adequate training whatsoever." Public understanding was much needed regarding this important educational service. Pritchett pointed out that the study had revealed an enormous over-production of uneducated and ill-trained physicians, owing mainly to the very large number of commercial schools that admitted a mass of unprepared youths. Nearly half the schools had an annual income below $10,000, and were practically dependent on students' fees for their support. Universities and colleges failed to recognize the cost of teaching medicine properly, and had annexed medical schools without adequate provision for their maintenance. Hospital facilities necessary for clinical teaching were also largely lacking. Pritchett stated: "In view of these facts, progress for the future would seem to require a very much smaller number of medical schools, better equipped and better conducted than our schools now as a rule are . . ." and he expressed the opinion that fewer and better educated physicians were a great public need, and that medical schools should be articulated not only with universities but also with the general system of education. He called for an improved attitude of the medical profession toward standards of practice requiring educational and medical patriotism and asked that public opinion demand well-trained practitioners to be determined by law. He closed his strong statement with words that were prophetic: "It is hoped . . . that this publication may serve as a starting-point both for the intelligent citizen and for the medical practitioner in a new national effort to strengthen the medical profession and rightly to relate medical education to the general system of schools of our nation." This hope was fulfilled to a remarkable degree. Flexner's report began with a historical survey in which he discussed how medical education fell from its fine beginning at the end of the eighteenth century to a low level when the medical schools became commercial and students' fees were their sole support. He wrote: "In the wave of commercial exploitation 59

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which swept the entire profession so far as medical education is concerned, the original university departments were practically torn from their moorings." As the science of medicine developed, the medical schools had a different function to perform and it "took them upwards of half a century to wake up to the fact." It was in this spirit that Flexner travelled from school to school, gathering details regarding their standards and methods, and comparing them, at least in his mind, with those of Johns Hopkins. Flexner's report includes a detailed account of every medical school in the country. He was impressed by the very low educational requirements for admission into the majority of the schools and by the great overcrowding of students, many of whom were not prepared to pass the examinations for admission into the majority of standard colleges as undergraduate students. He advocated at least two years of college work, including chemistry, biology, and physics, as the minimum requirements for the study of medicine, and discussed the great extension of medical knowledge and the development of technique which could not be covered by the poorer schools. He found that only 22 of the existing medical schools required two or more years of college training, about 50 required high school graduation only, which left approximately 80 schools without a well-defined or strictly administered educational standard for the admission of students. Besides pointing out the defects in many schools, Flexner gave a comprehensive discussion of the essentials of good teaching, emphasizing the importance of the scientific spirit and the great value of research in keeping the schools alive and in promoting the progress of medicine. He pointed out the urgent need of medical education for financial support, without which the necessary improvements could not be made, and advocated the development of the requisite number of properly supported medical schools and the speedy demise of all others. The fact that 120-odd schools out of 155 were almost entirely dependent on students' fees for financial support indicated the magnitude of the reform he proposed. Flexner laid down a program for the reconstruction of medical education. He estimated that 30 medical schools of 300 students each, operating in various regions, would meet the present needs of this country and that about 120 schools should cease to exist. He argued that "practically the medical school is a 60

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public service corporation. It is chartered by the state; it utilizes public hospitals on the ground of the social nature of its service. The medical school cannot then escape social criticism and regulation. It was left to itself while society knew ho better. But civilization consists in the legal registration of gains won by science and experience; and science and experience have together established the terms upon which medicine can be most useful." Abraham Flexner's report is of great importance because of the changes it produced in medical education. Backed by the American Medical Association and its Council on Medical Education and Hospitals, the medical profession was forced to adopt a new attitude. The whole atmosphere of medical education in this country seemed to change. The poorest schools soon gave up, some of the better ones consolidated, and some of the universities were rudely awakened and saw that they could no longer fail to take responsible control over medical schools that bore their names. People of wealth, as individuals or through foundations, began to make bountiful provisions for medical education on a new scale. There is a striking difference between the situation in 1910 when 155 medical schools existed, largely unendowed and differing greatly in standards of proficiency, and the situation in 1956 as indicated by the report of that year of the Council on Medical Education and Hospitals of the American Medical Association. That report listed 76 four-year medical schools in the United States and 11 in Canada that were approved by the American Medical Association. Nearly every one formed an integral part of an important university; all required three or four years of collegiate study for admission; and they expended, together with 6 schools of basic medical sciences, approximately $178,000,000 a year, of which $111,000,000 were basic budgeted funds and appropriations and $67,000,000 were research and teaching grants from outside sources. The schoolteacher, Abraham Flexner, who played a conspicuous part in the great reform of medical education never returned to the schoolroom. After making a study of medical education in Europe published as Bulletin Number Six of the Carnegie Foundation and, I dare say, spending some of his time defending his American report, he became assistant secretary of the General Education Board in 1912 and later its secretary. For sixteen years, until his resignation from the Board in 1928, Flexner was 61

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a leading figure in the study of the needs and ways of advancing medical education in this country. His influence was great as, through his incomparable nationwide experience and knowledge, he was able to determine wisely where improvements should be made in the standards of education. He became the principal adviser in regard to the way in which great sums of money might best be expended for medical education, not only by the Board of which he was secretary, but also by some of the leading philanthropists of his time. The General Education Board, created by John D. Rockefeller, expended a large part of its resources in assisting medical schools because Abraham Flexner and other of Mr. Rockefeller's advisers became convinced that the major needs for the welfare of this country lay in medical education and research. This led to the magnificent support of medicine by the Rockefeller fortune. The Johns Hopkins Medical School educated Abraham Flexner regarding the educational standards American medical schools should strive to attain, and he, in turn, held up this medical school as the example of what such an institution should be. It is therefore fair to say that Welch and Flexner collaborated as the outstanding leaders in the revolution of American medical education. This revolution had its inception in the development of the Johns Hopkins Medical School and Hospital and generated the "Heroic Age of American Medicine" in which my adventures in medical education occurred.

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H O S P I T A L internship was a problem facing the senior medical students—a problem which was not settled in my - day until a few weeks before graduation. There was excitement in the air at the medical school when the time came in March or April for the announcement of the academic standing of the students in the graduating class. The four students with the highest standing had first choice of the internships in the Johns Hopkins Hospital, and usually chose the medical service under Osier. The next four were likely to choose the surgical service under Halsted. There were four internships in obstetrics and gynecology and several appointments in pathology or in special services, so that about sixteen students at the top of the class of fifty had the opportunity of serving an internship in the Johns Hopkins Hospital. This was the first step toward the long and thorough postgraduate training on the resident staff which offered the best hospital service in this country at that time. For that reason a Hopkins internship was especially desirable and the prospect of obtaining one after graduation was a constant incentive for good scholarship and hard work.

A

The Problem of Hospital Internship When the standing of the members of my class was announced, I was disappointed to find myself in the middle of the class, just one place below the last man on the list who wanted a Hopkins internship. I therefore went to New York to take the competitive examinations f o r an internship at the New York Hospital and at St. Luke's. Here again I failed by a narrow margin. A t the New York Hospital I was offered an internship on the private 63

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patient service, which I declined; at St. Luke's I was the first alternate and would be appointed only if a successful candidate should decline an appointment, which no one did. With a feeling of frustration, I inquired of my friend Warfield Longcope, then the resident pathologist at the Pennsylvania Hospital in Philadelphia, if I would have any chance of getting an internship there. From his reply I gathered that as I was a Quaker I might have a chance. So my next step was to apply for an internship there. The Pennsylvania Hospital had a long-standing custom of appointing one resident physician every three months for a twoyear service, and although I learned that there were several wellentrenched candidates for the next appointment, I decided to try my luck. It was necessary for candidates to call on each of the twelve hospital managers, and as these calls were usually made at their homes in the suburbs of Philadelphia, several days and considerable planning were required. With the advice of a rival candidate, I managed to carry out this ordeal and met an impressive group of prominent citizens who seemed to take much interest in the young men aspiring to appointments at the hospital. I was encouraged by the president of the board of managers, who, seeing the Canby in my name, said that he and I were relatives. More emphasis was placed on general qualifications in Philadelphia than in New York, where a two-day examination of medical knowledge was given by the hospital staff. Although the method of appointing residents at the Pennsylvania Hospital had the disadvantage of seeming to favor Philadelphians, it worked well toward the selection of men of superior cultural and educational background and tended to keep up the line of some of the famous families of physicians on the hospital staff. I was accepted as a qualified candidate and was told that I should serve as a substitute on the resident staff for two weeks during the following summer. Realizing that it would be a number of months before I could get an appointment at the Pennsylvania Hospital, I accepted the proposal of Dr. Martin B. Tinker to be his assistant at the Clifton Springs Sanitarium in the Finger Lakes district of New York. He was about to leave the Hopkins surgical staff to inaugurate a surgical service at the sanitarium, and I left Baltimore the day after I graduated to join him there. Martin Tinker 64

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was a man of sterling character, a broadly trained surgeon and a splendid example and teacher for a beginner in medicine. He had taken a medical degree at the Jefferson Medical College in 1893 and also at the University of Berlin in 1899. In between he had taught hygiene and physiology at Harvard, where he had taken a B.S. degree, and had taught anatomy and surgery at Jefferson. My association with him during the summer of 1903 was a valuable and happy experience. The Clifton Springs Sanitarium occupied a large hotel-like building accommodating two hundred or more patients. It stood beside a sulphur spring that was supposed to be medicinally beneficial and whichfilledthe air with a mild odor of rotten eggs. A fervent religious spirit pervaded the sanitarium, an important therapeutic adjunct for some of the patients, but the medical standards were at that time somewhat antiquated. A few years later the medical service was much improved when Charles P. Emerson became the medical superintendent and added several well-trained young men to the staff. At Clifton Springs I assisted Dr. Tinker with his surgical operations and acted as his anesthetist, worked in the clinical laboratory, and had charge of a few medical patients. The first patient assigned to me was a delightful old lady from Philadelphia, who informed me as soon as I had introduced myself, that I was her fifty-first doctor. I did not tell her that she was my first patient, but this situation was a bit startling, to say the least, to a medical neophyte. However, we became good friends and her accounts of experiences with some of the leaders of the medical profession were instructive. Toward the end of the summer, after I had spent two exciting weeks as a substitute on the resident staff at the Pennsylvania Hospital, I accepted an appointment to teach anatomy in the Ithaca division of the Cornell University Medical College. As I had planned to stay with Dr. Tinker only during the summer, this seemed to be another favorable opportunity to fill the time before an internship at the Pennsylvania Hospital would be obtainable. The professor of anatomy at Cornell, Abram T. Kerr, had known me as a first-year medical student when he was making a study of the nerves of the skin at the Hopkins. In September I went to Ithaca with an appointment as assistant demonstrator in anatomy, the bottom rung of the academic ladder, at a salary commensurate with that position. 65

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About two months after arriving at Cornell, I was asked by Warfield Longcope to come to the Pennsylvania Hospital as his assistant in pathology. He had recently been made director of the Ayer Clinical Laboratory at the hospital, replacing Simon Flexner, its former director, who had been called from his professorship at the University of Pennsylvania to organize and direct the Rockefeller Institute for Medical Research in New York. Knowing my interest in pathology and that I was aiming at a residency in the Pennsylvania Hospital, Longcope offered me the appointment as his assistant. I was elated by this offer and gladly accepted, but we arranged that I was to remain at Cornell until the end of January, when the heaviest teaching load in anatomy would be completed. The half year at Ithaca was very pleasant and profitable; I enjoyed greatly my associations with Dr. Kerr and with the staff of the medical school, and my association with my old college fraternity, Alpha Delta Phi, was also pleasant. I dined at the fraternity house each evening and had interesting contacts with a number of university activities. The Pennsylvania

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I arrived in Philadelphia on February 1, 1904, to begin my work as assistant pathologist of the Pennsylvania Hospital under Longcope. He had been my senior by two years both in the college and in the medical school at Johns Hopkins, and we were old friends. He was a splendid student of medicine with a fine cultural and medical background, being a direct descendant of Nathan Smith, the illustrious pioneer in medical education, and of his son Nathan Ryno Smith, the eminent teacher of surgery and leader in the University of Maryland. Longcope's great-uncle, Alan P. Smith, had been the last physician of Mr. Johns Hopkins, who had selected him as one of the original trustees of the Johns Hopkins Hospital. Longcope had carried on the family traditions very well, attaining a much respected place in the Pennsylvania Hospital and in Philadelphia, and he was later to achieve high academic honors. I was indeed fortunate in having the opportunity of working in pathology with him under very favorable and congenial conditions, and I soon realized that my earlier disappointments in securing an internship were in reality strokes of good luck. The Pennsylvania Hospital has a long and honorable history 66

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which has been interestingly told by Dr. Francis R. Packard.* It is the oldest hospital (in the modern sense of that word) in what is now the United States, its charter having been granted by the Assembly of the Province of Pennsylvania on May 11, 1751. The need for a hospital at the time, when Philadelphia with its 15,000 inhabitants was one of the richest and largest cities in the British colonies, was first recognized by Dr. Thomas Bond, who aroused interest for the support of this project. He soon found it necessary to have the backing of Philadelphia's leading citizen, Benjamin Franklin, before he could secure the support of other important people of the town. Franklin not only gave his enthusiastic support to Bond's plan, but with his remarkable sagacity and energy became the leading figure in financing, organizing, and conducting the affairs of the hospital. He was the first clerk of the board of managers, and its early proceedings are recorded in his handwriting. The hospital was opened in temporary quarters in 1752, and the first building of the present hospital at Eighth and Spruce Streets was constructed in 1755. The cornerstone bears the following inscription composed by Franklin: In the Year of Christ MDCCLV. George the Second Happily Reigning (For he sought the Happiness of his People) Philadelphia Flourishing (For its Inhabitants were Publick Spirited) This Building By the Bounty of the Government, And of Many Private Persons Was Piously Founded For the Relief of the Sick and Miserable: May the God of Mercies Bless the Undertaking. It is a remarkable composition, with its expression of good will to the British Crown, its reminder to the government and to the public of their responsibilities toward the sick and miserable, * Francis R. Packard. Some Account of the Pennsylvania Hospital of Philadelphia from 1751 to 1938. Philadelphia: The Pennsylvania Hospital, 1938. 67

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and its invocation of Divine Blessing, expressed in so few words. A wit in later years remarked upon its appropriateness by saying that the inscription began with an M.D. and ended with an undertaker. The building for which the cornerstone was laid, the east wing, was still giving excellent service when I was there, being used as the men's medical ward containing about seventy beds. The interior was ultimately reconstructed in 1955, when the building was two hundred years old. The old part of the hospital facing Pine Street toward the south is a beautiful example of colonial architecture. It was built in several stages as funds were secured, and was completed in November 1796. The hospital admitted "the insane" as well as medical and surgical patients until 1841 when a new hospital for "the insane" was built in what was then country, west of Philadelphia. The original building consists of a central portion with the east and west wings at each end. On the third floor of the central building, the first surgical amphitheater in America was built in 1804, and the renowned Philip Syng Physick, known as the father of American surgery, began there to operate before students. Packard tells a story of Physick's successful removal of a huge tumor from the head and neck of a man in 1805 which created so much interest that it was reported with the patient's name in Paulson's American Daily Advertizer, the public press of that day. The tumor was preserved as a museum specimen and in 1924, one hundred and twenty years later, it was examined microscopically by Dr. John R. Paul, the hospital pathologist, who found it to be a mixed tumor of the parotid gland. As Dr. Packard remarks, this must establish a record for the length of time in the return of a report from a laboratory—and without complaint from the surgeon. Eventually bedrooms for the resident staff were built around the old amphitheater, and where formal American surgical teaching had its birth, there was a sitting room for the house staff in which at times some rather noisy parties took place. In 1773 medical apprentices (medical students) were first received into the hospital, but in 1824 the system was begun of having recently graduated physicians live in the hospital. One of my fellow residents, George Crampton, long since a prominent Philadelphia ophthalmologist, had a brass name plate made for every resident up to our time, and put them up on the wall of 68

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the old amphitheater. Thereafter, it became the custom for each resident to have his own name plate made, to mark his room while he was at the hospital and to be added to the collection when he finished his resident service. Thus, there are on the walls of the first surgical amphitheater in America the names of every resident physician of the hospital since 1824. On the second floor of the central building is the hospital library, one of the most notable medical sanctuaries in America. It was begun by the gift of a book from John Fothergill, the distinguished Quaker physician of London, who took much interest in the development of medicine in the American colonies and befriended the early American medical students in London. The book, An Experimental History of the Materia Medica, was sent as a present to the hospital in 1762 "for the Benefitt of the Young Students in Physic who may attend under the Direction of the Physicians." The library, much grown since then, occupies a large, impressive room extending all across the front of the building. Besides the collection of books, which includes some rare and precious specimens, the library contains a number of interesting mementos of early American and European medicine. On the wall outside, on either side of the library door, hang two portraits I never ceased to admire of that preeminent physician Benjamin Rush and of Samuel Coates, the president of the board of managers for many years. Both were painted by Thomas Sully in 1813 and are thought to be among the best paintings of that distinguished American artist. The Pennsylvania Hospital has many possessions and traditions handed down from the early days of American medicine that indicate the hospital's rich medical heritage and create the atmosphere in which the medical staff lives and works. The hospital was greatly enlarged and modernized in 1893, when the surgical wards were built along the northern side of its property facing Spruce Street. In 1897 the Garrett building was opened, providing a receiving ward, surgical amphitheater, children's surgical ward, and other modern hospital facilities. The hospital contained about three hundred beds when I was there and except for about thirty private rooms, all were in the wards to which any patient was admitted entirely free of charge. The Ayer Clinical Laboratory was built in 1899, adjoining the medical wards. It occupied a small separate building providing well-planned space on the first floor for the autopsy room, 69

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the morgue, and offices; on the second floor were chemical, bacteriological, and pathological laboratories, with facilities f o r routine laboratory work and f o r research. In the basement was a museum containing in its cases and cupboards a valuable collection of specimens accumulated over many years. The laboratory staff consisted of the director, the assistant pathologist, and a resident physician who spent the first three months of his regular service there. There were two men who kept records, assisted at the autopsies, and were generally useful, and there was a technician who prepared sections f o r microscopic examinations and carried out other technical procedures. The man in charge of the building, George Freis, was a well-known character in the hospital; he had been there f o r fifty years, ever since, as a young German sailor, he had been admitted with both legs fractured. He left behind him, when he retired in 1907, not only a fine record of long service but also several volumes in which he had meticulously written with perfect penmanship descriptions of all the autopsies performed since the laboratory opened. Besides the staff there were usually several volunteer workers in the laboratory, some of whom accomplished pieces of very acceptable research. The resident staff of the hospital in my day was small and intimate. W e had our meals together at one large table, presided over by Miss Martha G. Byerly, the matron of the hospital and a pioneer in hospital dietetics. W e often gathered in her sitting room after dinner f o r friendly talk, and she did much toward creating the cordial relations that pervaded the hospital. This comradeship among the residents had great professional advantages, as it allowed everyone to hear about and to see any case of unusual interest anywhere in the hospital. It was especially valuable f o r the laboratory staff to be able to see and study special cases on the wards, as it gave us an uncommon opportunity to correlate symptoms and signs of living patients with post-mortem findings as revealed by the autopsies in the laboratory. It would be hard to find in any hospital better opportunities than ours f o r the correlation of pathological and clinical study so essential f o r the training of the doctor. The A y e r family, which had contributed the funds to build and maintain the laboratory, made a special g i f t to the hospital in 1901 for the support of the Bulletin of the Ayer Clinical Laboratory. This g i f t not only afforded a means of publishing work 70

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of scientific interest carried on in the hospital, but served as an incentive to conduct special studies and stimulated an interest in medical research. The Bulletin, published once or twice a year, contained the first of Longcope's important studies of Hodgkin's disease and a number of papers by some of the visitors who worked in the laboratory from time to time. I published two papers on heart disease in the Bulletin, and three studies on bacteriology, one on typhoid fever (then a very prevalent disease), and two on meningitis. I became interested in the museum of the laboratory which contained many rare specimens, some of unusual historic importance. I undertook to review and arrange the specimens and to revive the catalogue of the museum. This was the work of many evenings in which George Crampton, one of the residents, joined me. It was a very interesting and educational project and led to at least two exciting findings. The first was a specimen of a heart in which there was a tumor in the region of the bundle of His. My interest in this part of the heart had recently been aroused by the work of Joseph Erlanger, then at Johns Hopkins, who demonstrated that when a clamp was applied on this structure in the heart of a dog, the cardiac rhythm was much disturbed and the heart rate markedly slowed. The heart in our museum was that of a patient who had died in the hospital in 1879. His clinical record showed that he was a typical example of the well-known Adams-Stokes syndrome, marked by periods of unconsciousness and excessively slow heart beat, the cause of which was unknown at that time. The clinical record, written over twenty-five years before, gave an excellent description of an unconscious spell of the patient and of a pulse rate of eleven beats per minute at the end. The patient had undoubtedly suffered from what was called "heart block," of which only one or two cases had been described since Erlanger's work had revived interest in this condition. The case was reported in the Bulletin and attracted the attention of Professor Friedrich Müller of Munich, so that when he visited the Pennsylvania Hospital, he asked me to come to Munich and work in his clinic. This gave me the idea of going to Germany for study, which I did after finishing my hospital service. The other exciting finding in the museum was a number of framed, colored anatomical and obstetrical drawings and plaster casts which had been hidden away in cupboards and which aston71

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ished and delighted me as I took them out. I had a feeling of awe and reverence when I discovered that I had unearthed one of the greatest relics of early American medical teaching—the famous collection sent by Dr. John Fothergill of London to the Pennsylvania Hospital in 1762. These pictures and casts were first used by William Shippen, Jr., when he began his private lectures, which preceded the founding of the first American medical school by John Morgan in 1765, in association with Shippen. There is a long story about these truly beautiful pictures and casts, told by Krumbhaar* in his history of the early teaching of anatomy in this country, in which a number of the pictures are reproduced. They are now preserved in the library of the hospital and although the drawings were done in crayon, Dr. Packard reported in 1938 that the pictures had retained their bright colors and were as beautiful as when they were first drawn. During the summer of 1905, I was asked to take care of a young man with exophthalmic goiter while he had a rest cure on board the family yacht. Having obtained a competent young doctor to substitute for me in the laboratory, I spent ten weeks cruising leisurely up the Atlantic coast to Maine and back. As during the cruise several serious medical problems had to be faced without consultants, it proved to be a valuable experience and was sufficiently remunerative to give me a good start toward financing my future year of study in Europe. After two and a half years in the laboratory of the hospital, I was appointed a resident physician beginning on July 1, 1906. The service of the resident physician was progressive, changing every three months for two years. It started with three months in the laboratory, nine months on the three medical wards, three months principally on the ambulance, six months on the two surgical wards, and the final three months in charge of the receiving ward. There were eleven doctors living in the hospital: eight going through the service, the chief resident, his assistant, and the resident pathologist. The visiting staff consisted of six physicians (two on service for four months each) and four surgeons (two on service for six months each). There were two or three assistant visiting surgeons and a few surgical specialists. The * Edward B. Krumbhaar. "The Early History of Anatomy in the United States." Annals of Medical History 4:271, 1922. 72

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visiting physicians were James Tyson and Alfred Stengel, then the senior and junior professors of the University of Pennsylvania; James C. Wilson, professor of medicine at the Jefferson Medical College; Arthur V. Meigs, a member of a distinguished Pennsylvania Hospital family; Morris J. Lewis; and J. Alison Scott. The surgeons were Richard H. Harte, Robert G. Le Conte, John H. Gibbon, and James P. Hutchinson. On the medical wards, where my greater interest lay, the resident had charge of about thirty-five patients and was responsible for all medical procedures except the routine laboratory work. The visiting physicians spent only an hour or two a day on each ward, and the chief resident came to see patients only when called. The residents literally lived with their patients —taking their histories, making all examinations, and directing their treatment, the diagnosis and treatment of each case being checked by the experienced visiting physician. This is a very different situation from that existing in the modern, highly organized medical clinic, with its large house staff, various specialists, and perfected organization under a single physician-inchief acting as director of the service. However, the conditions at the Pennsylvania Hospital fifty years ago were ideal for the direct study of patients and provided unusual opportunities for developing self-reliance and medical responsibility. The medical patients were mostly cases of acute disease and had as a rule serious conditions. In the summer many of them suffered from typhoid fever which was still prevalent in Philadelphia. In spite of heavy duties on the medical service, I found time for carrying on special studies and published one paper on gallop rhythm of the heart studied by the best graphic methods we had in the days before the electrocardiograph, and another on blood pressure in meningitis. The three months on the ambulance, which followed nine months of medical service, meant being ready to go out day or night in the one-horse ambulance driven by Dick Howard, whose years of experience were most helpful to neophytes. Many episodes on the ambulance service can be recalled—both serious and amusing. Among the latter, I remember a call one evening to a fire. Harry Dillard, a fellow-resident, went along. We drove up a narrow street to a safe distance from a blazing warehouse and had just taken our stand when the Jefferson Hospital ambulance drove by us and stopped nearer the burning building. We 73

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knew we had a rival, and in a few minutes an unconscious fireman, overcome by smoke, was carried out. The Jefferson boys immediately rushed back to their ambulance for a stretcher while Dillard and I ran in, picked up the burly fireman fore and aft, and carried him down the street, meeting the chagrined Jeffersonians on their way back with a stretcher. Although we, in white ducks, were covered with soot, we triumphantly drove off with the victim to our hospital and felt that we had scored a notable victory. On the surgical service of the hospital, the residents did surgical dressings, assisted at operations, and gave anesthetics, besides running the surgical wards. Every now and then the residents would perform operations under the supervision of the attending surgeon, the number depending on the surgical aspirations of the resident. In the final service, on the receiving ward, a great variety of medical problems were encountered, as there, practically all patients admitted to the hospital were first seen, and emergency cases were treated. It was presided over by Miss Lyle, a nurse with years of experience in meeting emergencies, who taught us many useful things that doctors sometimes need to do in a hurry. When, as frequently occurred, a patient who had swallowed poison was hurried in by the police, it would be only a minute or two before Miss Lyle would have everything ready for the doctor to pass the stomach tube. A resident was always on duty in the receiving ward, as one of us slept there every night. Some of the receiving ward episodes were unforgettable lessons and come vividly to mind even after fifty years. I recall that three horse-drawn police wagons rushed in eighteen stevedores who had been injured by an explosion in the hold of a ship and who were full of nails. It turned out that the explosion had burst kegs of nails and sent them flying at the stevedores. The first thing Miss Lyle did was to pass around a drink of whiskey to each of the frightened and injured men, as a prelude to the task of getting out the nails, which had caused severe injuries to some of the men. Another surprising and amusing case was that of a man who came in one snowy winter evening with a lacerated hand and said that an elephant had bitten him. That raised suspicions, but the man was found to be sober and serious, and explained that he had been bitten while feeding a circus elephant in winter quarters near the hospital. This case was added to bites 74 v

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by dogs, cats, a parrot, a snake, and an owl, which made up the collection I treated in the receiving ward. I had a break during my surgical service which took me on my first trip to Europe. One of the attending surgeons had advised the patient with exophthalmic goiter whom I had looked after on the summer yachting trip, to have his thyroid removed by Theodor Kocher, the world's leading thyroid surgeon. The attending surgeon asked me to accompany the patient and his family to Kocher's clinic in Bern, Switzerland, and arranged for my leave of absence from the hospital. In the autumn of 1907 I spent five weeks in Switzerland, where I had interesting contacts with Kocher and met some of the members of the distinguished Bern faculty, including Sahli in medicine, Kronecker in physiology, and Langerhans in pathology. After spending two weeks on beautiful Lake Geneva, resplendent in autumn colors, while my patient was making a successful convalescence, I returned to Philadelphia and finished my service at the hospital on July 1,1908. The four and a half years at the Pennsylvania Hospital were filled with splendid opportunities for the study of medicine, with cherished friendships, and with many valuable and happy experiences. The sentiments of a Pennsylvania Hospital resident were well expressed by Packard when he wrote: "There are few physicians who do not look back with fond remembrance on the years and the place in which they passed their hospital interneship, years full of their first real contact with the practical duties of their profession, with plenty of clinical and pathological material for study under the guidance and aid of able and experienced seniors, and the pleasant intimacy of their fellow internes. When with these advantages their residency is passed in a hospital which offers every modern facility and yet is redolent of such memories and traditions as few, if any, institutions in this country possess, the sentimental attachment of former residents to the Pennsylvania Hospital can be readily understood." Munich

On July 8, 1908, I sailed from Baltimore for Germany and spent three months in Hanover, in the pension of Frau Major Behrens, a widow with a spinster daughter. My purpose in staying in Hanover was to improve my German before going on to Munich, and I worked hard at it with a good teacher. Fraulein 75

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Behrens was very helpful, as she awakened my interest in German history, culture, and politics, and guided the household of four or five American and English students on excursions to the charming medieval towns of Goslar and Hildesheim and on a walking trip in the Harz Mountains. It was a valuable introduction to Germany and stimulated my interest in the German people, their music, history, and traditions. In October 1908 I went to Munich to work in the clinic of Professor Friedrich Müller. His clinic in the "Allgemeines Krankenhaus" consisted of three hundred ward beds; an outpatient department; laboratories for chemical, physiological, and bacteriological research; a division for experimental work on animals; and a very useful though small library containing all the important reference books and most of the leading medical journals. Müller had nine highly trained assistants, who had charge not only of about fifty ward patients each, but also of the various laboratories, where they worked with a number of special students, several of whom were Americans. Some of these assistants were on their way to university professorships, and they were an interesting and stimulating group with whom to be associated. Müller was then in his prime as the foremost professor of medicine in Germany. Being a Bavarian, he felt at home in Munich and had recently declined professorial calls to Berlin and Vienna. I was much impressed by his clinical lectures, which he gave every morning at nine o'clock before about two hundred students who crowded his auditorium. Each lecture began with the presentation of a patient who served as the focal point of the discussion to follow. After the medical history had been read, the diagnosis was often announced, and an examination of the patient including the demonstration of physical signs, the simpler laboratory tests, and instrumental examinations, was made by the professor or an assistant before the class. A projection lantern, charts, drawings, and diagrams were freely used, and the students were given as complete and clear a description of the case as possible. Treatment was always discussed, and recent contributions of pharmacology were sometimes explained. The best feature of Müller's teaching was the prominent place he gave to pathology, a field in which he had thorough training. Many of the specimens shown to illustrate bodily changes caused by the disease under discussion were from cases he himself had 76

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studied both clinically and anatomically, and he spoke of them with reassuring certainty. Bacteriology was also brought into close relation to the study of patients, and in this field also Müller showed intimate firsthand knowledge of laboratory methods. Müller's teaching was done with an intensity of manner which was comparable with the intensity of work with which his life had been filled. He always had a thorough understanding and detailed knowledge of the disease illustrated by the case presented. He seemed to know just what points he wished to emphasize and did it in a masterly way, at times approaching the dramatic. The sincerity and directness of his teaching were very stimulating. Müller's lectures made one feel that he was a great teacher because they were based on his incessant, broad, and intense study of internal medicine and its allied sciences. His teaching went far beyond his lectures to undergraduate medical students, for it included the direction of advanced students in various fields of study and research. This necessitated not only a thorough knowledge of present-day medicine but an ability to see future possibilities, so that promising problems for investigation could be suggested and the most likely methods of solution advised. His knowledge of the various branches of the medical sciences was such that he knew when one branch might borrow from another, and he was able to coordinate many fields successfully. Müller's clinic represented an outstanding example of the true university spirit which bases teaching primarily on research. The clinical lecture was the core of medical instruction, and the opportunity to learn by hearing and seeing was developed to its highest degree. However, this method had one fault: the chance to learn from doing—so well practiced in British medical schools, and, more recently, so extensively developed in America —was seldom available to Müller's students. As soon as I was settled in Munich the question was: "how could I carry on some work of my own in the clinic?" I had been given a place in the physiological laboratory, and a kymograph by which graphic records of the circulation could be made had been put at my disposal. Professor Müller, remembering the studies I had made at the Pennsylvania Hospital, thought this was a field in which I could find my way around. However, after a few days spent in putting the equipment in order, I was quite at sea. 77

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I had seen a young man in a long white coat going about the clinic with trays on which he carried strips of pulse tracings, and he looked like an American. In a few days I met him in the library. I remarked, "I see you are interested in the heart," and his reply was, "Oh, you speak English." He, too, was somewhat lost in the maze of German science, and when I told him that I came from Philadelphia we found we had several mutual friends, as he came from New York. His name was George Draper. We were soon talking about our scientific problems and he asked me to join him, as Müller had given him a problem which needed two workers. It was a study of the "presphygmic period of the heart," of which I had never heard. Draper explained that by graphic methods it should be possible to measure the time between the beginning of the contraction of the heart and the first evidence of the pulse in the artery. The professor thought it would be valuable to devise a method of measuring this period in heart disease, to determine whether it is prolonged when disease has weakened the heart muscle. The ultimate objective would be to develop a method to gauge the functional capacity of the heart. This problem was to be carried on under Ernst Edens, the assistant especially concerned with the heart and circulation and one of the leading German workers in that field. Draper and I spent many hours together on our problem, studying patients on the hospital wards and records in the laboratory. A long paper on the study of the presphygmic period of the heart was published in an American journal. It now seems quite dull and not calculated to advance appreciably the progress of medicine, but it was quite successful from the German academic point of view, which welcomed the addition of new, wellsubstantiated facts regardless of their useful application. A shorter paper on this work was translated into German by Edens and published with the professor's approval in a leading German journal. We thereby met our academic obligation as guests in Müller's clinic by adding one more publication from his department of medicine. Munich before the First World War was indeed one of the most delightful cities in the world, and modern culture there had reached a high level. It represented a remarkable combination of science and art, and there was a widespread participation of young and old, rich and poor, in a simple and joyous way of life 78

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—all the people sharing in the spirit of fellowship known as the Bavarian "Gemütlichkeit." Munich had a great university and famous art galleries, splendid opera and symphony orchestras, jovial beer halls, fine theaters, and beautiful mountains for winter sports. George Draper was a congenial companion, and the week ends usually found us on delightful excursions in the Bavarian Alps. Christmas of 1908 was spent at Garmisch visiting our friends the Hanfstaengels, followed by a two-day walking trip to Innsbruck in Austria, over the beautiful snow-covered Fern Pass. We crossed the Austrian border with only a "Grüss Gott" from the one guard stationed there. We had no passports and did not need them; freedom then was international; the world was at peace, and the peoples of all nations were friends—a striking contrast to the international conditions today. We enjoyed the famous Munich carnival, the six weeks beginning in January when the whole city joined in a festive time, culminating in a great celebration on the day and night before the beginning of Lent. My stay in Germany was an intellectual and cultural awakening for me. The stimulation of the scientific spirit in medicine, the experiences of music and art, the beautiful out-of-doors, and, most of all, meeting and knowing interesting people of many nationalities. I left Munich in May, travelling to Bremen via Hanover to say good-by to my friends there and then stopping in Groningen in northern Holland to visit Karl Friedrich Wenkebach, whose studies of irregularities of the heart beat had greatly interested me. He was then the professor of medicine in the not very wellknown university of Groningen, but his studies of the heart attracted such attention that he was soon called to be professor of medicine in the famous medical school of Vienna. We had an interesting and spirited discussion of our work. I sailed for Baltimore from Bremen on a small North German Lloyd steamer which carried cabin passengers across the Atlantic for $56, a cost that encouraged European study by young Americans in those days. Philadelphia

Again

In June 1909 I at last started to practice medicine, "hanging out my shingle" in Philadelphia in a small house on Fifteenth Street, between Spruce and Pine Streets, where Warfield Longcope and Charles Mitchell of the Pennsylvania Hospital staff took me into their bachelor quarters. 79

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During the first few months, I saw a few "private" patients and assisted some of the older physicians by occasionally visiting their patients in the suburbs and by doing some of their laboratory work. I was appointed clinical pathologist at the Presbyterian Hospital of Philadelphia, which gave me a small income and interesting work. My first assignment there was to construct and equip a clinical laboratory in an abandoned ward, and to provide the facilities required to carry out the clinical tests and examinations that the staff of a general hospital would be likely to call for. I had an opportunity to assist in the teaching in the University of Pennsylvania Medical School, and the outlook seemed promising for getting on in Philadelphia, where I expected to remain permanently. These plans were upset, however, in the spring of 1910 when I was offered the position of resident physician in the new Hospital of the Rockefeller Institute for Medical Research. As this hospital was to open in September of that year, its director, Rufus Cole, was recruiting a group of young men who had shown aptitude in research and who had had good training in the care of patients to form the resident staff of the hospital. He asked me to take the senior position as resident physician, having direct supervision of the care of patients and opportunities for clinical research. This appointment seemed to open the way to an academic career in medicine, in which I was much interested, and I accepted. This brought to an end my brief experience as a private practitioner. Although it lasted only sixteen months, this experience gave me useful insight into the problems young men face when they start out in the practice of medicine.

CHAPTER

IV

THE HOSPITAL OF THE ROCKEFELLER INSTITUTE -< 1 9 1 0 - 1 9 1 3 >-

T

HE founding of the Rockefeller Institute for Medical Research was an important event in the progress of American medicine, its primary purpose being to promote the development of medicine by providing support and facilities for research in the medical sciences. The establishment of the Hospital of the Rockefeller Institute was the second step and represented an expansion of the original program to include the study of disease in patients. The members of the hospital staff, like those working in the laboratories, were to devote their full time to the institute, conducting research and operating the hospital which provided the material for clinical study. There was no other hospital in the world devoted entirely to medical research and the connection of such a hospital with laboratories for the study of the medical sciences was equally unique. Appointment as Resident Physician My acceptance of the appointment to become on September 1, 1910, the senior resident physician of the Hospital of the Rockefeller Institute was an adventure into what was at that time the medical unknown. It meant withdrawing from medical practice and devoting myself exclusively to academic medicine, which was at that time in an insecure (although expanding) condition in America. The proposed plan of operation and program of work were explained to me by Rufus Cole, who had been appointed director 81

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of the hospital. The senior resident physician was to be his righthand man, with responsibility for the general medical care of patients and for organizing and administering the medical service so that the patients received the best possible medical treatment while their diseases were being intensively studied. He was also to have his own field of research. The resident staff was to be composed of young men who had had good hospital training and had shown aptitude for medical research. I accepted the position because the association with Rufus Cole was very attractive and because the scientific and social environment which the plan promised to create would be a happy situation in which to live and work. As I was by this time much interested in an academic career, the thought appealed to me that the position of senior resident physician would probably lead to a desirable academic post when the time came to leave the hospital. The History of the Rockefeller

Institute

The Rockefeller Institute for Medical Research had its origin in the mind of the Reverend Frederick T. Gates, a Baptist minister who had become the principal adviser to John D. Rockefeller in business and philanthropy. His mind was turned to medicine by reading Osier's Principles and Practice of Medicine in the summer of 1897, and his imagination was stirred by the humanitarian possibilities of modern medicine and by its retarded development in America. According to Raymond B. Fosdick,* Gates was fired by the idea that an institution for medical research would be of great value and presented a vigorous statement to Mr. Rockefeller advocating establishment, on a permanent basis, of an institute that would give competent men an opportunity for uninterrupted scientific inquiry in the field of medicine. These views appealed to Mr. Rockefeller, and after careful consideration he made his initial gift of $200,000 in 1901. In the same year the Rockefeller Institute was incorporated, its purposes being set forth in its charter, which states: "The objects of said corporation shall be to conduct, assist and encourage investigations in the sciences and arts of hygiene, medicine and surgery, and allied subjects, in the nature and causes of disease and the * Raymond B. Fosdick. The Story of the Rockefeller Foundation. New York: Harper, 1952. 82

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methods of its prevention and treatment, and to make knowledge relating to these various subjects available for the protection of the health of the public and the improved treatment of disease and injury."* The expenditure of funds was entrusted to the board of directors, composed of such eminent leaders in American medical science as William H. Welch, president; T. Mitchell Prudden, vice president; L. Emmett Holt, secretary; Theobald Smith, Christian A. Herter, Hermann M. Biggs, and Simon Flexner. This organization had the leadership of William H. Welch, who had been a principal adviser regarding its formation; one of his most ardent disciples, Simon Flexner, was appointed director. As Osier's textbook had been the stimulus of the idea in the mind of Gates, as Welch took a large part in bringing the idea of the institute into being, and as Simon Flexner, who had his scientific training at Johns Hopkins was its first director, the Rockefeller Institute may justly be called an offspring of the Johns Hopkins Medical School and Hospital. The institute was inaugurated in a small laboratory in a rented building at 127 East 50th Street, New York City, on October 15, 1904. It was equipped for the study of pathology, physiology, and biochemistry and had a staff, under Flexner's direction, consisting of Samuel J . Meitzer, Eugene L. Opie, Hideyo Noguchi, J. E . Sweet, and P. A. Levene. The results achieved in this first laboratory were so encouraging that Mr. Rockefeller purchased a tract of land at the end of 66th Street, overlooking the East River, and provided additional funds for building and operating a new laboratory which was opened in 1906. The Development of the Hospital In 1908, through the influence of Christian A. Herter, the directors decided that the program of the Rockefeller Institute should include the study of disease in man and that a hospital was needed to facilitate such study. Accepting this idea, Mr. Rockefeller provided funds for a hospital of sixty-nine beds and increased the endowment of the institute to cover the cost of its operation. Rufus Cole was appointed director of the Hospital of the * The Rockefeller Institute for Medical Research: New York, 1953.

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Rockefeller Institute and took a leading part in its development as will be related subsequently. He graduated in medicine from Johns Hopkins in 1899 and was the last resident physician to serve under Osier before the latter departed for Oxford in 1905 and was the first resident physician under Osier's successor, Lewellys F. Barker. Cole was therefore a connecting link between two important periods in the Johns Hopkins school. Barker's appointment represented a significant change in American medicine which deserves to be discussed, especially as it had definite bearing on full-time clinical teaching. The contrast between Osier and Barker was striking; except that they were both Canadians and students at the University of Toronto, in 1870 and 1890, respectively, they belonged to different schools of medicine. Barker's appointment as Osier's successor was symbolic of changes which may be characterized as the intrusion of science into clinical medicine. Osier was a great physician and a preeminent teacher, but he was not an investigator in the present-day sense of the word. He was primarily interested in the manifestations of disease in patients, and his great skill and experience in observing and interpreting these manifestations made him a peerless diagnostician. His statistical method of studying the symptoms and physical signs of disease gave him the special knowledge required to predict the outcome of an illness and made him especially skillful in prognosis. He was not deeply interested in the study of the essential problems of disease requiring prolonged laboratory and experimental investigation; he was concerned with outward manifestations rather than with the broad biological significance of disease. When Barker was appointed to succeed Osier as professor of medicine at Johns Hopkins, he had had little clinical experience but had become distinguished in pathology and anatomy and had been for five years professor of anatomy at the University of Chicago. He had done brilliant work on the anatomy and diseases of the nervous system and was generally recognized as a man with a superior mind and unusual qualities of leadership. Barker was much interested in the promotion of research within the medical department and wished to develop it along true university lines, similar to Müller's clinic in Munich which he had visited the year before his appointment as professor of medicine. He therefore established laboratories for clinical in84

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vestigation in the biological, chemical, and physiological fields of medicine, and appointed to his staff men with special training in these sciences. He considered the promotion and direction of research to be a major obligation of a university professor of medicine—an obligation requiring not only broad and concentrated personal study, but also the devotion of much time and thought to the research work of the staff. This was an important advance in American medical education, representing an extension of the true university spirit into a department of medicine characterized by research as the basis of teaching. It was an accomplishment in which Barker had much justified satisfaction throughout his life. Herein lies the significant difference between Osier and Barker. It may be said that Osier belonged to the British school of medical teaching and Barker to the German school. Osier's primary interest, the direct study of patients, could be carried over directly into the practice of medicine outside the hospital, and because of his experience, skill, and personality he was constantly in demand by the public and by practicing physicians, who valued very highly his services as a consultant. Barker's concept of a professor of medicine was that of a teacher thoroughly involved in research, whose primary interests would not be interrupted by medical practice outside his departmental activities. However, the professorship of medicine at that time was not sufficiently supported to allow Barker to carry out his concept. He was forced to engage in outside practice, which became so extensive that he felt himself unable to withdraw from it later when adequate support was secured to establish the professorship on a full-time basis. This comparison of Osier and Barker has, it seems to me, a bearing on the long and heated discussion of the full-time plan of clinical teaching in American medical schools. Barker was among the first to advocate full-time clinical teachers, which he did in 1902. Osier was definitely opposed to the plan when its adoption at Johns Hopkins was under discussion some years after his resignation, and his opposition was strongly expressed in a letter to Ira Remsen, then president of the university. A division among medical teachers occurred when the plan of full-time clinical teaching was put into effect at Johns Hopkins in 1913 and continues throughout this country to the present time. On one side have been some of the leading physicians who 85

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combined teaching and medical practice and who looked upon Osier as the ideal teacher. On the other side have been younger men with training and experience in clinical research who urged its further development as a fundamental function of a universitydepartment of medicine according to the concepts of Barker. Under the direction of Rufus Cole the Hospital of the Rockefeller Institute has been a potent force in setting an example and providing training in research on diseases in patients—designated clinical research. Cole had developed the first of Barker's research laboratories, that devoted to biological study, where he carried on the first systematic clinical research undertaken at Johns Hopkins. He studied typhoid fever, then a prevalent disease, with particular interest in the isolation of the typhoid bacillus from the blood of patients. Isolation of bacteria from the circulating blood of patients was then a relatively new and rare procedure, and Cole's work, among the first of its kind, served to establish the blood culture as a routine clinical procedure—one which threw much light on the nature of typhoid fever and other diseases and became generally accepted as a means of making definitive diagnoses. Previous to this time practically all hospital laboratory work was concerned with the diagnosis of disease; Cole's work was a study of the disease itself. His activities in developing this new concept constitute his outstanding contribution to American medicine. Cole's decision to accept the directorship of a small research hospital with many new problems to face and with uncertainties as to what might be accomplished in this unique project was a difficult one, as he had just been offered the professorship of medicine at the University of Michigan as successor to George Dock. However, after conferences with Welch and Flexner he accepted the directorship. In the latter half of 1908 he went abroad to familiarize himself with research activities, especially those conducted in the medical clinics of the German universities, and gathered useful ideas regarding methods of organizing clinical research. He found nowhere in Europe a research hospital such as that proposed by the board of directors of the Rockefeller Institute, and it was necessary to plan the hospital without a prototype. By November 1908 Cole had formulated plans for the organization of the hospital in memoranda presented to the board of directors. The plans were carried out almost unchanged. In April 1954 I visited Dr. Cole and reviewed many incidents 86

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of our association. At that time he put at my disposal a number of unpublished statements he had prepared for the directors of the institute, which are of importance in the history of American medicine because they expressed for the first time a number of Cole's ideas that have since received general acceptance and have influenced the course of academic medicine in this country. In his statement presenting his ideas on the program for the hospital, Cole wrote that it should "apply the intensive method to clinical study as opposed to the extensive or statistical method formerly in vogue." He advocated opportunities for experimental work on animals for persons studying disease in patients by stating that "while clinical study must from the nature of things, be largely investigative, as opposed to the experimental method of the laboratory, yet I think the best results can be obtained from clinical study when those engaged upon it have at the same time facilities for undertaking experimental work on animals along parallel lines." It was his opinion that the physical and intellectual barrier between the laboratory and wards then existing in many hospitals had seriously delayed the advancement of medicine in this country; he urged that the hospital be developed as a true research laboratory and expressed the fullest sympathy with the closest possible connection between the institute laboratories and the hospital. This relationship represented new and favorable conditions for the development of clinical medicine as a science. In regard to the research that was to be undertaken, Cole wrote that "while the appointments made to the hospital staff will, to a considerable extent, decide the lines of work to be undertaken, and while the greatest possible freedom should be given to all workers, it is important that the work of the hospital should be carried out along general lines laid down by those in control." He suggested a simple plan of hospital management, with the director as physician-in-chief being responsible for the medical service and for general oversight over other departments such as nursing and housekeeping. The hospital staff was to consist of the physician-in-chief, several part-time specialists, including surgeons and a radiologist, and a limited number of physicians with proven research ability who were to be nonresident members of the staff. Among this number there was to be a welltrained chemist who would make some of the more complicated 87

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routine examinations, oversee the work of the physicians who might not have special training in chemistry, and assist in directing the younger men in the chemical aspects of their investigations. The resident physicians were to form the core of the staff, in which Cole was especially interested. The physician-inchief was to have full charge of the admission and care of patients, general supervision of the research work undertaken in the hospital, and direct responsibility for the faithful service of the physicians on the staff. He would also have sufficient time for independent research so that his labors might serve as an example to those associated with him. He was to recommend and concur in all appointments to the medical staff, and together with the director of the Rockefeller Institute and a committee of the board of directors, decide upon the nature of the investigations to be undertaken each year in the hospital. Cole placed especial reliance on the resident physicians, as he thought upon them mainly would depend the success of the hospital in the advancement of medical knowledge. As they would have the immediate care and treatment of patients, it was necessary that all members of the resident staff have clinical experience and be prepared to give the patients the best of medical service. His important stipulation was that the resident physicians should all have been actively and personally engaged in medical research and be able to undertake the independent studies that he considered essential if the hospital was to produce its anticipated results. He emphasized the importance of obtaining for the resident staff young men of a peculiar type and exceptional ability, and that in order to obtain them exceptional opportunities would have to be offered for clinical investigation. Above all, they must have independence and excellent facilities for work, which "are more important than salaries and comfortable living arrangements, though the latter should not be neglected." The lines of study should be more or less regulated by the special interests of the residents. Each should have a ward assigned to him and be provided with patients to enable him to continue the investigations which he had already commenced. Cole recommended that each resident physician be responsible for not more than twenty patients and that as he was to undertake special independent research, he should not be required to give too much time to the immediate care of patients. The resident staff was to be headed by the senior resident 88

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physician, a position which was to be filled by a man with considerable medical experience, qualified to keep general supervision over all patients and to see that they were properly cared for. The senior resident physician was to retain his position as long as he desired, and as long as he continued to be productive in research. Cole hoped he would continue in academic medicine, as there was at that time a growing demand for men with such training, and he anticipated that the hospital would serve as a school for them. It may have seemed that Cole had set himself a difficult task in recruiting a group of young men fulfilling the specifications he had laid down and on whom he could rely to attain the objectives of the hospital. However, the time was ripe for carrying out his plan; he was able to find the men; and he showed from the beginning a remarkable ability in the selection of staff members for the hospital—an ability which was displayed throughout his entire career as director of the Rockefeller Hospital. Cole's concepts, formulated in 1908, formed the basis of important developments in the scientific study of disease in patients, spoken of as clinical research. Under his direction the hospital has had a strong and lasting influence on the progress of medical education and medical practice in this country. Not only has the Rockefeller Institute set new standards of scientific work in clinical medicine, but through the men trained there, it has had much influence in the progress of medicine in this country, in Europe, and in China. The Organization

of the

Hospital

On September 1, 1910, I reported at the Hospital of the Rockefeller Institute to fill the post of senior resident physician, and on the same day George Draper arrived, the first assistant resident to be appointed to the staff. As we had worked together in Munich and had been closely associated in Philadelphia during the previous year, our start in the hospital was the continuation of an old friendship. Miss Nancy P. Ellicott was superintendent of the hospital, and her assistant, Miss Mary B. Thompson, was in charge of the nursing service. Both had been imported from the Johns Hopkins Hospital. Within a few weeks, Homer F. Swift and Henry Marks arrived from Europe and Alphonse Raymond Dochez moved into the hospital from the institute laboratories, to complete the initial resident staff. Francis H. 89

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McCrudden took over the direction of the chemical laboratories; Alfred E. Cohn was added to the research staff; Arthur W. M. Ellis and Francis W. Peabody, a short time later, joined the resident staff. The hospital, overlooking the East River, had eleven floors (three below the ground level), and besides the usual hospital facilities and living quarters for the staff and nurses, there were four floors for patients in the main hospital building—sixty patient beds in all—and two upper floors for laboratories, an operating room, and other accessories. A small building adjoining the main hospital had nine rooms separated by glass partitions for cases of communicable diseases, and an autopsy room with facilities for pathological work. The lowest floor for patients, the third, contained eighteen private rooms; the next three floors had small, six-patient wards at each end and two single rooms—fourteen beds in all on each floor—the arrangement of beds being planned so that small groups of patients with the same disease could be together. The laboratory facilities for chemical, bacteriological, and physiological research were extensive in relation to the size of the hospital, and the building was admirably designed and equipped for the purposes for which it was planned. The doctors' quarters on the first floor were especially attractive because of the interesting and ever-changing view of the East River. At night, with the illuminated Queensboro Bridge a few blocks away, the scene was truly dramatic, particularly when viewed from the resident physicians' rooms and the staff sitting room that opened onto a balcony above the river. In September the hospital was nearly completed and equipped, but the organization of the medical service had to be undertaken immediately. This included designing and printing clinical record forms, temperature charts and admission forms, and all the other details needed to put the hospital in readiness for its opening on October 17, 1910. The weeks preceding that date were full of activity and anticipation, and on the opening day the resident staff was proud to show the hospital to the many visitors who came to mark the occasion. I have never forgotten the remark of Dr. Francis Delafield, professor of medicine at Columbia University, who was shown about the hospital by George Draper, whom he had known from boyhood. Dr. Delafield looked about without comment until he was leaving. Then he said: "George, it won't do you any good 90

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if you haven't any sense," a terse expression of the basic principle that it is brains rather than physical equipment that really count. The next problem was to assemble the clinical material for the studies that had been selected by admitting patients with the diseases that were to be investigated. In order to facilitate the solution of this problem an effort was made to give the public, and especially the medical profession, an understanding of the objectives and plan of work of the hospital, and a statement was published by the Rockefeller Institute explaining that the hospital planned to study "disease as it actually appears in human beings, under conditions equally favorable to treatment and to scientific observation. A common motive actuates the Institute as a whole, namely, that of advancing knowledge and of securing more perfect means of preventing and healing disease. Thus the work of the Laboratories and Hospital is unified. Their common aim, and the physical connection of the different buildings with each other, often admits of the same problems being studied both in their biological or pathological and in their clinical aspects. In the organization of the scientific staff of the Institute, the principle has been recognized that the ultimate purposes of medical research and discovery may be greatly served by the study of biological and chemical problems that, as such, may appear remote from medical application. It has not thus far been the purpose of the Institute to choose rare and strange diseases, in preference to those more prevalent or familiar, on which to spend its resources. On the contrary, the diseases now under investigation, whether in the Laboratories or in the Hospital, include many of those which are regarded as the chief scourges of mankind. Special workers in chemistry, pathology, bacteriology and physiology reinforce the clinical staff in the investigations carried on in the hospital. "The capacity of the Hospital is about seventy beds. The work at any one time is confined to selected cases that bear upon a limited number of subjects chosen for investigation. The subjects chosen in the first year were acute lobar pneumonia, acute anterior poliomyelitis (infantile paralysis), syphilis, and certain types of cardiac disease. Patients are admitted only by the Resident Physician to whom cases are referred by physicians or hospitals, or by direct application. The Director issues bulletins from time to time informing physicians of the diseases chosen 91

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for investigation. While making the fullest use of its opportunities for observation and study, the Institute recognizes at all times the paramount right of the patient to receive the most effective treatment within the power of the attending physicians. A patient does not impair that right by the voluntary character of his application for admission. "Under the By-laws of the Corporation, no charge can be made to persons treated at the Hospital, for professional care or service rendered, or for board and lodging. All discoveries and inventions made by any person while receiving compensation from the Institute become the property of the Institute, to be by it placed freely at the service of humanity in accordance with the beneficent purposes of the founder." Excellent cooperation was given by physicians practicing in New York and attached to some of the leading hospitals. Many of them were interested in clinical research but were without the facilities for pursuing it. They also appreciated the advantages to their patients of obtaining free medical care under the unusual conditions provided by the hospital, with excellent nursing service by carefully selected graduate nurses, and with a well-trained resident staff having a relatively small number of patients under its care. Within a few weeks the problem of clinical material was solved by the admission of a number of patients with the diseases selected for investigation. While some of the staff were readying the hospital for the admission of patients, others were busy with laboratory arrangements and equipment. The work of the hospital soon began to run quite smoothly, thanks to the strenuous efforts of Miss Ellicott, Miss Thompson, and Miss Frances T. Tucker, the housekeeper, all working under Dr. Cole's direction. The Staff and Its

Research

The principal initial research activity was the study of acute lobar pneumonia, which Dr. Cole had chosen as his special problem. Pneumonia was very common especially in the winter months in New York, and had at that time a very high mortality, with no specific or direct method of treatment. Over 20 percent of the victims of lobar pneumonia then died, and the primary object of the research was to discover some means of reducing this high death rate. Dochez and Marks of the resident staff worked with Cole. Dochez, who worked on the bacteriological problems of 92

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pneumonia, had graduated from the Johns Hopkins Medical School in 1907 and had immediately joined the staff of the Rockefeller Institute in pathology and bacteriology, where he had spent three years before transferring to the hospital. The primary object of the work undertaken by Dochez as part of Cole's plan of attack on pneumonia was the development of an antipneumococcus serum by the injection of horses with gradually increasing doses of the pneumococcus. A number of difficulties were encountered which led to a thorough study of the organism and resulted in differentiating a number of types of pneumococcus, each with a varying degree of virulence and each presenting a different problem of diagnosis and treatment. Sera specific for each type were prepared, and with them considerable success was achieved in lowering the mortality rate. But it was not until the discovery of the sulfa drugs and, later, penicillin, that a specific cure for this dangerous disease was found. This work in pneumonia was greatly augmented by Oswold T. Avery, who joined the staff in 1913. Avery was a talented bacteriologist whose work on the chemistry of the pneumococcus, which he continued until his retirement in 1943, represents one of the most conspicuous contributions to medical science made in America during recent years. He worked closely with Dochez until the latter resigned from the staff of the hospital in 1919 to become assistant professor of medicine at Johns Hopkins. Dochez was called in 1921 to the Columbia University College of Physicians and Surgeons where he had a brilliant career as professor of medicine and, for a time, as head of the department of bacteriology. Dochez and Avery were an outstanding team in bacteriology throughout their active lives. Both were bachelors and lived together until their academic retirement. Many important ideas regarding the infectious diseases were hatched in the minds of these two quiet, thoughtful, scientific philosophers, who began their illustrious work together in the early days of the Rockefeller Hospital. Henry Marks worked as Cole's direct assistant on the pneumonia service. He was a Harvard graduate who, after an internship at the Massachusetts General Hospital, had spent two years studying pathology abroad. At the end of the first year he left the Rockefeller Hospital, and after working for a year in the institute laboratories, became interested in neurology. Finally he became a writer of novels and went to live in Europe, being 93

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one of few men who did not follow his work on the staff of the Rockefeller Hospital by a career in academic medicine. In January 1911 Francis W. Peabody joined the resident staff and began the study of the disturbances of respiration and some of the chemical effects of pneumonia in the blood of patients. Peabody was a Harvard graduate who had interned at the Massachusetts General Hospital. He had spent two years on the resident staff in medicine and pathology at the Johns Hopkins Hospital, followed by six months in Germany working with the chemist Emil Fischer and with Fresenius. He left the Rockefeller Hospital to become the first resident physician of the Peter Bent Brigham Hospital, where he worked closely with Dr. Henry A. Christian on its organization and its establishment as an important teaching hospital of the Harvard Medical School. Peabody later became a professor of medicine at Harvard and the first director of the Thorndike Memorial Laboratory of the Boston City Hospital. He also took a leading part in the Rockefeller Foundation's establishment of the Peiping Union Medical College. Peabody died in 1927 at the age of forty-six. His death was a sad blow to all who knew him as well as to American medicine, for in him were combined unusual charm, a finely trained mind, extraordinary ability as an investigator and teacher, and a beautifully balanced personality. Another field of work, initiated by Homer Swift, was the study of syphilis and its treatment by "salvarsan," Paul Ehrlich's remarkable new discovery, then known as "606." Swift's work was the first comprehensive study of this drug made in America. He was joined in this project by Arthur Ellis a few weeks after the hospital opened, and they soon began to study and treat syphilis of the central nervous system, one of the most serious and truly terrible complications of the disease, and one for which no adequate form of treatment had been discovered. Swift and Ellis worked out a method of applying the new drug directly at the site of disease through the spinal canal, which became known as the Swift-Ellis method of treatment. It proved to be of definite benefit in some cases of tabes dorsalis, known as locomotor ataxia, and in other forms of the disease. Swift, a graduate of the University and Bellevue Hospital Medical College, had interned at the Presbyterian Hospital in New York. He had spent two years on the staff of his alma mater teaching pathology and dermatology, and had a short period of 94

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study abroad before joining the resident staff of the Rockefeller Hospital. He eventually became the senior resident physician, serving for two years in that post before undertaking a fiveyear period on the medical faculties of Columbia and Cornell. He did important scientific work in the Army Medical Corps during World War I, after which he returned as a permanent member of the staif of the Rockefeller Institute and devoted his life until retirement to the study of rheumatic fever, making important contributions to the knowledge of this baffling disease. Swift once said to some of us in the hospital soon after he began his work on rheumatic fever that he aspired to have engraved on his tombstone, "Here lies the man who discovered the cause of rheumatic fever." Although he never quite reached his goal, this remark was indicative of the tenacity of purpose and unfailing scientific endeavor that marked his character and work. Arthur Ellis, a Canadian and a Toronto Medical School graduate, settled in England after long service with the British forces during World War I. He was appointed professor of medicine in the London Hospital School of Medicine, where he was the first full-time professor heading its new medical teaching unit. Later he was appointed to one of the highest posts in British medicine, regius professor of medicine at Oxford, which had once been filled with great distinction by Sir William Osier, the other Canadian to be so honored. Ellis, too, was knighted by the British monarch several years ago. He wrote me in 1943, soon after his Oxford appointment, "I can never be sufficiently grateful for the luck which brought me to the Rockefeller and to the companionship and friendship of the group that you and Rufus [Cole] had collected. They were good days in every way and I agree with you that subsequent records suggest that we did not waste our time. I have often thought what a remarkable act of faith it was that we should all have been there consciously attempting to fit ourselves for full-time posts in medicine, when no such jobs existed anywhere." George Draper and I began our research on the heart and circulation by endeavoring to continue along the lines on which we had worked and thought together when we were in Munich. Our attention was focused on methods by which the functional capacity of the heart might be measured. In those days the type and extent of the disease present in the heart could be fairly well determined, but it was not much more than guesswork to con95

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elude how much the efficiency of the diseased heart was impaired in maintaining the circulation, and to what extent the work of the heart should be limited by cutting down physical activity to prevent symptoms of heart failure. Although we made some progress in this field, our interest and attention were soon diverted by the arrival from Germany of the string galvanometer, known as the electrocardiograph. To put into operation this complicated instrument for recording the action of the heart was indeed a formidable problem. At that time there were only two such instruments in New York, the first having been recently imported by Dr. Alfred E. Cohn on his return from working with Sir Thomas Lewis, the English pioneer in electrocardiographic study, and the other by Dr. Walter B. James, professor of medicine at the College of Physicians and Surgeons. One of these instruments was subsequently used in the Mt. Sinai Hospital by Cohn, while the other was installed in the old Presbyterian Hospital by James. These instruments and the one received by the Rockefeller Hospital marked the beginning of electrocardiographic study in this country, although a similar galvanometer was imported by Thayer at Johns Hopkins at about this time, and another a little later by Dock at Washington University in St. Louis. Fortunately we were able to call on Dr. Horatio B. Williams, a physicist in the department of physiology at Columbia, who had already set up the electrocardiograph for Dr. James. He was for some years the "high priest" of the electrocardiograph in this country, and later became the professor of physiology at Columbia. Thanks to Dr. Williams' efforts, our instrument was put into operation on March 5, 1911. The electrocardiograph has become so widely used throughout the world in the study of the heart that this bit of history regarding its introduction in America is of some historic interest. The instrument was invented by Willem Einthoven of Leyden in 1903, on the basis of knowledge regarding the electrical effects produced by the contraction of the heart muscle. The complicated apparatus was constructed by Edelmann in Munich and placed on the market shortly before the Rockefeller Hospital was opened. As soon as we had the instrument in operation we began to take and study electrocardiograms which gave an accurate record of the rate of the heart, any disturbance in its rhythm, and changes in the mechanism of the heart beat leading to cardiac irregulari96

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ties. Draper and I worked together for two years studying heart disease and problems of the circulation. George Draper was a graduate of the College of Physicians and Surgeons of Columbia University, and after completing his internship in the Presbyterian Hospital in New York, he went to Germany, first to the laboratory of Paul Ehrlich in Frankfurt and then to Miiller's clinic in Munich where we met and worked together. On returning home, he spent a year as the resident pathologist in the Pennsylvania Hospital under Warfield T. Longcope, and was then appointed to the Rockefeller Institute Hospital. After two years there he entered practice in New York and became much interested in the psychological aspects of medicine. Eventually he became a professor of medicine at Columbia and developed in the medical clinic the field of anthropology as related to clinical medicine. Alfred E. Cohn joined the staff soon after the hospital was opened. Cohn, also a Columbia graduate, had his clinical training in the Mt. Sinai Hospital in New York, followed by several years of study in pathology and clinical medicine in Germany and London. He had a fine understanding of pathology and physiology and conducted many important studies at the institute, where he remained until he retired. When the hospital was opened, a Journal Club was organized for discussion of the studies being carried on and of the literature relating to them, and in later years Cohn presided over these meetings and kept the club alive for many years. He had a philosophical mind, and wrote a number of notable essays bearing on medicine and research which attracted favorable attention. During the summer of 1911, the program of the hospital was suddenly shifted to undertake a study of poliomyelitis (infantile paralysis) which had made its appearance in this country in epidemic form for the first time in a number of years. An even more severe epidemic occurred in 1916, and poliomyelitis has remained a prominent medical problem since that time. Poliomyelitis was being studied in the institute laboratories by Simon Flexner and Paul F. Clark, with special reference to its mode of transmission. In order to correlate clinical studies of poliomyelitis with the laboratory studies, the isolation building was opened and all during the summer was filled with children suffering from the disease, most of them with severe paralysis and a number with fatal respiratory symptoms. This was before 97

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the invention of the respirator, the so-called "iron lung," and to see these children die and be unable to prevent their suffocation was a most distressing experience. Peabody, Dochez, and Draper gave their full time to the study of poliomyelitis during that summer, and published a monograph on the clinical aspects of the disease that is a classic. During 1912 Francis R. Fraser and Frederic M. Hanes joined the resident staff, and Florentin Medigreceanu came to work in the chemical laboratory. Fraser, who came from Edinburgh, worked in the physiological division with Cohn and after two or three years accepted an appointment at Columbia under Longcope, then the professor of medicine in the College of Physicians and Surgeons. Subsequently, Fraser returned to London to become the first full-time professor of medicine in the medical school of the ancient St. Bartholomew's Hospital, where he took a leading part in developing the medical teaching unit. Later he was appointed by the University of London to organize and direct postgraduate medical education in London, an accomplishment for which he was knighted. Fred Hanes, a Johns Hopkins graduate with excellent training in pathology at Columbia University, had a relatively short period on the staff of the hospital, but continued in academic medicine, becoming the professor of medicine of the Duke University Medical School. Medigreceanu was a Rumanian with much enthusiasm for chemical research. His life, of great promise, was lost in the First World War, in which he became involved soon after hostilities broke out in Europe. Donald D. Van Slyke, a doctor of philosophy from Michigan, was a member of the institute laboratory staff in the early days of the hospital. His work in biochemistry spurred his interest in some of the research problems of the hospital. In 1914 he transferred to the hospital staff and for many years was one of its greatest assets, carrying on the important studies on blood gases, on amino acids, and on other problems that made him one of the leading biochemists of our time. On July 1, 1912, I ended my service as senior resident physician of the Rockefeller Hospital, continuing on the staff as an associate. In December I was married and lived in a small apartment near the hospital. During that year, I carried on experimental studies in the institute laboratories, some of them with a member of the staff of the physiological division, John Auer, 98

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and gained valuable experience in planning and conducting experimental work on animals. In the spring of 1918,1 was asked to go to St. Louis to discuss the position of associate professor of medicine in the Washington University Medical School, which was then undergoing a thorough reorganization. After visiting St. Louis, seeing the new medical school buildings then under construction, and conferring with George Dock, the professor of medicine, Robert S. Brookings, president of the university board of trustees, and others, I was happy to accept the position to be effective in September 1913. The Influence of the Rockefeller

Hospital

The expectations with which I accepted the appointment on the staff of the Rockefeller Institute Hospital had been more than fulfilled. My close association with Rufus Cole was happy and rewarding. He had a fine philosophy regarding medicine and the way in which clinical research should be developed and pursued. He also had high scientific ideals for the hospital and for members of its staff, which he applied with wisdom and breadth of view. He was more intensely interested in his own research problems and in those of the hospital staff than he was in the details of administration, and he gave me an opportunity to exercise my initiative and judgment in the organization and administration of the medical service of the hospital. I enjoyed the administrative work, which did not materially interfere with the study of scientific problems in which I was particularly interested. It was truly a privilege to live and work in the scientific atmosphere of the institute. The splendid training and serious purpose of all the hospital staff created a friendly companionship, linked by a common interest in the field of medical research and clinical study with delightful social relations. There was no antagonism or rivalry, and a spirit of mutual regard for each other's work and cooperation whenever possible fostered a happy situation. Those days in the Rockefeller Institute were recalled in a letter written in 1928: "Life in the hospital was full of joy. A few patients in whom we had special and intensive interest; laboratories such as none of us had ever before seen in any clinic; varied interests both within and without the realm 99

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of medicine; the East River with its great span of light at night, and its lapping waters; a blazing hearth about which we gathered after dinner—all these things gave a setting in which friendship deepened and true sympathy thrived." The splendid scientific and friendly atmosphere pervaded the entire Institute where we had contacts, more or less frequently, with such men as Simon Flexner, Peyton Rous, Hideyo Noguchi, Alexis Carrel, Jacques Loeb, Samuel J. Meitzer, John Auer, P. A. Levene, and Donald Van Slyke—all associated with the institute at that time. The conspicuous places later taken by the men who made up the staff in the early days of the hospital indicate the widespread influence exerted by such a small group. They went out from the hospital thoroughly imbued with the scientific spirit as applied to the study of disease in patients and carried this spirit into schools of medicine in this country and abroad. This process has continued over the years, and a number of the most important posts in this country, in England, in Denmark, and in China have been filled by men who had a decisive part of their medical training in the Hospital of the Rockefeller Institute. In 1931, twenty years after the hospital opened, of 103 members of the staff still living, 64 were professors, and 83 percent were engaged in academic work, 24 percent of the total number being in academic positions in foreign lands.* This record is an indication of the contribution made by the hospital to medical education and shows the correctness of Cole's statement when the hospital was opened, that there was a growing demand for men trained in clinical research. It is a great tribute to Rufus Cole, the creator of the hospital and its director for nearly thirty years. I consider it a valued privilege to have been associated with him in the early and formative days of the hospital. * According to figures gathered by Alfred Cohn.

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JOHNS HOPKINS HOSPITAL Administration building. The resident staff occupies the second and third floors (see page 38)

WILLIAM Η. WELCH Taken in his Johns Hopkins office about 1910. A photograph of William Osier is on his right (see page 44)

PENNSYLVANIA HOSPITAL The central building contains the library on the second floor. The first surgical amphitheater in America occupied the top floor (see page 68)

JAMES Η. KIRKLAND Chancellor of Vanderbilt University, 1927 (see pages 148-149)

VANDERBILT UNIVERSITY MEDICAL SCHOOL The laboratories and nurses' home are on the right; the hospital wards on the left; the university campus in the background (see pages 159160). Photograph is reproduced by courtesy of Colonel Walter M. Williams, 105th Observation Squadron, Tennessee National Guard

SIR JAMES MACKENZIE Standing before the clubhouse on the famous golf course at St. Andrews, Scotland (see page 169)

THE VANDERBILT MEDICAL FACULTY Professors of the new Vanderbilt University Medical School, opened in 1925. Left to right, front row: Glenn E. Cullen, Waller S. Leathers, G. Canby Robinson, Barney Brooks. Second row: James M. Neill, Paul D. Lamson, Ernest W. Goodpasture. Third row: R. Sydney Cunningham, Horton R. Casparis, Hugh J. Morgan, Walter E. Garrey, C. Sidney Burwell (see pages 173-175)

Photo : Wurts Brot hers, Huntington,

N.Y.

NEW YORK HOSPITAL-CORNELL MEDICAL CENTER View across the East River from Welfare Island (see pages 205-207)

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> the summer of 1913 progressed the time approached for the move from New York to St. Louis to assume the position of associate professor of medicine in the Washington University Medical School. The passage of time was also leading to another event which was the cause of concern. The young Robinson family expected its first baby to arrive in the middle of September, and as the medical school was to open on September 25, a conflict of interests, to say the least, seemed inevitable. However, our daughter Margaret, being as considerate and helpful regarding her birth as she has been throughout her life, solved the problem by being born on the last day of August, even though she weighed by then only four pounds. An Adventure in St. Louis By the middle of September I left the young mother and diminutive baby behind to seek my fortune in the West, an American tradition of bygone days, with two immediate objectives in mind. One was to find a place for my family to live, and the other was to orient myself in the medical school and to set forth from there on my career as a teacher of medicine. Dr. George Dock was the professor of medicine under whom I was to work. During the first few days, however, I was under the guidance of Mrs. Dock, who was very kind and helpful in finding a suitable little house for my family and advising me how we should settle, even turning over to us her proficient house101

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maid so that all was in order when my wife and baby arrived several weeks later. This, we felt, was the height of Southern and Western hospitality, which seemed combined in St. Louis to make the social life there especially attractive. In 1913 the Washington University Medical School was in the midst of a fundamental reorganization, and a number of newly appointed professors were transforming a good medical school of the older, poorly financed, essentially local type, into a school with all the attributes of a true university. This transformation was made possible by greatly increased resources, new and spacious buildings, and favorable relations with a new general hospital and a fine children's hospital. Both of these institutions were cooperating with Washington University in creating almost overnight a medical school and hospital center which was to take its place with the leaders of this country and develop into an institution of international renown.* The reorganization of the Washington University Medical School is one of the most interesting and dramatic events in the history of American education, and the hero of this notable achievement is Robert S. Brookings. His energy, foresight, captivating personality, and able leadership, as well as his outstanding generosity, place Robert Brookings in the forefront of all American businessmen who have contributed to the advancement of education. The Washington University story is part of the great reform of American medical education that began about fifty years ago, and the development in St. Louis is a notable example of the results of the sudden awakening that took place at the turn of the century. The Origins of Medical Education in St. Louis

In order to understand the full significance of this remarkable development, let us see what went before, who were the medical leaders in St. Louis, and what was the environment in which they labored. In 1764 a trading post was founded on the west bank of the * In March 1955 I visited St. Louis and had a delightful reunion with the three emeritus professors who had been members of the first faculty of the reorganized school: Robert Terry, the anatomist; Joseph Erlanger, the physiologist; and Philip Shaffer, the biochemist. They not only drew freely 102

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Mississippi River by Auguste Chouteau at a point selected by Pierre Laclede, a New Orleans merchant. The post soon became the leading fur-trading center in the West. It was incorporated as a town in 1808, and its importance was greatly augmented by the beginning of steamboat traffic on the Mississippi in 1817. Missouri was admitted as a state into the Union in 1821, and one year later St. Louis was incorporated as a city of 5,600 inhabitants, largely of French descent. By 1840, when the first medical college was opened, the city had 16,469 inhabitants. In that year Dr. Joseph Nash McDowell arrived in St. Louis to start the great "school of the West." He is considered the greatest personality in medicine in the Southwest before the Civil War. A graduate of Transylvania University, the West's first medical college, he had taught in its medical school, in the Jefferson Medical College in Philadelphia, and in the Cincinnati Medical College. He was a nephew of Ephraim McDowell, the famous surgeon of the Western frontier and the performer of the first ovariotomy; he was the brother-in-law of the influential leader in medical education, Daniel Drake, with whom he had been closely associated in efforts to improve medical teaching. McDowell was not long in forming a medical school in St. Louis. With four other physicians he organized the department of medicine of Kemper College, which opened in the autumn of 1840 and was the first medical school west of the Mississippi, later to be known as the Missouri Medical College. McDowell was a speaker of unusual ability, and as a sample of his emotional oratory—a kind which had great force in this new country at that time—the conclusion of his address at the laying of the cornerstone of the medical school building may be quoted: "Our motto must be—peace and to our posts. People, Trustees and Professors each to your respective duties, and the wind of persecution may howl a hurricane, and the lightning of malice may fall upon us, but if our good ship be light and free, our gallant on their memories of early days, but gave me much published historical material. The greatest help was Miss Marjorie E. Fox's unpublished manuscript of an authorized "History of the Washington University School of Medicine," based on official records and preserved correspondence, and I have been privileged to draw upon it freely. The registrar of the school, Mr. W. B. Parker, was also very helpful. I had at that time the opportunity to see the great medical center into which the school of medicine had grown and to meet again my associates of former days who were still active there. 103

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mast may be bent but not broken. And like the proud eagle soaring aloft, she will ride the billow to its tip of foam, and glory in the strength that overcomes the storm." It is evident that McDowell had in mind the opposition to come from the medical department of St. Louis University which was soon to be organized with the cooperation of the St. Louis Medical Society. In 1842 this department, which eventually became St. Louis Medical College, was opened. As McDowell had foreseen, it was for many years the rival of Missouri Medical College. These two colleges, among the strongest in the West before and after the Civil War, fought for medical supremacy in St. Louis until at last they were united in 1899 as the medical department of Washington University. The history of these two schools reflects much credit on their faculty members. McDowell was, until his death in 1868, the leading spirit of Missouri Medical College. During the Civil War the operation of the college was suspended, and its building was taken over by the Federal troops as a prison, six cannon being cast from the college bell. McDowell himself served in the medical corps of the Confederate Army. After the war, he returned to St. Louis, refurnished the wrecked building, and reestablished the medical college. He was much loved as a teacher and lecturer; he was proud of his gift of oratory and would never permit any other professor to deliver the introductory lecture or the valedictory address. In fact, for many years Missouri Medical College was known as McDowell's College. The leader of the St. Louis Medical College was Charles Alexander Pope, who joined its faculty in 1844 at the age of twenty-five. After graduating from the University of Pennsylvania, he studied in Paris, where he achieved an outstanding record and made a very favorable impression on his French professors. Pope was appointed professor of surgery at the age of twenty-nine, and dean of the school two years later. He was such a dominant figure in the school that it was popularly known as Pope's College. At thirty-six he was elected president of the American Medical Association, the youngest man ever to be chosen for this high office. William Beaumont, pioneer in the physiology of digestion, was appointed a member of the first faculty, but apparently never taught. Ε. H. Gregory, Pope's successor as professor of surgery, was elected to the presidency of the American Medical Association in 1886; the much revered 104

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John T. Hodgen, professor of surgical anatomy and dean of the college, was elected to this honored position in 1880. When Dr. Pope died in 1870 the professors, headed by Hodgen, formed the Medical Fund Society to create a corporation to purchase the medical building which had belonged to Pope. They agreed that each member of the faculty would pay annually the full amount of his share from the college to the society until the purchase price of the building had been collected, with twothirds of the funds paid in being considered a debt of the college to the faculty members. The Medical Fund Society managed the finances of the St. Louis Medical College for many years, contributing to its support in various ways. It still exists as an incorporated body with officers. The Medical Fund Society deserves special mention in the medical history of St. Louis because it maintained standards of medical education that were definitely higher than those of most of the commercial proprietary schools which existed throughout the country at the time the society was founded. It fostered a spirit of public service, did its best to elevate both educational and scientific standards, and encouraged the cultivation of the best in medicine which ultimately placed the medical department of Washington University in a position to receive great benefactions. In 1887 the society proposed that St. Louis Medical College be incorporated into Washington University. This union occurred in 1891. In 1899, when Missouri Medical College merged with St. Louis Medical College to form the medical department of Washington University, a new era began which lasted up to the reorganization of the Washington University Medical School in 1910. The university announced in the 1899-1900 bulletin of the medical department that "the union of the two oldest and most representative of the medical colleges in the West was undertaken and successfully consummated in behalf of a broader and more thorough training, and we firmly believe that this object will be accomplished." The faculties of both schools resigned so that the formation of the new faculty could be more easily undertaken, and a committee composed of five members from each school organized the new faculty of eighteen clinical teachers, with Henry J. Mudd as dean. The two medical schools that were then combined had survived a difficult period of medical education in St. Louis. During the time these schools existed, medical education had run wild. About thirty medical schools 105

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had been chartered in St. Louis, there being at one time as many as twelve schools in operation. Their educational standards were generally very low, and their existence was usually brief. During the first decade of the present century, the combined faculties of the two oldest medical schools west of the Mississippi, functioning as the medical department of Washington University, made valiant efforts to bring about improvements in medical education. The lack of financial support beyond students' fees was immediately recognized as the greatest barrier to growth, and the medical department appealed to the corporation of Washington University for support, pointing out that the "fee of the student, it must be remembered, does not cover the cost of his tuition." Thus the problem was briefly stated which was to have farreaching effect on medical education throughout the nation. Hundreds of medical schools that had been operated without endowment were doomed. Students' fees were no longer sufficient to support a school that offered more than a series of lectures by practitioners of medicine. Medical schools were being forced by the progress of science to broaden the curriculum, lengthen the course, improve facilities, and employ men trained in the medical sciences as full-time teachers. Not only were these improvements being looked for by the young people entering medical schools, but the state boards of medical licensure were demanding higher educational standards to which the medical schools had to respond so that their graduates would be eligible for licenses to practice medicine. The schools that were integral parts of universities were expanding as rapidly as financial support would allow, while the proprietary schools, supported only by students' fees, could no longer pay their faculty members adequately and were unable to make the improvements in their facilities which the growth of medical science and technique demanded. It was this condition, as has been pointed out, that made Abraham Flexner's extensive report on medical education in 1910 such an influential and far-reaching publication, stating with clearness and force that unendowed medical schools could no longer be continued. Washington University, having assumed nominal responsibility for its medical department, was almost immediately brought to realize by the medical faculty that financial support was required. The first two years of the medical course had been reor106

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ganized on a university basis, the course had been lengthened to four years, and plans for raising entrance requirements to include one year of college training were under way. In 1904 the university provided a hospital by converting the Missouri Medical College's former building into a hospital of 125 beds. In 1905 Robert S. Brookings, who had been a member of the corporation of Washington University for ten years and had become its president, turned his mind and energy toward the medical department. He proposed that it be put on the same basis as other departments, the university assuming control and financial responsibility of the medical school. The medical faculty voted to agree to this plan and it was consummated by the board of directors of the university on March 2, 1906. Robert S. Brookings and Washington

University

From that time on the history of the Washington University Medical School is dominated by Brookings, and an understanding of his achievements, philosophy, and life is necessary if the progress of the medical school is to be clearly comprehended. Fortunately, a masterly biography has been written by Herman Hagedorn, so that many details of Brookings' life are available.* After a thorough study of the man and his works, Hagedorn writes in the preface of his book: ". . . the life of Robert Brookings is a life of things accomplished, of personal success, of effective public service, and of institutions imagined and created. But the story is worth telling only because, through the romance of achievement, runs the thread of a more significant romance, the spiritual growth of a self-made man. Robert Brookings began his career at seventeen as an exultant go-getter in the hey-day of go-getting; he ended it sixty-five years later as a social philosopher, free of the prepossessions of his class and time, advocating radical readjustments and providing the machinery for the development of an intelligent economic system. Interwoven with this story is yet another—that of a simple-hearted, rather childlike man, endeavoring to steer his course by an inner light which the dust of the American market-place might from time to time obscure but could not blot out; and seeking, sometimes * Herman Hagedorn. Brookings: 1936.

A Biography.

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naively, always sincerely, to live the responsible life in an irresponsible age." Robert Brookings was born in Cecil County, Maryland, near the headwaters of the Chesapeake Bay, on January 22, 1850. His father, a country doctor, died when Robert was only two years old. His mother, Mary Carter, was the daughter of a landowning Quaker; her second husband, Robert's stepfather, Henry Reynolds, also a Quaker, was a widower with "a flock of children." Although the family moved to Baltimore after his mother's second marriage, Robert usually spent his summers with his mother's family in Cecil County, where he accompanied his uncle, Dr. Robert Carter, on visits to patients, and sometimes was allowed to roll pills, so that he was called in the neighborhood "the little doctor." It is tempting to associate these childhood experiences with his great contributions to medicine in later life. Brookings' stepfather was a carpenter and builder, at first in Baltimore and later in the country. Brookings' immediate family was large, being composed of an older brother and a younger sister, the children of his stepfather, and those of his mother's second marriage—ten in all. Robert's formal education was not extensive, but his mother recognized his love for music and had him taught to play the violin. He spent a few months at the West Nottingham Academy, a distinguished old school in Cecil County, where George Bechtel, a young Princeton graduate, was head master. His mother, Dr. Carter, and Bechtel had the strongest influence in convincing him that the first duty of a man was to make something real of his life. At the age of sixteen, Brookings attended one session at a business school in Baltimore and then went to St. Louis to join his brother Harry, who wrote enthusiastically of the opportunities in that city which was booming after the Civil War. Harry had a job with Cupples and Marston, dealers in woodenware. As soon as seventeen-year-old Robert arrived on New Year's Day 1867, he went to work there as a receiving clerk and began to learn the business. In 1868 he became a travelling salesman and was soon known as "the fiddling drummer" because he carried his violin on his travels —an innovation that helped to make many friends for him in a territory extending throughout the West as far as the Pacific Coast. He was a very successful salesman and became a member of the firm of Cupples and Marston at the age of twenty-one. He spent ten years "on the road" selling woodenware at a time 108

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of ruthless competition, but by the end of the seventies the Cupples Company dominated the woodenware trade in the United States. About this time Brookings settled down in St. Louis. He had made money rapidly and was worth a million dollars by the age of thirty, and even before that time he had looked forward to devoting himself to public service. The fact that he was sensitive, felt the lack of a cultural background, and was socially ill at ease, seems to have led him to make a grand tour of Europe in 1880, visiting the British Isles, France, Italy, and Switzerland. This trip awakened his interest and left him hungry for a cultured life. On his return he rented the top floor of the house of Mrs. Keim, the daughter of Dr. William Beaumont, the Army surgeon who had made important physiological studies of human digestion on the wounded Alexis St. Martin. With her help, Brookings endeavored to improve his social behavior, as his business triumphs left unsatisfied many of the desires of this young merchant and artist who wanted to create something more than a dominating business. In 1894 he went again to Europe, staying a year and devoting much time to music in Berlin. Soon after his return he became a prominent figure in St. Louis. In 1895, at the peak of his business career, he built the Cupples Station, which put into effect a new plan for handling the large rail shipments in and out of St. Louis. This enterprise was to play an important part in the development of Washington University. By this time he was asking himself what he was struggling for, and on the advice of Mr. Cupples, he became a member of the board of directors of Washington University, then an almost moribund institution. He decided to devote himself to the field of education, as Carnegie, Rockefeller, and others had begun to do, and to make Washington University an institution that would attract adequate support for the development of a leading university to give opportunities to youth. Washington University had caught his imagination and as Hagedorn expresses it: "In its glow, his second life began." He evolved a long-range plan after studying universities at home and abroad, decided that a new plant was necessary, found the $300,000 to purchase a site of 111 acres on the western edge of the city, and had building plans drawn according to his idea of the future university. His friends stood by him and gave funds for buildings, and in 1899 he had raised what was then consid109

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ered an adequate endowment for a university of higher learning, a major portion of which consisted of the Cupples Station, valued at $3,000,000, which he and Cupples gave to the university. At about this time Brookings was elected president of the board of the corporation of Washington University composed of twelve or fifteen of his friends of long standing, all of whom admired his astonishing command of facts, his remarkable memory, and his strong pull toward achievement, and gladly accepted his leadership. The future site of the university was then occupied by the financially successful Louisiana Purchase Exposition, which erected three permanent buildings at a cost of $650,000 and turned them over to the university. In 1904, soon after the exposition closed, Washington University moved to its new location. In 1908 David Franklin Houston was called from the University of Texas to serve as chancellor. By that time much of the excitement of the launching of the new Washington University had subsided, and Brookings was ready for new fields to conquer. The new challenge was not long in coming. The Beginnings of a New Era The medical department of Washington University soon aroused the interest of the new chancellor fresh from the University of Texas, whose medical school at Galveston had, under the administration of William Spencer Carter, developed effective leadership in medical education and research in the Southwest. Houston endeavored for months to reorganize the medical faculty, but Miss Fox reports "it was difficult to work such changes from the inside, especially when the necessary funds were still not available. The objectivity of a leader from outside the department, nonpartisan in the continued rivalries of the two old colleges, money and the faith of public spirited citizens in the opportunity of medicine in St. Louis—all of these things were needed before great progress could be made. These needs were to be met in a most unexpected way." This unexpected way was the dramatic effect of the visit of Abraham Flexner to inspect the Washington University medical department in April 1909, as part of the national study of medical education he had undertaken. His report of the school came as a shock to Mr. Brookings. Miss F o x has written an admirable account of the stirring events that followed. 110

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Flexner's study was conducted under the general direction of Henry S. Pritchett, president of the Carnegie Foundation, which financed it. Pritchett had been professor of astronomy in Washington University for fourteen years and expected the medical school to be superior because of Brookings' interest. On the contrary, Flexner "found the school a little better than the worst I had seen elsewhere, but absolutely inadequate in every essential respect." Brookings received the report with indignation and departed immediately for New York to argue the case, but returned with Abraham Flexner who agreed to demonstrate "on the grounds" the meaning of his criticisms. In two hours Brookings was convinced that the criticisms were justified and wasted no time in calling the university directors together that same day, to meet Flexner and to hear his suggestions regarding the future of the medical school. Flexner's advice was to abolish the school and "form a new faculty, reorganize your clinical facilities from top to bottom, and raise an endowment which will enable you to repeat in St. Louis what President Gilman accomplished in Baltimore [i.e., at Johns Hopkins]." Under the stimulus of this discussion Brookings evolved a new dream, "the vision of a medical school serving the Southwest which should have the finest standards of excellence." His vision had the enthusiastic support of the directors, who voted at this very luncheon meeting to carry out Flexner's recommendations. At a meeting of the medical faculty on May 31, 1909, Chancellor Houston asked its opinion of the proposed reorganization. Dr. Robert Terry moved that "it is the wish of the medical faculty that there be a reorganization of the teaching corps and curriculum of the medical school, and that this reorganization be placed in the hands of the Chancellor and the Board of Directors." This motion was carried unanimously, although it meant the relinquishing of all administrative power by the faculty and was equivalent to its resignation. This was an essential step in clearing the way for the great development that was to follow, and Houston reported that the action of the faculty was "a gesture at once indicative of the unselfish interest in the welfare of the school and in the status of medical education and should be recorded to their everlasting credit." Robert Terry told me recently that he had always thought Flexner's condemnation of the old school definitely overdrawn, but that no doubt Flexner saw in Brookings a great champion 111

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of medical education if he should be sufficiently stimulated to back the cause. Flexner's analysis was certainly correct, for even if he drew too dark a picture, it was a fine piece of educational diplomacy that worked. Flexner's report stated: "There is abundant evidence to indicate that those interested in Washington University appreciate its 'manifest destiny'; it bids fair shortly to possess faculty, laboratories, and hospital conforming in every respect to ideal standards." This is an indication of the leadership and energy with which Brookings went to work in making his dream come true. Among the many questions that were raised by the determination to build a medical school "conforming in every respect to ideal standards," were where is the money coming from? what constitutes an ideal medical school ? and who is the best available medical man to give professional leadership to this great undertaking? The first question tended to hold in check the enthusiasm of the university directors, but Brookings convinced them that the money could be raised, and as the plans for reorganization proceeded he was successful in getting substantial financial support from members of the university board and from other friends in St. Louis. However, he was not able to obtain funds from Andrew Carnegie through his appeal to Pritchett, or at this time from the General Education Board endowed by John D. Rockefeller. But the greatest financial support came from Brookings himself, who stood always ready to meet the costs of essential needs until he had given to Washington University a large proportion of all he possessed. In order to become informed as to what constitutes an ideal medical school, Brookings immediately consulted Pritchett, Abraham Flexner, and Welch, and accepted the Johns Hopkins Medical School as his ideal. He visited the Hopkins and other leading schools and discussed details of organization with members of their faculties. In October 1909 a committee of three directors and the chancellor of Washington University was appointed to survey the problems of the medical school, and in November Flexner returned to confer with it. The committee made an important report in December 1909, setting forth a plan of reorganization that in a general way determined the future policies of the university: "The Committee is of the opinion that no greater service can be rendered in St. Louis than 112

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through a well-organized and properly equipped medical school. The field is practically unoccupied. Strictly speaking, there is not one first class medical school west of the Blue Ridge Mountains, and there are very few well-organized medical schools in the East. A properly organized medical school should not only efficiently teach modern medicine along well-understood lines, but should also emphasize in-season and out-of-season preventive medicine, which is the line of development of the future, and should recognize its duty to the public through lectures intended to reach it directly. We believe that in the field of medicine is offered the most unique opportunity for the University to render great service not only to the city and this immediate section, but to the whole Southwest. Striking efficiency in this field will react on the entire University and extend its reputation. The time for action is opportune and the necessity is urgent." It added, in the light of the Flexner report about to be issued, that "it will be difficult for those schools that are not rendering satisfactory service to continue to exist after this report is published." The committee pointed out that by resolution the existing medical faculty had cleared the way for the university to reorganize the medical school. It called attention to the very favorable situation that existed just at that time for providing new and outstanding hospital facilities for the medical school through an affiliation with the Barnes Hospital, which was about to be built with funds that its trustees had been holding and accumulating for nearly twenty years. The St. Louis Children's Hospital, then occupying an antiquated building, was also interested in a new plant and in affiliating with the university. The affiliation of these two hospitals with the medical school, which was eventually accomplished, was a major factor in the success of this great project, as will be subsequently related. The committee made several recommendations for the immediate improvement of the existing school, and advised "as an ultimate plan, to locate the laboratories and the instruction rooms of the medical school with such part of a hospital as the University may need under its own control near the other two hospitals referred to, and to do there the major part of the hospital work and the outpatient work." This seems to be the first expression of the idea of creating a large medical center, dominated by the Washington University Medical School. The committee recommended that the first step to be taken was to secure 113

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"a professor of internal medicine whose training is thoroughly scientific, who has recently been in touch with well-organized medical schools and teaching hospitals, whose eminence as a physician is recognized, who shall assume immediate responsibility under the Board and Chancellor for the execution of the plans of the Board." It recommended further that the plan outlined be approved and executed as rapidly as possible and that the chancellor be authorized to secure the services of the professor of internal medicine. The report was approved by the corporation. In December 1909 David L. Edsall, recommended by Simon Flexner and William H. Welch, visited St. Louis as Mr. Brookings' guest. Edsall, then at the age of forty, was professor of therapeutics and pharmacology at the University of Pennsylvania and admirably fulfilled the specifications of the committee. After his visit to St. Louis, he wrote a sound letter to Chancellor Houston in which he discussed the needed hospital facilities and suggested that the university erect a building connected with the hospitals that would house the department of pathology and provide space for research and teaching in clinical medicine and facilities for conducting an outpatient department. He indicated that other buildings would be needed for the departments of the medical sciences. As Edsall's letter was an important factor in directing the future of the Washington University Medical School, part of it is quoted. "I am deeply convinced," he wrote, "that it is an unparalleled opportunity to take a stand that will not only render wonderful service to the whole of that great region of the country, but will also act as an example and a standard for the rest of the country. It must be remembered that Hopkins started a medical school not only with a 'big four,' but with several other men who were very carefully chosen and who have since become the biggest men now there. To start with four big chairs, well filled, would give your school enough impetus to put it close to the leaders. I question whether it would be enough to make it get recognized as of the first rank, and I question whether the very best men could be secured to go to a school that has not been of the first rank unless more than this can be done. If, on the other hand, all the chairs that are at present recognized as being of the first importance were to be filled at once with first-class men and suitable provision made for them as to laboratories, equip114

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ment and budget, I feel with the greatest confidence that, except for a possible man or two who might be tied to his present place by special reasons, the best men available could be secured; and once that were done I am sure everyone acquainted with the medical situation would say that with a complete faculty, free from 'dead wood,' you would have without question the commanding situation in the country. To accomplish this I should consider it necessary to fill the chairs of medicine, surgery, pediatrics, pathology, physiology and pharmacology, and preventive medicine. I should recommend that Terry be retained in anatomy." Edsall also discussed financial requirements, suggesting the salaries required to attract to the school the type of men he had in mind. Brookings and Houston offered him the deanship of the medical school. The reorganization committee gave careful consideration to Edsall's letter, but the increased costs his suggestions called for seemed a serious obstacle to reaching the ultimate goal to which Brookings wished to lead the directors of the university. At this time Brookings made a strong plea to Pritchett with the hope that Carnegie funds might be obtained. He estimated that an endowment of $3,000,000 was necessary to develop a strong medical school, which seemed impossible unless the great bulk of the money needed could be secured from some outside source. He wrote: "This larger scheme appeals to me very strongly, and is so much the best worth doing of anything that I know educationally in this or any other section of the country that I would be willing to make sacrifices which I can ill afford to do at present to bring it about. . . . If I had the money I would not permit any other man in the country to have a hand in it." These statements illustrate not only Brookings' clear vision of what constituted a medical school of first rank, but with what tenacity he held to his urgent desire to have only the best, and the pressure he felt to support the project with his own funds—which he did eventually to an unprecedented extent. In January 1910 Harvey Cushing was offered the professorship of surgery, and in March he visited St. Louis. He was at that time a surgeon on Halsted's staff at Johns Hopkins and was much interested in joining Edsall in this promising development. However, neither he nor Edsall committed himself to accept the appointment. Brookings agreed with Edsall that the best men could be obtained if they could come to Washington 115

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University as a group and be given not only satisfactory facilities for their work, but also freedom to determine the policies of the medical school. He thought of Edsall and Cushing as the first two of this group and made it clear to them that he could obtain all the financial support needed from year to year until the medical school was adequately endowed. In a letter to the directors written just before he sailed for Europe on January 22, 1910, Brookings made extensive commitments to the university, including the payment up to half a million dollars for the clinical building suggested by Edsall. He also agreed to make annual payments to provide an adequate budget on condition that certain stipulations were carried out by the university. He also committed himself to pay annually half of the funds necessary to consummate the contract with the Barnes Hospital and stipulated that the university was to enter into a formal contract with the hospital. He authorized Chancellor Houston and Edsall to be the sole judges as to the personnel to be chosen as heads of departments of the medical school. This important letter was considered by the corporation on January 27. The corporation then formally agreed that the reorganization of the medical school was to be controlled solely by Washington University along the lines Brookings had laid down, and the board took steps to enter into contractual relations with the trustees of the Barnes Hospital. Brookings returned from Europe in April 1910, having visited hospitals and medical schools abroad, and was, as Miss Fox has written, "thoroughly informed concerning the status of medical education in America and in Europe. His enthusiasm was as great as before, and he could now proceed with confidence which came from having thoroughly studied the situation." From this time forward progress was rapid. Funds were obtained from directors of the university, notably Adolphus Busch, Edward Mallinckrodt, William K. Bixby, and Robert S. Brookings, to purchase the land and erect the magnificent laboratory and clinical buildings, and commitments were obtained to support adequately the annual budget of the medical school. The provision of excellent hospital teaching facilities was worked out with the trustees of the Barnes Hospital and with the directors of the St. Louis Children's Hospital. The Barnes Hospital played an important and timely part in the St. Louis development and seems to have fulfilled its "mani116

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fest destiny" in medical history. Robert A. Barnes bequeathed $1,000,000 in 1892 to endow a hospital "for sick and injured persons, without distinction of creed, under the auspices of the Methodist Episcopal Church, South." The trustees appointed by Barnes decided that the building fund stipulated at $100,000 was insufficient and that construction must await the accumulation of interest on their investments. In 1905, however, they purchased a fine site for the hospital on Kingshighway fronting on the eastern boundary of Forest Park, on the west of which, about two miles away, stood the new buildings of Washington University. The site chosen for the hospital determined the location of the medical school. While the trustees were studying hospitals, Brookings was studying medical schools, and as Samuel Cupples, his business associate, was one of the hospital trustees as well as a director of the university, it was natural that they should explore their common interests. The Barnes Hospital's trustees commissioned architects to plan the hospital in 1908, and Brookings convinced them that if the hospital was used for teaching its service would be greatly broadened and that a staff controlled by the highly trained professors of the medical school would be of great professional value to patients. The hospital became affiliated with the medical school in 1910, agreeing to provide the facilities for university clinics, including teaching and research, while the university agreed to furnish facilities for an outpatient department and a school of nursing, and to assume the costs of the facilities required for teaching and research. The hospital was planned originally with about 220 beds and was later greatly expanded to contain 485 beds. The original hospital was completed and occupied in 1914 at a cost, including land and equipment, of about $1,150,000. It had an endowment of nearly $1,000,000, indicating the wisdom of the waiting policy of the trustees and the fortunate coincidence of their readiness to build just when the medical school was prepared for the affiliation. The connection with the St. Louis Children's Hospital was worked out along the same general lines as that between the university and the Barnes Hospital. The Children's Hospital had as the president of its board Mrs. Robert McKittrick Jones, who combined unusual qualities of leadership with vision, energy, and charm comparable with those of Brookings. They worked together with the same purpose and untiring zeal, and Mrs. 117

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Jones deserves a high place among those who helped to make the entire project a success, not only by guiding the affiliation of the Children's Hospital but also by stimulating the interest and backing of the leading people in St. Louis in promoting this great medical development. The St. Louis Children's Hospital did not have the financial strength of the Barnes Hospital, and again Brookings came forward to encourage its affiliation with the university by contributing funds which enabled the hospital to include in its building program a separate pavilion for contagious diseases and for teaching facilities. In the formal contract with the hospital, signed in July 1912, the university agreed to provide facilities for the pediatric outpatient department, to equip and maintain the hospital laboratories, to build a nurses' residence and help in recruiting students for the school of nursing, and to treat ward patients without charge for professional services. In return, the hospital agreed to grant the fullest rights to the university to use ward patients for medical research and clinical instruction. By 1912 plans were completed for the two hospitals and for the laboratory buildings, with the three institutions working together with clear objectives and common understanding. Two laboratory buildings were located across Euclid Avenue from the hospital area. The north building contained the administration offices of the school; a large auditorium; the library; and laboratories for experimental surgery, comparative pathology, and anatomy. The south building contained laboratories for biological chemistry, physiology, and pharmacology. A powerhouse and a refectory for staff and students were also planned. In the hospital area, the Barnes Hospital was the central structure, with a separate building for private patients, and beside it, toward the rest of the medical school, was the building for the outpatient departments and laboratories for the departments of medicine, pathology, and bacteriology—all connected by corridors to the hospital. On the other side of the Barnes Hospital was the Children's Hospital with its separate building for contagious diseases and teaching facilities. Beside it was planned the school of nursing and the nurses' residence, which were not built until 1916. All the buildings were supplied with heat, light, and power from the central power plant and all were connected by corridors or tunnels. 118

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The planning of the buildings was carried on under the direction of the heads of the departments which were to occupy them, this being an important function and opportunity of the newly appointed professors. As a result of this planning the finest group of medical buildings erected up to that time in this country was created, containing all the essential facilities for a medical school with high university standards. The buildings are especially imposing because of their beautiful site overlooking Forest Park, one of the largest and most highly developed city parks in the nation. Forming the New Faculty

During the year following Flexner's report, which had awakened Brookings and the other directors of Washington University to the fact that a fundamental reorganization of its medical school was urgent, not only had funds been raised and hospital facilities secured, but the university was in a position to recruit an outstanding group of men as heads of the various departments of the medical school and hospitals. Although Edsall, who had been counted on so heavily as professor of medicine and dean, and Cushing, who would have given eminence to the department of surgery, had declined their appointments, Brookings and Chancellor Houston were prepared by April 1910 to build up a new medical faculty. George Dock was called to serve as professor of medicine and dean; Eugene L. Opie was appointed professor of pathology, John Howland professor of pediatrics, Joseph Erlanger professor of physiology, Philip A. Shaffer professor of biological chemistry, and Robert J. Terry professor of anatomy. All accepted with the provision that the others would come and that the plan of giving them freedom in determining the policies of the medical school be carried out. It was decided that the appointment of professor of surgery should be made on the recommendation of the new appointees. These six professors, constituting the executive faculty of the medical school, had their first meeting with Chancellor Houston on June 10, 1910, hardly more than a year after the reorganization was initiated. This was undoubtedly the most remarkable accomplishment in the history of American medical education and is to the everlasting credit of Robert Brookings, who by then 119

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was considered by educational leaders to have a more thorough knowledge of medical education than any other American layman. It is interesting to note the background of the group forming the original executive faculty all of whom except Dock and Shaffer were in their thirties. George Dock, who was then fifty, was a medical graduate of the University of Pennsylvania and had served as a professor in the University of Texas, in the University of Michigan, and in Tulane University in New Orleans. He acted as dean of the medical school during the first two years after its reorganization. Eugene L. Opie, a Johns Hopkins graduate, had been called from the staff of the Rockefeller Institute of Medical Research; Erlanger, also a Johns Hopkins graduate, had been professor of physiology at the University of Wisconsin. John Howland was a graduate of the University and Bellevue Medical College in New York, where he had practiced pediatrics, held several hospital appointments, and shown interest in research. Shaffer, who was not yet thirty, held a Ph.D. degree from Harvard and had taught at the Cornell University Medical School. Terry was the only professor with a long career on the old faculty; he had graduated from the Missouri Medical College and had had further anatomical experience in Edinburgh, Freiburg (Germany), and Harvard. These were then the men who had the serious responsibility of developing the new medical school and of determining the policies that had much influence for years to come. As each one came from a different institution, they brought together a variety of experience in medical education. They also brought to St. Louis from other cities a number of well-trained younger men as members of their departments. These young men included Roger Morris in medicine, Walter E. Garrey in physiology, Dennis E. Jackson in pharmacology, Walter R. Bloor and William McKim Marriott in biological chemistry, Victor E. Emmel in anatomy, George M. Smith in pathology, Ernest Sachs in surgery, and Borden S. Veeder in pediatrics. All eventually became professors at Washington University or at other institutions. Roger Morris, associate professor of medicine, resigned in 1913, and shortly thereafter became professor of medicine at the University of Cincinnati. I was appointed to take his place. Members of the old faculty served as heads of the various 120

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medical and surgical specialties. Henry Schwarz, who had had his early academic training in Glessen and Heidelberg in Germany, continued as head of the department of obstetrics. There were many well-trained and talented men in the old faculty who took part in building up the reorganized school, even though they had to relinquish authority; their splendid cooperation was an important factor in the success of the reorganization. Harmony and mutual respect between the old and new professors was largely made possible by the old faculty's conviction that a thoroughgoing improvement of the medical school was desirable and necessary. In describing the spirit of the new group of professors, Miss Fox has written: "These young men came to St. Louis with a tremendous sense of personal responsibility for the success of the enterprise, for they felt that the failure or success of the reorganization of Washington University would influence other attempts which might be initiated all over the country. Washington University would, they hoped, serve as a model, as the Johns Hopkins had, and their experience might benefit not only the local area, but inspire other schools to raise their standards and lift the whole level of medical education in America. They had the idealism and the enthusiasm which traditionally belong to youth. They had sound training and a devotion to standards of excellence." Although there was at first some opposition to the new group and resentment among some of the old and distinguished teachers, "the members of the new executive faculty had clear objectives and appreciation of their opportunity, and their refusal to compromise their own high standards was the real reason that the reorganization was complete. They entered into their task in September 1910 with industry and enthusiasm. They held many faculty meetings and had to learn . . . how to administer. They had to submerge individual interests to those of the school as a whole and the division between clinical and laboratory interests became lost." The new group soon found that Brookings thoroughly shared its attitude concerning the future of the school and that it was inspiring to work with him. The university directors adopted at this time an ordinance that formalized the general commitments to the new appointees and brought the medical school under the control of the board 121

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of directors in every respect, making the appointment of the dean and of faculty members subject to the approval of the corporation, and creating officially the executive faculty. In November 1910 Fred T. Murphy was appointed professor of surgery, being called from the Harvard Medical School and the Massachusetts General Hospital; in December David L. Edsall, whose path had not been smooth at the University of Pennsylvania, was finally persuaded to join the faculty as professor of preventive medicine. Now that a distinguished faculty had been assembled and funds for buildings and clinical facilities had been provided, Brookings again made a strong plea for financial assistance from Mr. Carnegie and then endeavored to get Mrs. Russell Sage to endow the department of preventive medicine, the expense of which he was personally carrying. These efforts to elicit support from outside the community were unsuccessful, leaving the entire problem of financing the medical project in the hands of the people of St. Louis, a burden that Brookings carried with the help of others especially interested in the university. The old buildings in midtown St. Louis had been thoroughly renovated to supply temporary laboratory and clinical facilities, and in the spring of 1911 contracts were let for the construction of the new buildings. At the same time the entire faculty was reorganized with the help of an advisory committee consisting of Washington E. Fischel, Norman B. Carson, and John B. Shapleigh, representing the old faculty, and the question of faculty titles was considered although not settled until May 1912. In regard to the basic policy of faculty appointments Miss Fox has written: "The problem of the executive faculty was to fill appointments with men who were interested in a career in academic medicine, not with clinicians, no matter how well qualified, who would, perhaps, find their interest chiefly in practice. The tradition of a medical school faculty composed of local practitioners devoting only part-time work to the school was too recent not to cause uneasiness among those who were attempting to set a new high [standard] in medical education. Junior positions were, as the (proposed) titles indicate, to be given to men who showed promise of future accomplishment." In January 1912 Howland and Edsall, both of whom had been given leaves of absence to prepare themselves for their professorships, arrived in St. Louis. Unfortunately, they were 122

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not to remain long. Edsall, who had made an important contribution in the early planning of the new school, resigned in May to accept the appointment of professor of medicine at Harvard, where he later became dean of the medical school and of the school of public health. Howland resigned in July 1912, having been appointed professor of pediatrics at Johns Hopkins, where he had a long and distinguished career. He was a dyedin-the-wool New Yorker of the finest type and was not entirely happy in the Middle West. He was therefore willing to accept the outstanding opportunity that came to him. During 1912 Eugene L. Opie replaced George Dock as dean of the medical school, holding this position until 1915, when the reorganization was accomplished and the new buildings occupied. He took a leading part in establishing high standards of teaching and in cultivating a true university spirit of scholarship in medicine. Opie deserves special recognition for the fine quality of academic leadership which he exerted. Although the laboratory departments were well started in 1910 by the new professors in their temporary quarters, the reorganization of the clinical departments was not actually begun until the fall of 1911 when Dock and Murphy took active charge of the medical and surgical departments. It was recognized that the reorganization at other schools had failed in the clinical departments because so many teachers were involved who had what they considered "vested interests" in the medical school. The executive faculty was especially concerned regarding the problems involved in this undertaking. The renovated University Hospital, which was to serve until the Barnes Hospital could be occupied, was reorganized with George Dock as physician-in-chief, Fred T. Murphy as surgeon-in-chief, Henry Schwarz as obstetrician-in-chief, Eugene L. Opie as pathologist, and Charles E. Bauer as superintendent. They proceeded to build up a staff that could be eventually transferred to the new hospital. During this year Julia C. Stimson was brought from New York to develop a department of medical social service in the University and the St. Louis Children's Hospitals, and she played a conspicuous part in the clinical reorganization. Miss Stimson had entered social work from the field of nursing and possessed fine qualities of leadership. She took over the direction and organization of the nursing service at the time of the move to the new plant, giving up eventually the direction of medical 123

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social service, and made a brilliant career in nursing. Miss Stimson went to France as a Red Cross nurse heading the nursing service of the base hospital organized by the medical school during the First World War, and before long had been appointed head of all Red Cross nurses overseas. Later she was called to head and develop the nursing service of the United States Army, and as Major Stimson she performed a great national service in establishing the Army Nursing Corps. During the period when Miss Stimson directed the medical social service, I worked closely with her as the chief of the medical clinic of the outpatient department. This association awakened in me an interest in medical social work that has never abated. The St. Louis Children's Hospital was reorganized along similar lines, with Borden S. Veeder in charge of the pediatric service in Howland's absence and with Murphy as surgeon-inchief and Opie as pathologist. They made up the committee that operated the hospital, with Charles E. Bauer as its superintendent. Early in 1913 Chancellor Houston was granted leave of absence to serve as Secretary of Agriculture in the cabinet of President Wilson, and Frederick Alden Hall was appointed acting chancellor. Houston, although perhaps overshadowed by Brookings, evidently was very effective in formulating and carrying out much of the early planning and in deciding who should be called to fill the new posts. The records show that he did more than is generally credited to him in the reorganization of medical education in St. Louis. Houston resigned as chancellor in 1916 and devoted the rest of his life to valuable service in the federal government. The Beginning of My Medical

Teaching

When I arrived in St. Louis in September 1913, the new buildings were well under way and there was much expectancy and enthusiasm in the air. I was soon making a beginning in medical teaching, of which I had a large and varied assignment. Although I had had practically no teaching experience, I was to learn, so to speak, by being thrown into the water and told to swim. I had prepared myself during the previous summer to teach the course of clinical chemistry and microscopy, a subject in which my predecessor, Roger Morris, was especially proficient. This was an important course for third-year students, 124

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aimed to give them the technique and knowledge for making the laboratory examinations of blood, excreta, and other specimens that could be of value in diagnosing a patient's disease. I also had the responsibility of the diagnostic laboratory of the hospital medical service and instructed individual students in the laboratory work connected with their ward patients. I was associate physician of the hospital, where I took a small part in the care of ward patients and the teaching of the fourth-year students who served as clinical clerks. I was also the chief-of-clinic in the dispensary, in charge of its medical service and of the teaching of clinical medicine to third-year students during their assignments to the medical outpatient department. During the spring trimester, after the laboratory course was completed, I conducted the course in physical diagnosis for second-year students, introducing them to the methods of examining patients. I had been strongly impressed by the importance of teaching students at the very beginning of their contact with patients to use their senses of seeing, feeling, and hearing as carefully and methodically as possible, and I subsequently taught physical diagnosis to students starting their clinical work in every school where I had professorial rank. I had and still have the conviction that there is nothing more important than to indoctrinate the medical beginner with the idea that the accurate and systematic use of his five senses in the examination of patients is an essential function of the physician which may never be omitted from medical practice. Besides teaching second-, third-, and fourth-year students, I was listed in the school catalogue as offering an elective course in electrocardiography to properly prepared undergraduate and graduate students. The medical department had purchased an Edelmann string galvanometer two years before. It had been set up by J. S. Brotherhood, Dock's resident physician during 1910-1911, but had been put away in the dispensary building after Brotherhood left. After a good many hours of work, I was able to get it again into operation and to inaugurate an electrocardiographic service during the year in the old hospital before moving into the Barnes Hospital. As the new hospital with its extensive outpatient department was nearing completion and would be occupied in the autumn of 1914, internal organization demanded attention. I was appointed chairman of a committee of three to organize the out125

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patient department, with Ernest Sachs, representing the surgical department, and Julia C. Stimson, the director of medical social service. We faced a large task which required visualizing all the activities that would go on in the various departments of the outpatient service, formulating methods of conducting them, and stipulating positions to be filled, printed forms to be used, and means of coordinating the work of the staff. It is clear that I was busy during my first year in St. Louis, and although I was not designated officially as a full-time clinical teacher and was not restricted by contract from engaging in private practice, my university duties left little time for outside work. I received a relatively small salary which I was expected to augment by private practice, and after a time I did see an occasional patient in consultation and had a few private patients in the Barnes Hospital. However, as might be expected, when the university obtained the funds in 1916 to place the clinical department on a full-time teaching basis, with salary increases for the principal professors, the new plan had my ready acceptance. By that time my own research activities were under way, and I had to find time for special studies in spite of a heavy teaching schedule. The increased financial support for the clinical departments provided more full-time assistants and more funds for the support of research, so that to me the initiation of the full-time plan of clinical teaching was a definite forward step which was much appreciated. Opening the New School The new buildings of what may now be called the medical center were completed in the latter half of 1914, and during the summer of that year the preclinical departments moved into their new laboratories. The hospital services were transferred after the Barnes Hospital had been dedicated on October 27, and somewhat later the Children's Hospital was occupied. All outpatient clinics began to function in their new building on December 14, to complete the move before the end of 1914. Moving into a new hospital is a difficult experience through which I have gone four times. Although months may be given to planning equipment and supplies, it is hard to foresee every contingency, and when responsibility for human life and human suffering is involved nothing can be overlooked for which there may be immediate need. The beginning days in a new hospital 126

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always create a strain on the medical and nursing staff, who have been accustomed to a well-running organization in an older hospital where a smoothly operating service had been built up over the years. I had direct responsibility only in the outpatient department, but my chief, Dr. Dock, delegated to me many of the details of organizing the medical service, in which I was much interested. By the time the new clinical facilities were put into operation, the medical department had been well organized, with a number of well-trained local physicians taking the responsibility for much of the outpatient service and teaching. The hospital resident staff was augmented by a splendid succession of recent graduates from Johns Hopkins, from the University of Michigan, and from our own school. I took special interest in organizing the laboratories of the medical department on the second floor of the building which also housed the dispensaries and the department of pathology and bacteriology. Here were laboratories for chemical, bacteriological, and physiological research closely related both to the patients and to the teaching laboratory of clinical chemistry and microscopy. I was particularly concerned with the physiological division, where I was to carry on studies of the heart, my main interest. The electrocardiograph that had been used in the old hospital was carefully transported and reassembled, and I was particularly pleased with an electrical switch that was constructed for me, by which each hospital ward could be thrown into contact with the electrocardiograph through a special set of wires, thus permitting records to be made without moving patients from their beds. I found this switch still on the wall of the laboratory in 1955, and had a nostalgic look at it, although with modern advances, it was no longer needed for its original purpose. A number of the members of the medical house staff worked with me on special cardiac problems: Hugh McCulloch, who has had an outstanding career in pediatrics in St. Louis and Chicago; Drew Luten, who continued for many years as one of the leading medical teachers of the school; Joseph F. Bredeck, who became distinguished in public health and served as the commissioner of health of St. Louis; Fred J. Hodges, now one of the leaders in radiology as professor at the University of Michigan; and George R. Herrmann, now professor of medicine at the University of Texas. My outstanding associate was Frank N. Wilson, who 127

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was appointed an instructor in medicine in 1916. We worked together for several years, and he eventually became one of the leaders in the field of electrocardiology. As professor of medicine at the University of Michigan he became recognized as a national leader in fundamental studies of electrocardiography and of heart disease. Wilson had a fine mind and was a quiet individual who stood out among his fellow-workers by reason of his scientific devotion and originality. During our association he was one of those young men who teach their seniors more than they learn from them. On April 28, 29, and 30, 1915, the Washington University Medical School was formally dedicated, and a notable group of educators representing the leading American universities attended the ceremonies and participated in the program. "For one man," Miss Fox has written, "the dedication ceremonies marked a great personal triumph. Against almost overwhelming difficulties Robert Somers Brookings had fought to provide buildings, organization and men. He had given, rarest of gifts, himself, his time, consuming interest and industry, and he had given quietly. None of the buildings bore his name; there was no outward evidence of his contribution, no exceptional mention of his service in the happy speeches which marked the occasion. Aside from the gesture made by Governor Francis, only William Henry Welch, to whom Brookings had first turned for advice, made a personal reference to him. It is given to few men to view the visible results of their efforts in such a satisfying way as could Robert Brookings as he walked about the grounds and through hospital corridors and laboratories at the dedication ceremonies in April 1915." At the beginning of the ceremonies Brookings made a modest, straightforward statement, saying that Washington University had undertaken to provide a plant and organization for the teaching of medicine and for medical research in conformity with high ideals of medical education. "We hope," he said, "that our efforts will contribute, in some measure, to raising the standard of medical education in the West, and that we will add, through research activities, our fair quota to the sum of the world's knowledge of medicine." On this occasion Eugene L. Opie, as dean of the medical school, gave a noteworthy address in which he outlined the general policies of the medical school and the objectives it hoped 128

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to attain. This address is an admirable expression of the new thought and attitude beginning to pervade medical education at that time. It sets forth the role of the university school in advancing knowledge and the influence of research on teaching. It is of historic significance because it announces the arrival of the new spirit of medical education in the Southwest. After reviewing the history of the medical school, Opie pointed out that medical education was then in a transitional stage between the old and the new, and defined the position Washington University must take if it was to represent the advancing standards of university medical education. "The school cannot afford," he said, "to neglect any means by which the benefits of medical knowledge of today may be transmitted through its students and its teachers to popular use. Its first purpose will be to make available to them the knowledge of today, and it must make sure that they obtain a preparation which will fit them to acquire new knowledge of the future. The ultimate success of the school will depend upon the relatively small number of unusually able men who will become fitted either as practitioners or as teachers to take the highest places in medicine." In advocating the importance of earnestly promoting investigation in medicine, Opie said that "the habit of keeping pace with the development of knowledge may be acquired by attempting to add to knowledge. The teacher who has contributed to a science has an immense advantage when he attempts to inspire others with a love of truth. . . . Investigation is founded upon the capacity to express reality and is opposed to pretense, egotism and contention. All who have the success of this institution at heart will continue to foster a spirit of loyalty to the purposes which they support." He discussed the difficulties of creating and maintaining clinical departments in the school and hospital that would have the true spirit of the university in regard to scientific research, and touched upon the importance of developing the department of preventive medicine which held a prominent place in the original ideas of organization. Opie closed his address by saying, "remedial and preventive medicine represent only one phase of exact knowledge, but the establishment of an institution devoted to the pursuit and dissemination of truths intimately related to individual and social welfare cannot fail to become a significant contribution to the intellectual life of a community in which it is established." 129

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The address of William H. Welch was especially significant because he discussed the development of clinical teaching. Welch had attained the position of "dean" of American medical education and was its leading "elder statesman." He had given wise counsel to Brookings from the beginning of the movement to reorganize the medical school and was deeply interested in its success. He said that the reorganization of the Washington University Medical School in accordance with the most advanced standards of modern medical teaching and research was one of the most significant events in the recent history of medical education in America. He spoke of the very favorable facilities of the school for clinical teaching through its hospital affiliations and said: ". . . the manner and extent to which the educational ideals of the university, which are now realized in the laboratory, can be applied also to clinical organization and teaching, is perhaps at present the most interesting and the most discussed problem of higher medical education." He described the plan recently adopted at Johns Hopkins, usually designated the fulltime or university system of clinical organization and teaching, which had been made possible by a generous gift from the General Education Board, and indicated his satisfaction in learning that a similar scheme of organization of the main clinical departments would be introduced at the Washington University Medical School when requisite funds were available. Welch then presented the principal advantages of the full-time plan, a basic condition of which was the payment of sufficiently large salaries to the professors in the clinical fields and to some members of their staffs to free them from the necessity of engaging in private practice and to allow them to devote themselves uninterruptedly to university activities. In support of this plan he said: ". . . the conduct of one of the main clinical departments in a first-class school and hospital demands today even more insistently than that of the laboratory the time and devotion of those in charge. The subjects themselves are the most important and occupy the most time in the curriculum, and the work of teaching, of investigation and of hospital practice, if properly performed, is quite incompatible with a considerable outside practice." After discussing various phases of this innovation in medical teaching, he said: "When one considers what a first-class modern medical or surgical clinic really means, its richness in opportunities for advancing the science and art of medicine, when pro130

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vided with the requisite staff, laboratories, equipment and funds, the influence which it can exert upon the ideals and standards of students and of the profession, where in the whole domain of medicine can be found a career surpassing in the strength of its appeal to scientific and humanitarian interest and desire for useful service that which is opened to properly qualified clinicians under this university system of clinical organization? Whether the full-time system be widely adopted or not—and financial considerations make doubtful its speedy extension to many medical schools—its underlying conception cannot fail to exert a profound influence upon clinical organization and teaching, as is already apparent." This address is one of the best discussions of the introduction of true university standards into the clinical departments of medical schools, which has brought about a conspicuous advance in medical education. Full-Time

Clinical

Teaching

At the time the plans for reorganization of the medical school of Washington University were formulated, it was the accepted policy of all American medical schools that clinical teaching be conducted by physicians and surgeons engaged in private practice from which they mainly derived their financial support. Under these circumstances clinical teachers could give only part of their time, energy, and thought to teaching and to directing their hospital services. They could not devote themselves wholeheartedly to scientific research and the publication of their studies. This method of organizing clinical departments had the advantage of requiring relatively small financial support, as compared with fully developed laboratory departments, and at that time none of the medical schools could afford to conduct their clinical departments in any other way. The development of clinical research in Barker's medical clinic at Johns Hopkins and at the Hospital of the Rockefeller Institute demonstrated that research in clinical medicine should be more widely developed and that clinical departments should be organized on a university basis with provision of laboratory facilities and of men with the training and ability needed to direct and carry on clinical research. To accomplish this the clinical departments had been reorganized on a full-time university basis at Johns Hopkins in 1913, requiring, as Dr. Welch pointed out in his address, large financial resources. 131

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Washington University was prepared, with its splendid hospital facilities and the research laboratories of the departments of medicine, surgery, and pediatrics, to embark on this new type of organization, provided funds could be obtained to pay the salaries necessary to maintain the professors and a group of associates on a full-time basis and to underwrite increased expenses of research. The idea of organizing the clinical departments on a true university basis was given careful consideration in 1913 by the medical faculty, university directors, and hospital trustees, all of whom gave enthusiastic support to the plan. In January 1914, Brookings formally applied to the General Education Board for financial assistance similar to that given Johns Hopkins and under the same conditions. His letter described the facilities of the medical school and reviewed the financial problems the university was facing, pointing out that "every dollar which we have secured has been given by our own people and we regret to say has pretty thoroughly exhausted, for the present at least, our giving ability." He said that the university directors, the hospital trustees, and the medical faculty had passed resolutions without a dissenting vote requesting the president of the university to make this appeal to the General Education Board, as they were all convinced that the future of medicine largely depended upon the adoption of full-paid clinical staffs in the major departments. Brookings added one personal note at the end of his letter which he hoped might have an emotional appeal. He wrote that he understood the General Education Board was to meet on January 22 which "happens to be my birthday, and I should of course appreciate a generous birthday present." I have no doubt, knowing the high esteem everyone had for him, that this little appeal carried weight with some of the board members. The General Education Board granted $750,000 to the university at this meeting, on condition that it raise an equal amount within five years, and that $1,500,000 be held as endowment to support medicine, surgery, and pediatrics on a full-time basis. On February 10 the university signed contracts with the General Education Board which stipulated that the members of the fulltime staff were free to render any service required by humanity or science, although they would derive no pecuniary benefit therefrom, and fees charged for professional services rendered to private patients within or without the hospital must be used to 132

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promote the objects for which the fund was created. The share of the fund to be raised by the university could not be secured at that time because endowment for the school and hospital and the building of the nurses' residence were considered to have priority, but in the spring of 1916 the General Education Board added $250,000 to its grant, and the remaining $500,000 was contributed by John T. Milliken, Mrs. Mary Culver, and Edward Mallinckrodt, their names being given, respectively, to the departments of medicine, surgery, and pediatrics. On July 1, 1916, the university plan of organization was put into effect with George Dock as full-time professor of medicine, Fred T. Murphy in surgery, and William McKim Marriott, appointed shortly thereafter as the full-time professor of pediatrics. Marriott, a Cornell graduate, had come to St. Louis with Shaffer in biological chemistry in 1910, and from 1914 to the time of his appointment had been on the pediatric staff at Johns Hopkins with Howland. His excellent chemical training was a great asset in pediatric research, and he built up an outstanding department of pediatrics, later serving brilliantly as dean of the medical school. A committee of the medical faculty composed of Shaffer (then the dean), Dock, and Opie studied the problems of inaugurating the full-time plan and Shaffer and Dock discussed the plan with medical leaders in Baltimore, New York, and Boston. In the fall of 1916 the reorganized clinical departments were put into operation. The establishment of the full-time plan was the last major problem of medical education to which Robert Brookings devoted himself. When the United States entered World War I in 1917, he was called to Washington to help organize the War Industries Board, but he remained president of the university corporation until 1928. His last visit to the university was in 1929 when the honorary degree of Doctor of Medicine was conferred upon him. This was one of the few times in American academic history that a university has conferred on a layman the honorary degree of Doctor of Medicine, and it was certainly richly deserved. No layman ever labored more energetically, more wisely, and with such success as Robert Brookings for the advancement of medicine. Turning his thoughts and talents to national economics in the service of the government, he became thoroughly engrossed in the problems of economics and government, which eventuated in his establishing the Brookings Institution in Washington to 133

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which he gave the same remarkable leadership that had been so important in the development of Washington University and its medical school. At the age of seventy-seven he was married to his friend of many years, Miss Isabel January, who did much to bring new happiness into the last five years of his life, which ended in 1932. The organization of the major clinical departments on a fulltime basis at Johns Hopkins and at Washington University was of much significance in the educational revolution taking place at that time in the American medical schools, and had a lasting influence especially on the schools that were subsequently established and the old schools that were basically reorganized thereafter. It changed the relationship between medical practice and medical teaching, affording for the first time opportunities for academic careers in the various fields of clinical medicine. It therefore seems appropriate to discuss some of the principles and methods involved in the adoption of this innovation. The desire to develop more fully the university functions and to elevate the status of scholarship in clinical medicine led to the establishment of the full-time teaching plan to provide improved opportunities for the pursuit of clinical research. It was designed to raise clinical departments to true university status in the modern sense and is, therefore, called the university plan of clinical teaching. In order to do this, salaries had to be provided which allowed a number of men in each department, including the professor and several of his associates, to devote their entire time to the departments and to embark on academic careers in clinical medicine. Well-equipped laboratories, ample libraries, and adequate hospital services under the professional control of the departments were essential, as were funds for assistants, technicians, apparatus, and supplies. To meet these requirements large resources were necessary, especially to provide adequate salaries for talented men whose potential earning capacity in medical practice was often much in excess of the largest university salaries, and who were essential to the success of the fulltime plan. According to this plan the heads of departments were to devote all their time and energy to supervising the care of patients in the wards and outpatient department of the hospital, to teaching, to directing the activities in their department laboratories, 134

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and to conducting research in their own special fields. These duties placed such exacting responsibilities on the department heads, that it was essential to free them from engaging in the private practice of medicine. This was done by providing salaries sufficiently large to relieve them of the necessity of augmenting their incomes by fees from private patients. In order to insure that the university would be the sole, constant interest of the professors, they were appointed with the understanding that when, for humanitarian or other reasons, they rendered services to patients who paid professional fees, such fees were to be used for the support of their departments. This was a just and practical restriction on those to whom full university salaries were paid, but it was the cause of much controversy throughout this country during the years of discussion of the full-time plan, especially by the members of the medical profession who were not participating in the plan. To those desiring to work intensely in clinical medicine at the university level, this financial provision was looked upon as an opportunity rather than a restriction. Men must be attracted to the university career not primarily by the salary, but by the spirit of research, by facilities for investigation, by a chance to gratify the productive instinct in science, by time to read, to study, to contemplate, and by opportunities to enjoy in company with kindred spirits the intellectual stimulation of a university career. The three basic objectives of university clinical departments are to provide the best possible care of patients, to teach and train students to make them the most efficient practitioners of medicine as is possible, and to discover, establish and disseminate new medical knowledge through research. In order to reach effectively all these objectives it was clearly recognized that the departments should be staffed not only by those whose main interest was in the academic activities of teaching and research, but also by physicians and surgeons whose activities were primarily in the practice of medicine within or without the confines of the hospital, and that it was important to have a proper balance and adjustment between these two groups of men to obtain the highest efficiency in the care of patients, in teaching, and in research. There must be no barriers between the two groups, and mutual professional respect, cooperation, and willingness to learn from one another is necessary to form a unified 135

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department. Clinical departments must be composed of various types of men who must be adjusted within the departments according to their ability, temperament, and training. Although diversity is necessary, every member of a clinical department who has the responsibility for patients must have an interest in them as individuals, and in the problems each one presents. This interest must be sufficient to impel him to master the technique of clinical methods and to awaken the humanitarian spirit without which the physician in the true sense of the word does not exist. A man who lacks this interest, or whose desire to accomplish research overshadows it, belongs more properly in the department of pathology or physiology, where the care of patients is not encountered. The unity of a department of medicine, in which I have had experience as a full-time teacher, is fostered by weekly clinical conferences, attended by the whole department, in the hospital wards and in the outpatient services, where there occurs a free exchange of ideas and what may be called auto-education. By this means much knowledge is disseminated throughout the department, and an effort is made to have the special skill and training of each member of the staff used for the solution of diagnostic, therapeutic, and research problems for which he is especially well qualified. The patients for which such a department is responsible should receive the best possible professional care and the highest quality of medical service, thus keeping the teaching services of a university hospital always in high public esteem. It is customary to have the medical wards and the medical administration in the outpatient department under the direction of full-time men who carry the routine of the organization. This creates a situation especially attractive to physicians in private practice who wish to keep abreast of the rapid advances in medical science and practice of which some member of the department is a special student. The full-time and part-time groups in a department of medicine are of great benefit to each other and to the teaching of both the art and the science of medicine—the art concerned with doing and the science with knowing. Clinical departments organized on the university plan can fulfill most advantageously their basic obligations to patients, to students, and to the pursuit of research, and can offer valuable opportunities to both full-time and part-time members of the staff who 136

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sincerely desire to be at the front of medical progress and to be leaders in medical thought and practice. World

War I and Its

Effects

The development of the clinical departments on a full-time basis in the Washington University Medical School was made difficult by the times, as by then Europe was engulfed in the First World War and the United States was making preparations to enter it. In 1915 Eugene L. Opie resigned as dean. Philip A. Shaffer was appointed, and the medical school was under his guidance when the departments of medicine, surgery, and pediatrics "went on full-time" and required adjustment and extension. Shaffer, the professor of biological chemistry, was the youngest of the group called to reorganize the school five years before, and he was only about thirty-five years old at this time. Although his term of active service as dean lasted only about two years, he had a long and distinguished career at Washington University, being the last of the original group to retire and exerting valuable leadership. He again became dean in 1937, when for some years he was a wise counsellor during the great expansion of the medical center. It was difficult in 1916 and 1917 to find men suitably trained for academic positions, but some excellent appointments were made. Frank N. Wilson, previously mentioned, and Alan M. Chesney, who was called from the Rockefeller Institute Hospital, were appointed to the full-time staff in medicine; Philip C. Jeans, Jean V. Cook, and Samuel W. Clausen were appointed in pediatrics ; while Barney Brooks and Edwin P. Lehman began their academic careers in surgery. All these men had distinguished records and eventually became university professors. Chesney became dean of the Johns Hopkins Medical School. An event causing great disturbance of the medical school was the organization of Base Hospital No. 21 under the auspices of the American Red Cross, and its departure for service in Europe on May 17, 1917. The organization, begun in 1916 with 28 officers, 65 nurses, and 185 enlisted men, was headed by Fred T. Murphy, professor of surgery. Members of the hospital staff rendered important service overseas, a number of them being detached from the base hospital for special duties. Julia C. Stimson, who was head of the nursing corps of the hospital, was especially distinguished as has been noted. Altogether, 85 members 137

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of the faculty and hospital staffs entered military service, among them being Dean Shaffer, who went on active service overseas in 1917 with the Food and Nutrition Division of the U.S. Sanitary Corps. When the base hospital was organized, I was one of a small group not allowed to participate, but assigned to duty in the medical school in order to keep it going as a training center for medical officers; when Shaffer left I was appointed acting dean. It was a rather tough assignment, especially as one of my duties was to hold together a teaching staff and prevent the men from entering military service. A list of essential teachers was made, and some who were on it thought of it as a "black list." I recall one patriotic enthusiast who pleaded with me for freedom to go, as he had had ancestors in every American war beginning with the Revolution, and could not be reconciled to breaking the chain. It took telegrams to the Surgeon General's office and the Red Cross to head him off. The students, except for those who were taken by the base hospital unit and graduated in France, put on uniforms and underwent military training in Forest Park in front of the hospital. During the war, instruction units for medical officers were established by the Army in the medical school and were conducted by members of the faculty. The first was the school of plastic, oral, and neurological surgery in which Vilray P. Blair, an outstanding leader in plastic surgery; Ernest Sachs, one of the American pioneers in neurological surgery; and Robert J. Terry, the professor of anatomy, took leading parts. A second Army school was established for the study of venereal and skin diseases and genito-urinary surgery. Among the activities stimulated by the war spirit that were organized and conducted in St. Louis were those related especially to the rehabilitation of the physically handicapped and designed primarily to serve the wounded soldiers returning from Europe. At that time almost no governmental provisions had been made for the rehabilitation of crippled soldiers. Very little thought or effort had been given to the problem of rehabilitation, which has since developed into an important field of medical and social service, especially in St. Louis. I became much engrossed in this field, primarily because of my interest in medical social service, and served on the first area board of the Federal Board for Vocational Education—the initial governmental effort to 138

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rehabilitate disabled veterans. The board consisted of four men: an employer, a labor man, a representative of the federal government, and a doctor—the position I filled. Its function was to advise disabled soldiers who returned to their home area (Missouri, Kansas, Iowa, and Nebraska) regarding the sort of training in schools and industry the government could offer them. This was a crude beginning of a very important service. Before long our little board was swamped, and the service was reorganized on a single-state basis. I joined another group to organize and operate the St. Louis Placement Bureau for Handicapped Men, headed by Mrs. Sidney I. Schwab, whose husband was professor of neurology in the medical school and had developed a successful service for psychoneurotic soldiers overseas. The objective of this bureau was to study the problem of placing the physically handicapped in industrial positions. To this end we inspected industrial plants and talked with superintendents and workers to discover jobs handicapped people could fill successfully, and to encourage their employment by educating employers and employees concerning the usefulness and practicability of the project. After we had demonstrated the value of the bureau, it was taken over by the St. Louis chapter of the American Red Cross. Being convinced that the medical profession generally should be informed and stimulated regarding the part it should take in the rehabilitation of crippled soldiers, I presented a paper at the annual meeting of the Missouri Medical Association in May 1918 on the responsibility of the medical profession to the crippled soldiers. I pointed out that their adjustment to civilian life required, besides the best possible medical care, the use of carefully selected and properly devised mechanical appliances, occupational therapy, vocational training, and careful placement and oversight in industry. The medical profession was urged to participate in such a program by giving the disabled soldiers intelligent medical and surgical care, encouragement, and psychological guidance, as well as by constant efforts to stimulate public opinion on behalf of the disabled soldiers. I also participated in the efforts of the American Red Cross to generate interest in rehabilitation of the physically handicapped and accompanied a group from its Midwestern area office as far as Oklahoma to speak on this subject. These efforts to arouse interest and start activities in re139

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habilitation in the Middle West toward the end of World War I are of historic importance, as they mark the beginning of the movement that is now officially active in every state of the Union and has the generous financial support of the federal government. The development of occupational therapy as a phase of the rehabilitation program was one of my major interests during the war years. Under a committee made up of the medical faculty and the social service department of Washington University and the St. Louis Junior League, which financed the project, a curative workshop was established in the Barnes Hospital. Here patients could be observed at work under the direction of an occupational therapist with unusual talent for giving them the needed encouragement and restraint. It afforded not only an opportunity to see the therapeutic value of regulated occupation, but also to judge the physical limitations, or sometimes lack of them, required by patients with heart disease, psychoneuroses, and other chronic ailments. Most of the patients were from the outpatient department of the hospital, and a number of them were later placed in suitable occupations by the St. Louis Placement Bureau, with which the workshop was closely coordinated. This experience created wider interest in occupational therapy, and the Missouri Occupational Therapy Association was formed with the idea of developing a school where occupational therapists could be trained for work in a number of the St. Louis hospitals. This project had the leadership of Mrs. Rachel Stix Michael, who carried out much of the work of this organization with a splendid spirit of quiet service. She refused to accept the presidency of the board of directors of the association when it was finally incorporated, and I was elected to this post. The school of occupational therapy was started in the Washington University department of fine arts. Eventually it was transferred to a university building adjacent to the medical school, became a school of the university, and developed into one of the leading centers for the training of occupational therapists in this country. The leadership of Rachel Stix Michael in the field of rehabilitation was later commemorated by giving her name to a special school for handicapped children established near the medical school by the City of St. Louis. In March 1919 I attended the International Conference for the Disabled in New York and presented a paper on occupational 140

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therapy in civilian hospitals, giving an account of the various rehabilitation projects in St. Louis. When I returned from a four-day trip, I found that one of my best friends had died of influenza while I was away. That event marked for me the beginning in St. Louis of that terrible world-wide epidemic which left a lasting impression on this country. Never in our history have we encountered anything so like the frightful epidemics of olden times. I served on a small medical committee to advise the St. Louis City administration and its commissioner of health. On our recommendation not only the schools, but all department stores, theaters, and other places where people congregated were closed for several days. Knowing at that time so little about influenza and the devastating pneumonia that often followed it, we were not sure what to advise. However, the public demanded some action, and the prevention of crowds was about the only measure we could devise that could be quickly applied to the general population. It probably was somewhat effective, as the epidemic was not as abrupt or as overwhelming in St. Louis as in some other large cities. This world-wide epidemic of influenza merits inclusion among the medical events of the first half of the present century, not only because of the devastation it brought, but because it stimulated popular interest in the public health movement which was getting under way at that time in the various states. Post-War

Adjustments

It is evident that the medical men who stayed at home during the First World War had much to occupy them, and we experienced a sense of relief when Base Hospital No. 21 returned to parade the streets of St. Louis and to be demobilized on May 3, 1919, after twenty-three months of foreign service. When the war was over several adjustments in the medical school had to be made. Philip Shaffer, returned from his tour of duty, asked to be relieved of the deanship, and I was appointed to carry on as dean as I had done in his absence. Fred T. Murphy, the professor of surgery, who had directed the organization of the base hospital and had led it overseas, reminded the executive faculty that when the full-time teaching plan had been approved, he had stated that although he would not raise objections, he did not consider himself suited to head the surgical department on a full-time basis. He therefore resigned. Murphy had 141

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heavy obligations to various members of his family as the only one suited to manage large business affairs which had been inherited, and this was doubtless a factor in his decision. He had given splendid service to the medical school, especially during the period of reorganization, and was an unusually fine, stalwart man. There seemed no way, however, to keep him in the medical school, as he wished to retire from surgery. He rendered thereafter valuable service as a member of the corporation of Yale, his alma mater, and as a trustee of his old school, Philips Academy at Andover, Massachusetts. Eugene Opie and I were designated to go to Chicago to investigate the possibilities of filling Murphy's place, and on our first day of inquiry Dean Lewis, who was later to go to Johns Hopkins as professor of surgery, told us of a young man named Evarts Graham, who was just out of the Army and seemed to be much interested in an academic career in surgery. Through our mutual friends, Henry Helmholz and Rollin T. Woodyatt, we spent the evening with Graham, who was soon invited to visit St. Louis and was appointed professor of surgery in 1919. Graham, a Princeton man, graduated in medicine at the Rush Medical College in Chicago, and had been appointed to its surgical department. He had had special training in pathology and chemistry and had taken a three-years' leave of absence in the Sprague Memorial Institute for Clinical Research in Chicago, where he had worked on chemical problems. The appointment of Evarts A. Graham as professor of surgery at Washington University, made without the prolonged struggle so often required in filling such positions, was indeed fortunate. He soon became a surgical leader, a pioneer in pulmonary and gallbladder surgery and in surgical research. He not only built up one of the finest surgical clinics in this country, but was awarded many international and national honors, and trained a number of surgeons who became professors in other medical schools. The department of pharmacology, which had not been originally developed as an independent department, was left without a head when Dennis Jackson, associate professor, was called to the University of Cincinnati in 1919 as professor of pharmacology. It was decided that an endowment of $300,000 should be sought to raise pharmacology to the level of other departments before appointing a professor. An appeal for funds was made 142

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to the General Education Board, which granted $150,000 for this purpose, contingent upon the university's raising an equal amount. Robert Brookings was no longer available in St. Louis as adviser and benefactor, so this situation was brought directly to the attention of Mr. Edward Mallinckrodt, who showed his continued interest in the medical school by generously contributing $150,000 to complete the endowment. The department was eventually designated as the Edward Mallinckrodt Department of Pharmacology, and E. Kennerly Marshall was appointed professor in 1919. Marshall had a thorough training in chemistry with both Ph.D. and M.D. degrees from Johns Hopkins, where he had been associate professor of pharmacology with the leader in this field, John J. Abel. Women students were first admitted to the medical school in 1919. This was a change of policy which I advocated strongly, not only because women should not be denied superior opportunities to study medicine, but also because they elevate the social tone of the student body and are often outstanding in their medical work. This was a forward step in medical education in the Middle West which was soon followed by practically all medical schools. The End of an Adventure

By the fall of 1919, academic tranquillity had largely replaced the hectic days of the World War. I was glad to concentrate more fully on the care and study of patients and to find time for work in the laboratory. I was interested in studies of the drug digitalis, both in patients with heart disease and in animals in the laboratory, and published the results of several completed studies. I was settling down with enjoyment in medical teaching and in various community activities, when I was suddenly faced with a proposal that required a serious decision. This was the offer from Vanderbilt University to direct the reorganization of its medical school under conditions to be related in the next chapter. I resigned from Washington University to accept this appointment on July 1, 1920. To leave St. Louis and begin a new medical adventure was a difficult decision, and my family and I had many regrets that it had to be made. We had spent seven happy years there and had strong ties both within the university and in the community that we could not break lightly. These years had been particularly 143

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full of interest and valuable experience, because I had the good fortune of participating in one of the most important developments in the annals of American medical education—the reorganization of the Washington University Medical School. The school and its affiliated hospitals, as I knew them at the time of reorganization, have continued to grow extensively and soundly into a great medical center. The people of St. Louis, following the example of Robert Brookings, have taken much pride in its development, and their example has encouraged generous support by foundations and other agencies outside the city. Today the medical center is one of the finest monuments of civic endeavor and liberal community support in this country.

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THE VANDERBILT UNIVERSITY SCHOOL OF MEDICINE -< 1 9 2 0 - 1 9 2 8

ANDERBILT University suddenly became of interest to me when its chancellor, James H. Kirkland, came into my office in St. Louis in November 1919 and told me that the university was to receive $4,000,000 from the General Education Board for the reorganization of its medical school. He asked me to suggest a man who might be suitable to direct this undertaking, and after we had discussed several possibilities, he surprised me by asking what I thought of Canby Robinson for the job. I replied that I had not thought of him, but would be glad to give him consideration although at that moment I was quite unprepared to make a decision. We agreed that I should visit the university at Nashville, Tennessee, and should confer with the officers of the General Education Board. Soon after my visit from the chancellor I had a talk with Wallace Buttrick, the chairman of the board, and Abraham Flexner, its secretary, in St. Louis, and found them much interested and enthusiastic regarding the prospects at Vanderbilt, where they anticipated that a medical school of first rank might be developed. On my visit to Nashville, I learned from Chancellor Kirkland that it was planned to reorganize the medical school completely, including the erection of new buildings. To facilitate the reorganization, all members of the medical faculty had submitted their resignations. He offered me the appointment of dean and professor of medicine, and as such I would direct the reorganization of the medical school. We visited the school, 145

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located about two miles from the main campus of the university on the other side of the city, and found a heterogeneous group of five or six buildings dominated by the unfinished Galloway Memorial Hospital on what was known as the South Campus. Funds for this building had been raised largely by members of the Methodist Church, and the hospital was named after an eminent bishop. However, the project had never been completed because financial support had given out several years before. The building had been acquired by the university, and part of the new plan was to remodel and complete this hospital and to build new laboratories adjacent to it. As to the other buildings—one had been built as a college in about 1850, another was occupied by the Vanderbilt Dental School, and a third had been built to house the University of Nashville Medical School which had been taken over by Vanderbilt. The original Vanderbilt Medical School building, about two blocks away, had been converted into a small hospital and dispensary which, with the Nashville City Hospital not far away, provided the facilities for clinical instruction. Viewing these buildings, it was natural to wonder why the General Education Board had selected Vanderbilt for its special interest, and had granted it the largest single appropriation the board had made up to that time to any institution. To understand this decision it is necessary to know something of the history of the university, of its medical school, and especially of the remarkable leadership of Chancellor Kirkland. Vanderbilt

University and Chancellor

Kirkland

The establishment of Vanderbilt University in 1875 was made possible by the gift of $1,000,000 by "Commodore" Cornelius Vanderbilt. He was much impressed by Bishop Η. N. McTyeire of the Southern Methodist Church, who visited him in New York and told him of the great educational needs in the South, impoverished by the Civil War. "Commodore" Vanderbilt first gave Bishop McTyeire a check for $500,000 with a letter in which he wrote: "If Vanderbilt University shall, through its influence, [contribute] to strengthening the ties that should exist between all sections of our common country, I shall feel that it has accomplished one of the objects that led me to take an interest in it." This was a remarkable statement from a man who was generally considered one of the ruthless "robber barons" who 146

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flourished in the post-Civil War period. His original gift was followed by an offer to provide land and buildings under the direction of the bishop, who, he stipulated, should be president of the board of trust. His total contributions amounted to $1,000,000. It would carry us too far afield to review the course of Vanderbilt University, its stormy relations with the Methodist Church, and its financial struggles and triumphs; we must confine ourselves to the story of its medical school. The first medical school in Nashville was established in 1850 as the medical department of the University of Nashville and had remarkable success in attracting large numbers of students. It was a typical example of the proprietary school, controlled entirely by its faculty and supported solely by students' fees. In fact the board of trustees of the university took the school under its wing with the specific provision that it would have no financial responsibility for the medical school. Vanderbilt University at its very beginning was interested in including medical education in its program, and this school became the first medical department of Vanderbilt, but continued its connection with the University of Nashville, its students choosing to graduate from either of the universities. In February 1875 Vanderbilt University granted the M.D. degree to sixty-one graduates—the first recipients of degrees from the new university. The medical department was conducted as an old-fashioned lecture course school for twenty years and was controlled entirely by its faculty. Changes began in 1893, when James H. Kirkland was appointed chancellor of the university, to be its distinguished leader for forty years. James Hampton Kirkland was born in Spartanburg, South Carolina, in 1859, the youngest of eight children of the Rev. William Clark and Virginia Kirkland. His father was a Methodist preacher who died when James Kirkland was a child, and he grew up in the South during the impoverished Civil War period. By outstanding mental endowments and qualities of character, he overcame all the obstacles that stood in the way of his obtaining the finest educational opportunities. He graduated from Wofford College in 1877 at the age of eighteen, having made a brilliant record, especially in Latin and Greek, and remained there to obtain his M.A. degree the following year. Under the inspiration of Charles Forster Smith, a fellow townsman who joined the Wofford faculty in 1875 on his return from Leipzig 147

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University, Kirkland's mind turned toward the German universities, then the intellectual leaders of the world. By teaching and living meagrely in association with the great minds of classical literature, he saved enough money to go to Leipzig in 1883, accomplishing, as he wrote, "what I have been longing for so many years." Kirkland received his Ph.D. degree in Leipzig in 1885 and remained abroad another year to work in Berlin and to visit other parts of Germany, Austria, and Switzerland. Three weeks after returning home in the spring of 1886, he was appointed professor of Latin at Vanderbilt, then the leading university in the South. In 1893, at the age of thirty-four, he was appointed chancellor. Kirkland has been admirably portrayed by Edwin Mims, who served under him for many years as professor of English, and I have drawn freely from this book.* Mims sums up Kirkland's qualifications as chancellor in the following words: "His disciplined and vigorous mind, his indomitable will and unflinching courage, his knowledge of the German educational system at its best, his experience in helping shape the educational policies of Vanderbilt, his instinctive knowledge of Southern conditions, his proficiency in public speech and in expository writing—all would stand him in good stead if he should become the head of an educational institution. So thought the Board of Trust of Vanderbilt when in June, 1893 they elected him Chancellor." I found that Kirkland indeed possessed all these qualities of mind and character when I came to work under him in 1920. He was one of the most far-seeing, wise, and sound administrators with whom I have had the good fortune to be associated, and his alert and penetrating mind, his integrity, his ability for clear understanding and expression, and his delightful sense of humor, all combined to heighten the pleasure and privilege of working with him. He took delight in flowers, being nationally known as a grower of iris, and his garden on the campus attracted visitors from far and wide. One of a group of ladies who had come from another city to see his beautiful display of iris did not recognize the chancellor in his gardening clothes working among his plants, and asked him: "Do you work for Chancellor Kirkland?" Without embarrassing the lady by revealing his * Edwin Mims. Chancellor Kirkland of Vanderbilt. Nashville, Tennessee: Vanderbilt University Press, 1940. 148

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identity, he replied: "No, Ma'am, I work for Mrs. Kirkland." This story, which he told on himself, is characteristic of the man who always worked for others. The History of the Medical School In his inaugural address in 1893 Kirkland made only an indirect reference to the medical school, speaking of the appalling lack of standards and ideals in the professions and saying: "Lawyers know little law and doctors less medicine when they begin their dangerous careers." One year after his inauguration, however, he began bringing the medical school under the control of the university. In 1895 the school was reorganized, and what was considered an adequate building to house it was erected in South Nashville. William L. Dudley, professor of chemistry in the college, who became its dean, was a potent force in bringing the spirit of the university into the medical school. The course was lengthened to three years, a graded curriculum including laboratory work in chemistry and bacteriology was adopted, and a dispensary was opened for clinical teaching. In 1899 the course was extended to four years of seven months each, bringing the medical school into conformity with the requirements for certification by the American Medical Association. Other improvements, including higher standards for admission and increased tuition, were instituted. The faculty was still dependent on students' fees for its remuneration, and with the increased costs of operation, its members received small payment for their work. They deserve much credit for the spirit in which the school was conducted and for their constant effort to improve the quality of medical education. This was the situation of the Vanderbilt Medical School when it was inspected by Abraham Flexner in January 1909. Compared with Johns Hopkins, his ideal, he found little to commend it, there being no striking differences between Vanderbilt and its rival medical school, the University of Nashville, then affiliated with the State University of Tennessee at Knoxville. There were at that time nine medical schools in Tennessee, three being for colored students. The state "protects at this date," as Flexner stated in his report, "more low-grade medical schools than any other southern state." Although sympathetic to local difficulties and the small amount of money available for medical education, his criticism indicates the low level of the medical schools, char149

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acteristic of the large majority of that day. He wrote: "The six white schools value their separate survival beyond all other considerations. A single school could furnish all the doctors the state needs and do something to supply the needs of adjoining states as well. Low as the entrance standard must be, it has been made lower in order to gather in students for six schools where one would suffice. The medical schools solicit and accept students who have not yet made the best of the limited educational opportunities their homes provide; and to this extent, not only injure the public health, but depress and demoralize the general educational situation." After a critical but tolerant discussion of the confused condition of medical education in Tennessee in 1909, Flexner prophesied: "If our analysis is correct, the institution to which the responsibility for medical education in Tennessee should just now be left is Vanderbilt University; for it is the only institution in position at this juncture to deal with the subject effectively. This does not mean that Vanderbilt has now any large sums of money available or that it should inaugurate impossible entrance standards. It can do neither, for the general situation countenances neither. The suggestion merely recognizes the facts that one school can do the work; that Vanderbilt occupies in Nashville the point of vantage; that, in the public interest, the field should be left to the institution best situated to handle it." Flexner pointed out some of the problems Vanderbilt University would have to face in assuming state-wide responsibility for medical education, and stated that every effort should be made to secure endowment specifically applicable to the medical department. He closed his discussion of medical education in Tennessee in the following words: "Let it be said ungrudgingly that these suggestions are offered in no spirit of unkindness. The State University and Vanderbilt have had their hands full. They have worked valiantly amidst conditions that might well appal the strongest hearts. They deserve no blame for the past, provided only they unselfishly and vigorously cooperate in forgetting it. In the last few years right courses of action in medical education have for the first time been defined. A decade hence it will be fair to look back and ask whether the universities of the state have followed them." It is interesting to recall that a decade after he published 150

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these prophetic words in 1910, Flexner, having become the secretary of the General Education Board, took an important part in securing a great endowment for the Vanderbilt Medical School. It is also noteworthy that after the revolution in medical education which Flexner's report precipitated, Vanderbilt University in Nashville and the University of Tennessee in Memphis survived as the two strong university medical schools for white students in the state, the University of Nashville having gone out of existence. The challenge made by Flexner to Vanderbilt University was taken up by Chancellor Kirkland, and action was undertaken to strengthen the medical school in 1911. The campus previously occupied by the Peabody College for Teachers in South Nashville was acquired by a contribution from William K. Vanderbilt, son of the "Commodore." At about the same time Kirkland appealed to Andrew Carnegie, and acting on the advice of Henry S. Pritchett, president of the Carnegie Foundation, which had financed Flexner's report, Carnegie gave $1,000,000 to the university in 1913: $200,000 for a laboratory building and $800,000 for endowment of its medical school. A condition attached to this gift stipulated that a board consisting of the chancellor, three trustees, and three outside medical teachers be appointed to administer the medical school. The outside members were William H. Howell of Johns Hopkins and Eugene L. Opie and Roger S. Morris of Washington University. Although the Bishops of the Methodist Church voted not to accept the Carnegie gift and expressed strong criticism of the giver, the board of trust overruled their veto and accepted the funds which served to tide the medical school over a critical period. These events took place when the question of the control of the university by the Southern Methodist Church was being fought out in the courts, creating a very difficult situation for Chancellor Kirkland. The case was decided largely on his clear and thoroughly informed evidence—that the legal authority over the university rested in the self-perpetuating board of trust and not in the Methodist Church. The medical school was definitely strengthened by the Carnegie gift, especially in its laboratory departments, where several well-trained full-time professors were added to the faculty. In 1915, Mr. William Litterer, a Nashville merchant, acquired the building of the University of Nashville Medical School, which 151

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had gone out of existence, and presented it to Vanderbilt. Although by that time Vanderbilt was the only medical school for white students in Nashville, it was still far from achieving the manifest destiny predicted by Abraham Flexner. In April 1917 Kirkland wrote to Flexner, his staunch friend and admirer, and by then on the staff of the General Education Board, telling him that the medical school would have to have another million dollars if it was to continue to hold its present standards even for a hundred students and submitting to him full particulars of the condition of the school. Over a year later Flexner replied by saying that he and Buttrick, the chairman of the board "had decided that among their future activities the Vanderbilt scheme comes at the very top, for it is close to our hearts." Before any action was taken, however, Kirkland was subjected to an intensive course of training on medical education which is, I dare say, unique as a preliminary to a great benefaction for that purpose. Dr. Thomas S. Cullen, professor of gynecology at Johns Hopkins, was a friend of Kirkland and of Abraham Flexner, as they all had summer homes near each other on a remote lake in Canada. Wallace Buttrick was visiting Cullen in Baltimore in January 1919 when Flexner was a patient in the Johns Hopkins Hospital with an injured leg, and Buttrick spoke to Cullen of their interest in Vanderbilt and of their admiration for Kirkland. Cullen suggested that he invite Kirkland to come to Baltimore, where the problems of the Vanderbilt Medical School could be further discussed, and with Buttrick's approval, sent Kirkland a peremptory telegram asking him to come to Baltimore at once, without giving any reasons. A second wire was necessary to say that it was not his health but his medical school that was the subject for discussion, and Kirkland came immediately. His visit was opened with a dinner at the Maryland Club attended by the president of Johns Hopkins, several members of the General Education Board who had come from New York, and the heads of departments of the Johns Hopkins Medical School. After dinner a lively discussion took place on medical education and on the strategic position of Nashville for a strong medical school, during which Kirkland said little but thought much. Two days later he dined with Dr. Welch, and arrangements were made for Kirkland to talk with each of the various department heads of the medical school. At the same time he 152

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was given a thorough physical examination; as the chancellor wrote to Mrs. Kirkland, Buttrick and Flexner evidently wanted a guarantee of the future. Kirkland returned to Nashville with renewed hopes and aspirations for the Vanderbilt school. In March 1919 Buttrick and Flexner spent three days in Nashville, going over the details of their report to the General Education Board. On the strength of this report, at its July meeting the General Education Board appropriated $4,000,000 to Vanderbilt University for a complete reorganization of its medical school. It gave the following reasons for its action: "1. Not a single medical school in the entire South possesses the facilities or the personnel needed to train men to meet existing conditions or to carry on the research by means of which unsolved health problems may be ultimately mastered. "2. The strategic point for the development of such a school is Nashville, because it is situated well in the heart of the South. "3. Vanderbilt University has played a leading part in creating and maintaining scholarly standards in the South; and, finally, and perhaps most important of all, the Chancellor of Vanderbilt University, Dr. Kirkland, has the vision, energy and leadership which are required in the launching and development of an enterprise involving the establishment of a modern school of medicine." This completes the story of the struggles and trials through which the Vanderbilt Medical School passed to arrive at a place where it was selected to carry a responsibility for the advancement of medical education in the South. It is evident that the wisdom, fortitude, and tenacity of Kirkland played a conspicuous part in making this remarkable record. It must also be recalled that he took a leading part in elevating general educational standards in the South that are a lasting memorial to his name. His organization of the Southern Association of Colleges and Secondary Schools in 1935 put him at the head of those striving constantly to raise educational standards and extend educational opportunities. He was sometimes spoken of as "The Chancellor of the South." Aware that professional and graduate education could attain high levels only when based on sound and thorough school and college training, he always saw education as a whole, regardless of the particular form it took or the avenues into which it led. 153

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The Medical Profession of Nashville The medical profession of Nashville, which had carried the burden of education f o r so many years with such meagre resources and at times with a discouraging outlook, had unusual qualities. Many of these physicians were men of broad culture who had enjoyed the influence of one of the South's leading universities. There was conspicuous leadership among the Nashville profession over many years which was usually dependent in part on oratorical accomplishments, and the relatively small city of Nashville has furnished more presidents of the American Medical Association than any other city of its size. Seven of its medical men, all members of the Vanderbilt faculty, have been elected to this high office, although one of them, Olin West, elected after serving twenty-five years as secretary of the Association, was prevented by ill-health from serving his term as president. Only the states of New York, Pennsylvania, and Illinois have furnished more A.M.A. presidents than has the city of Nashville, while Massachusetts and Kentucky provided an equal number. The Nashville presidents were Paul F. Eve, 1857; W. K. Bowling, 1875; W. T. Briggs, 1891; John A . Witherspoon, 1913; William D. Haggard, 1925; Harrison H. Shoulders, 1946; and Olin West, 1950. With this remarkable tradition of leadership among the physicians of Nashville, it is easily understood that they were not a docile or readily led group. Their cooperation in a plan of reorganization that called on them to relinquish cherished rights and privileges they had enjoyed as members of the Vanderbilt medical faculty was achieved through their respect for Chancellor Kirkland and their fine spirit of loyalty to the university. It paved the way for the acceptance of organizational changes led by new and "imported" professors. The Plans of Reorganization The foregoing review of the history of the Vanderbilt Medical School gives an idea of the foundation upon which the new school was to be built and of the situation that existed when I was asked to undertake its reorganization as dean and professor of medicine. The Vanderbilt appointment appealed to me especially for two reasons. One was the prospect of having eventually a department of medicine f o r which I would be responsible. The other and more important reason was the assurance of Wallace 154

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Buttrick and Abraham Flexner that the General Education Board would give sufficient financial backing to the Vanderbilt School to make it a first-rank institution that could set new standards of medical education in the South. This was the understanding I had of their intentions when I accepted the appointment, and it led to my only controversy with Chancellor Kirkland, to be discussed subsequently. Early in 1920 I had my first conference with Charles A. Coolidge and Henry R. Shepley of Coolidge and Shattuck, the Boston firm of architects engaged by Vanderbilt University to design the new medical plant. We met in Baltimore with Winford H. Smith, the director of the Johns Hopkins Hospital, who had been retained as consultant on hospital design. This was the first conference on the building program, and at that early date the desirability was discussed of coordinating closely the laboratory and clinical departments, a concept that became a noteworthy feature of the plant eventually designed. I recall that Mr. Coolidge said to me, "Doctor, I hear you have some ideas on this subject," which gave me an opening to express my concepts of the correlation of departments. This served as a challenge and stimulated my thinking which eventually was given concrete expression in the design I drew. In May I was presented to the medical faculty of Vanderbilt at a large dinner, at which speeches in glowing terms were made by the chancellor; Mr. Whitefoord R. Cole, president of the board of trust; Dr. Lucius E. Burch, dean of the medical school; and others, regarding the past and the future of the school, to which I attempted to reply by expressing the ideals and principles I hoped would dominate the future school. This dinner was followed by an amusing and somewhat baffling experience. I was to leave the next day for New Orleans to attend the annual meeting of the American Medical Association, and when I reached the train, I found myself in for a trip of about twenty-four hours in a sleeping car filled with the members of the Vanderbilt faculty who were also off for a jovial time at the A.M.A. meeting. Decks of cards and hip-pocket flasks were equipment few seemed to have failed to bring, and the first decision before the new dean, just presented with laudatory oratory, was how he should descend from the high spot to which he had been elevated to take his place of fellowship among his future colleagues. There seemed to be only one answer, so I plunged into the game with a prayer 155

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that I would be able to keep my head and my money. Fortunately, my prayer was answered, as I won fifteen or twenty dollars in the poker games with the professors. What was more important, I established a reputation of being a first-rate poker player (a valuable asset to the Southern mind)—a reputation which I retained only by never again playing cards with my far superior gaming associates. The start was propitious and marked the beginning of many good friendships. After reviewing the situation of the existing medical school with the chancellor, Dean Burch, and other members of the faculty, it was decided that I would, for the present, take no part in the operation of the school, but would devote myself to studies of future organization and program, to consultations regarding building plans, and to the search for men to compose the faculty. In June 1920 my family and I moved from St. Louis to Baltimore, so that I could consult more readily with the architects and with Winford Smith and also so that I could participate in the work of the medical department of the Johns Hopkins Medical School. This would also serve as a vantage point from which to look for men to fill faculty positions. The first order of business was to formulate a plan of reorganization of the Vanderbilt Medical School which would give detailed consideration to the costs of building and to the annual budget required to operate the medical school and hospital. Before undertaking this task, I endeavored to find out from Abraham Flexner what could be expected from the General Education Board in support of the Vanderbilt School beyond its present commitments. It was clear that the $4,000,000 grant and the $1,000,000 given by Andrew Carnegie would be inadequate to build and support the sort of medical school and hospital I envisaged. I was anxious to know the meaning of the assurance that the General Education Board was interested in a medical school of "modern standards," and the extent to which it would support the creation of a first-rank school. After a period of general discussion with Flexner in which the answer to my question seemed to be evaded, Wallace Buttrick, then chairman of the board, came into his office, discussed my question more directly, and asked me to draw up and submit a plan of reorganization with details of costs. This request was the origin of the only serious controversy I ever had with Chancellor Kirkland. It is discussed in detail by Mims in his biography of Kirkland, 156

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and although he quotes extensively from my correspondence relative to this plan of reorganization, he gives an erroneous interpretation, being apparently unaware of the conditions under which my memorandum was written. The plan which I drew up during the summer of 1920 was based upon my experience in medical school administration at Washington University. It included a discussion of the coordination of scientific and clinical study and teaching as an innovation to be accomplished not only by coordinated physical facilities, but by building up a faculty of men with interests and points of view that would foster integration of research and teaching. This memorandum also discussed the possibility of building an entirely new medical plant on the main campus of the university, which would mean abandoning the existing plant of the medical school. The plan described how the various departments should be organized, outlined the need for a school of nursing, formulated the admission requirements to the medical school, and gave a detailed annual budget for each department. These estimates were based on a modest but adequate scale of salaries that were considered the minimum to attract men of first rank to the faculty. The estimated annual income required to operate a relatively small university hospital was also included. Much thought and effort went into the formulation of this plan before it was submitted to the officers of the General Education Board and to Chancellor Kirkland. Although it contained no extravagant or idealistic fantasies, as the chancellor seemed to think, it estimated that an endowment of about $10,000,000 would be needed for a complete university medical school and hospital equipped to teach 200 students. I was disappointed and discouraged to receive no reply or discussion of the plan from Buttrick or Flexner, who had requested it. When Flexner finally answered a letter of inquiry, he said that the report had been embarrassing to them, and that the questions raised should have been addressed to Chancellor Kirkland. Flexner advised me to take what we had and make the most of it. Chancellor Kirkland's response to the plan was centered on the theme that "no one will on the strength of such a presentation alone be willing to put up the amount of money that is required according to your ideas"; my thought was that great gifts should be made only when the details of needs had been carefully considered. This evidently had not been the case when it was decided 157

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that the $4,000,000 contributed to Vanderbilt would assure the development of a medical school of "modern standards" and of first rank. The chancellor's reaction was that of a sound and cautious administrator who had been responsible for obtaining the greatest single gift Vanderbilt had ever received. He must indeed have been disappointed to be told that it was insufficient for the great project he had so carefully fostered. He said that I had "hypnotized" myself and wrote at length along the same lines Flexner had used. My reply was sharp, as I wrote to the chancellor, in a letter quoted by Mims from the chancellor's files, that "my faith, hope, and enthusiasm were severely strained by the manner in which my plan of reorganization was received, and the statement in your last letter that the unwillingness of the officers of the Board to discuss my plan with me clearly indicated to you their feeling that my ideas cannot now be carried out, at least in the way I indicated, has made me feel that I am not the proper person for the work which is before you." I have gone into this matter at some length because I think it has been somewhat misinterpreted in the biography of Chancellor Kirkland. It may be dismissed by saying that eventually the chancellor and I came to see more clearly eye to eye, and that the Vanderbilt Medical School was finally built on the main campus of the university and was reorganized almost exactly as suggested in the plan drawn up in 1920. Although the chancellor seemed to stand firm and unmoved during our first period of disagreement, he soon thereafter agreed to build the school on the campus and sought the funds that would make this change of location possible. It was evident that he had not ignored the analysis of costs which I had prepared. Although I was convinced that the medical school would profit greatly by being an integral part of the university instead of two miles away, the increased costs of construction seemed prohibitive. However, other influences were brought to bear. Mims gives credit to Charles Cason, a former secretary of the Vanderbilt Alumni Association who had a position with the Rockefeller Foundation, for discussing this matter of location with Buttrick and Flexner and strongly advocating the campus site. The chancellor decided to accept the idea if the funds could be found, and in April 1921 a conference was held between the officers of the Carnegie Corporation and the General Education 158

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Board to discuss a plan for cooperating with Vanderbilt to make the change of location possible. On the strength of this interest, Kirkland, on behalf of the board of trust, requested $4,000,000, half to be given by each foundation, and although the grant was not made in full, the Carnegie Corporation appropriated $1,500,000 in May 1921 and the General Education Board the same amount a few days later. The location of the medical school was then decided and the full amount of these two new contributions was to be used for the erection of the laboratories and hospital of the medical school on the university campus. All other funds were reserved as medical school endowment. An amusing incident occurred when this new gift was announced in the Nashville Banner. Wishing to headline two important pieces of news, the Banner appeared with a seven-column headline at the top: "Bank Robbery on Broadway." Immediately beneath this was a five-column headline: "Vanderbilt Gets $3,000,000." At first glance one would infer that the university had used a unique method of adding to its resources. The work of nearly a year on plans for remodelling the Galloway Memorial Hospital and the other buildings on the old South Campus had to be discarded. Henry R. Shepley, a young talented architect then in his thirties, had taken over the main task of designing the new buildings, and we began a period of happy association that was to last a number of years. I endeavored to tell him what use each part of the plant was to have and the activities that would go on there; he showed great skill, ingenuity, and good taste in designing the suitable structures. He was the anatomist and I the physiologist, as it were, and we pooled our concepts and understanding in a very congenial way. In the summer of 1921, while at Blue Ridge Summit, I began to ponder how the buildings could best facilitate the coordination of the work to be carried on by the staffs of the various departments and tried to embody this idea into a single structure. I hit upon a scheme which seemed to have merit and I drew a rough plan in which the laboratories occupied a three-story court, open toward the north and the hospital wards a similar court open toward the south. The two courts were connected by a building in which the laboratories of the clinical departments were located. Another building with a court was added at the front to house the administrative department of the hospital, the library, and other general services. Shepley and his associates 159

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found the plan workable, and by allotting suitable space to the various departments, the continuity of interests and services could be readily established. For instance, the departments of pharmacology and physiology were arranged to lead into the laboratories of the departments of medicine and pediatrics, while the departments of anatomy, pathology, and bacteriology could be brought close to the surgical and special departments. This was the beginning of the design of the Vanderbilt Medical School which, of course, took months to elaborate, but the completed building had the form of those crude drawings I had made in the Blue Ridge Mountains. From the time when I first faced the problems of building the new plant of the Vanderbilt Medical School and reorganizing its faculty, I thought I should see as many other institutions as possible and discuss widely the general principles of medical school organization. I was familiar with the Johns Hopkins methods, especially as transplanted to Washington University, but I thought I should go abroad if possible, in order to gain a wider view. Although the latter project had to wait, I was offered two valuable opportunities in 1920 to carry out this idea. I had heard an enthusiastic account of the new hospital at the University of California, and when my friend Warfield Longcope told me he was going to the Pacific Coast during the summer, I planned to join him. We went West via the Canadian Pacific and visited the University of California, the Stanford Medical School in San Francisco and Berkeley, and Stanford University at Palo Alto as the guest of its chancellor, Ray Lyman Wilbur, who had formerly been professor of medicine and was a leader in medical education. On my way back I stopped at the Mayo Clinic, where my friend Reginald Fitz from Boston was on the staff. This visit gave me a fine opportunity to see at first hand how that stupendous center of group practice operated. Later in the autumn another opportunity to visit medical schools was offered me when George E. Vincent, president of the Rockefeller Foundation, asked me to accompany a group of Belgian medical professors on a tour of some of our medical schools. The group included De Page, a leading Belgian surgeon; Dustin, a professor of anatomy; Rene Sand, a leader in public health; and Jules Bordet, an eminent bacteriologist and Nobel prize winner. We visited the universities of Michigan, Chicago, and Iowa, Western Reserve University and the Lakeside Hospital 160

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in Cleveland, Washington University in St. Louis, and returned to Baltimore and Johns Hopkins. Besides providing an opportunity to study various medical schools, this tour offered me the privilege of discussing the problems of medical education with eminent men whose experience had been quite different from my own. After the decision was reached that the Vanderbilt Medical School was to make an entirely new start on the main campus of the university, it was evident that several years would be required to design and build the new plant and that the reorganization of the faculty should wait until progress had been made in planning the facilities. Only one new appointment had been made, that of John P. Peters as associate professor of medicine. He was a brilliant young man and a fine example of the new type of medical teacher, well-trained in chemical and metabolic research, and an enthusiastic devotee of academic medicine. Peters accepted the appointment with the understanding that he would be given leave of absence from Vanderbilt on salary, and spend a year in the Rockefeller Institute Hospital, where he worked during 1920-1921 with Donald Van Slyke. From this association came their useful book on the chemical aspects of medicine. When it became clear that a delay of several years in the reorganization was inevitable, Peters accepted an offer from the Yale Medical School, where he had an illustrious career. In the fall of 1920 I settled down in Baltimore and started studies on the gases in the blood in the chemical division of the Johns Hopkins department of medicine, directed by Walter W. Palmer. I also took part in establishing the Journal of Clinical Investigation and served as editor-in-chief in its early years. During the year there were frequent conferences with the architects of the Vanderbilt plant and an occasional trip to Nashville to discuss particular questions with Chancellor Kirkland. In the following summer, I wrote a monograph, "The Therapeutic Use of Digitalis," which was published as the first paper in the new journal, Medicine, just established under the editorship of David L. Edsall and John Howland. AN

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In the spring of 1921 the department of medicine at Johns Hopkins was in a difficult situation which jeopardized its recently developed organization on a full-time university basis. An 161

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emergency was created by a series of events in which I became involved. As I was "on the ground," so to speak, and as the developments at Vanderbilt did not require my constant attention at that time, I was asked to serve temporarily as head of the department. This episode is significant in the movement toward establishing the clinical departments of medical schools on a full-time basis and is therefore related here in some detail. The pioneer undertaking of establishing the department of medicine on the university plan at Johns Hopkins encountered difficulties. The first problem occurred in 1914 when Lewellys F. Barker, the professor of medicine, declined to accept the appointment on a full-time basis which required that he relinquish his private practice. His practice was large and was extensively integrated with that of other Baltimore physicians in a type of group practice of which Barker was the leader. He had been one of the original exponents of the full-time plan and had organized the first American medical clinic on a university basis, yet when the opportunity came to him to head the medical department on this basis, he was unable to adjust his life and affairs in order to do so. Theodore C. Janeway, son of the distinguished New York medical teacher, Edward G. Janeway, accepted the call to be professor of medicine at Johns Hopkins and chief of the medical service of the Johns Hopkins Hospital on a full-time basis. He was at that time professor of medicine at Columbia and chief of the medical service of the Presbyterian Hospital, as well as one of the leading medical consultants of New York. Janeway brought a few able men with him to Baltimore, notably Herman 0. Mosenthal, and organized his clinic along the general lines established by Barker. As time passed, Janeway was not happy in his transformation from a very active New York consultant and teacher to a full-time university professor in Baltimore. In 1917 he resigned his professorship with the idea of returning to New York, partly because his restrictions from practice created a financial hardship and partly because he was no longer entirely in sympathy with the full-time plan. Before his resignation became effective, however, Janeway succumbed to an attack of pneumonia, his strength having been overtaxed by his work in the Surgeon General's Office which he had performed in addition to his duties at the Hopkins from the time this country entered the First World War. 162

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William S. Thayer, who had been Osier's right-hand man since the opening of the medical school, had first refused the post as Barker's successor, but accepted the professorship following Janeway's death. However, Thayer went to Poland on a Red Cross mission to investigate typhus fever and was later drawn into the medical department of the American Army. He served as the chief medical consultant of the American Expeditionary Forces in France with the rank of Brigadier General, and did not take up his active duties as professor of medicine at Johns Hopkins until 1919. During the war the full-time plan was temporarily in abeyance, and the medical department was ably directed by a part-time professor, Louis Hamman. So it was not until the First World War was over, that medicine at Johns Hopkins had its wholehearted beginning on the university basis. Thayer was a highly cultivated physician of international renown and had made a number of important scientific contributions. He gathered together a promising group of younger men active in medical research, including Walter W. Palmer and Alphonse R. Dochez, who directed the chemical and the biological laboratories; Edward F. Carter, who had charge of the physiological laboratory; and Allen K. Krause, a leader in research in tuberculosis. The younger men in the department included Arthur L. Bloomfield, Dana W. Atchley, Robert F. Loeb, William S. Ladd, Francis R. Dieuaide, and Hugh J. Morgan, all of whom subsequently made outstanding contributions to medical education as professors and administrators. A distinguished group of parttime men also participated in the teaching—Lewellys F. Barker, Thomas B. Futcher, Thomas R. Brown, Louis P. Hamberger, Thomas R. Boggs, Louis Hamman, and Charles R. Austrian. It seemed that at last Johns Hopkins had an excellent, well-rounded, and productive department of medicine with the spirit, men, and facilities that make a true university department. The only symptom of weakness was an antagonism that divided the younger men into the so-called research and clinical groups, a situation that disturbed Thayer and with which he seemed unable to cope. The department of medicine was badly shaken in the spring of 1921 when Thayer resigned because he did not enjoy his administrative duties and wished to make way for the appointment of Walter W. Palmer, to whom the professorship was then offered. At about the same time Palmer was offered the professor163

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ship of medicine in the College of Physicians and Surgeons of Columbia University, and after rather long hesitation he accepted the latter post. Not only did Palmer leave Johns Hopkins but he took with him to New York Dochez and the splendid group of men whom he and Dochez had attracted. At the same time Verne R. Mason and Henry M. Thomas, Jr. retired from the house staff to enter practice, and Hugh J. Morgan accepted an appointment on the staff of the Rockefeller Institute Hospital. The department had lost its core, although Carter and Krause, full-time associate professors in specialized fields, and two or three others, including Henry S. Willis in tuberculosis and Clyde G. Guthrie in clinical pathology, remained. There was too little time before the start of the next academic year to attempt to fill permanently the professorship of this disorganized department, so I was asked to serve during the year beginning July 1, 1921, as acting professor of medicine and physician-in-chief of the Johns Hopkins Hospital. Vanderbilt University granted me a leave of absence in the belief that I would have an excellent experience in preparation for my future duties in Nashville. This belief was fully borne out. The first problem was to fill up the ranks of the department. Alan M. Chesney was called from Washington University and William S. McCann from the Cornell Medical College. Chesney, a Johns Hopkins graduate and a former member of the hospital house staff, had had a thorough training in bacteriology at the Rockefeller Institute Hospital. He had joined the faculty of Washington University just before the United States entered the war and had served in France with its base hospital. Chesney was assigned to direct the biological division of the medical clinic, a duty which he carried on for a number of years. Later he served as dean of the medical school, finally becoming its historian. McCann had been trained in metabolic research and chemistry under Eugene F. DuBois and Graham Lusk at Cornell, and he directed this division of the medical clinic until called to be professor of medicine in the new medical school of the University of Rochester. To fill the position of resident physician presented a problem as there seemed to be no one on the ground suitable for this responsible post as developed in the Johns Hopkins Hospital, and no one had ever been brought in from the outside to fill this position since the medical school was opened. However, it was 164

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necessary to look afield, and on the recommendation of Roger Lee and Paul D. White of Harvard and of the Massachusetts General Hospital in Boston, the position was offered to C. Sidney Burwell. Burwell, a Harvard graduate who had trained at the Massachusetts General Hospital, had just returned from a Red Cross mission to Latvia. This proved to be a very happy solution, despite Johns Hopkins tradition, as Burwell had not only excellent training and fine clinical judgment, but also an attractive personality and a delightful sense of humor. He won his way completely with all his associates. This appointment was the beginning of a long association which I cherish highly, as will be recounted subsequently. The house staff under Burwell was organized with five assistant residents and four interns from the class of 1921. Krause, Carter, Guthrie, and Chesney formed the group of full-time associate professors, Guthrie being made the director of the outpatient department in charge of teaching thirdyear students. McCann was appointed full-time assistant professor. There were also on the full-time staff three instructors, including Burwell and Willis, six assistants, and four fellows; there were also about thirty-five part-time members of the department when the school opened in the fall. I was particularly anxious to bring together more closely the part-time and the full-time members of the department. In order to give them all an understanding of what I proposed to do and the plans I had in mind, a meeting of the whole department was called just before the school opened. The group was composed of some of my own teachers, a number of my contemporaries and classmates, as well as of a group of younger men—fifty or sixty in all. To address such a meeting when I had just been appointed their temporary leader was quite an ordeal, but the evening went off very well, thanks to their sympathetic and friendly attitude, and to the desire all shared to strengthen the medical department which had been brought close to chaos. The spirit of the place and the affectionate sentiment for the medical school and the hospital were the cohesive forces effective in strengthening the department, and the full-time plan appeared to be saved. I have always looked back upon that year as an especially happy one, during which I had the chance to follow the trail broken by my revered teacher, William Osier, and feel the inspiration of his example. It was an opportunity to teach and conduct clinics, to administer a department, to gain experience in choosing men 165

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and coordinating their work, to serve on the advisory board of the hospital, and to learn from the inside how the Johns Hopkins Medical School was operated. All these experiences were of inestimable value when the time came to put the reorganized school at Vanderbilt into operation. The advisory board of the medical school wasted no time in looking for a permanent professor, and I was very pleased when Warfield T. Longcope was selected to take over the organization I had hurriedly formed. Longcope had been a friend of mine through college and medical school days at Johns Hopkins, and was my chief in pathology for over two years at the Pennsylvania Hospital. He had gone from Philadelphia to New York to be an associate professor under Theodore Janeway at Columbia, and had succeeded him as the Bard professor of medicine in 1914 when Janeway went to Baltimore. He had devoted himself since his medical graduation in 1901 to the study of pathology, bacteriology, and clinical medicine and had never become extensively engaged in medical practice outside the hospitals with which he was connected. He was an excellent student of medicine of the university type and was well-prepared for the professorship at Hopkins. It was a relief to me to have this matter so happily settled; I could then turn my thoughts again to Vanderbilt University. A

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By June 1922 the general design of the new Vanderbilt Medical School and Hospital had been determined. Since three years would be required to build and equip the plant, there was time to go abroad to study hospitals and medical schools and to gather ideas about medical education in other countries. I had long felt that this would be desirable to broaden the concepts on which the Vanderbilt School would be developed. Chancellor Kirkland agreed that the university would defray the cost of this study and provide $2,000 for the purchase of books for the library, particularly sets of German journals. At that time the market was especially favorable for the purchase of books in Germany because the inflation of the currency made the dollar exchange rate very high. We arranged a family trip to Europe, taking along our two young children. My wife had spent thirteen years in Berlin, where her father, although an American, had been a teacher of music, and she had had all her schooling there. She 166

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spoke German like a native, and was happy at the prospect of visiting again the country of her childhood and youth. We left New York on June 29 on the Swedish steamer Oscar the Second and after sailing around the north of Scotland, landed in Copenhagen. In Denmark I had a delightful visit with August Krogh, one of the world's leading physiologists, at his lovely summer home by the sea. During my few days in Copenhagen, where I enjoyed good talks on medical education with members of the medical faculty, I was especially interested in the university hospital. Here I saw an arrangement of beds for ward patients which divided them into groups of four, while still retaining a large number in one administrative unit. This plan had definite advantages over the long, hall-like wards that were then in general use in the United States, especially from the point of view of patient comfort, and impressed me as an improvement which we should introduce at Vanderbilt. Eventually this arrangement of beds was incorporated in the hospital plans and found to be an innovation which had a far-reaching influence on future hospital design in this country. The visit to Copenhagen was followed by six weeks of vacationing in Germany—in a village on the Baltic Sea and in the Harz Mountains. In September I began my study of hospitals, laboratories, and medical education in Berlin. Through letters of introduction and through medical friends I met a number of the professors of medicine and pathology and visited the most important hospitals. In Berlin and in Leipzig I was able to buy many complete sets of German medical and scientific journals for the Vanderbilt Medical Library. At Leipzig I attended the annual meeting of the Gesellschaft für Naturwissenschaft, comparable to our Association for the Advancement of Science, and listened to papers presented by a number of university professors whom I had long known by name and reputation. I also had a pleasant reunion with my Munich teacher, Friedrich Müller before moving on to visit the medical schools at Marburg and Frankfurt. We then went to Holland—to visit Leyden where the professor of pharmacology, W. Storm van Leeuwen, devoted himself to showing me the old school and the new one then under construction. While there, I had the privilege of meeting Willem Einthoven, the inventor of the electrocardiograph and the man 167

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whose work had helped me so much in my own. I was especially drawn to Leyden as, in the early part of the eighteenth century under the influence of the illustrious Boerhaave, it had been the center of medical education in Europe from which the great school at Edinburgh developed. I also visited Utrecht, where I met several interesting members of the university medical faculty, including the eminent pharmacologist Magnus, whose laboratory, from which much fine research has come, occupied an old church. In October we settled down in London for six weeks and I visited the leading medical schools, where I had many acquaintances, and enjoyed a splendid opportunity to learn how medical education was conducted in England. St. Bartholomew's Hospital, the oldest medical school in London, had special interest for me as its professor of medicine, Francis R. Fraser, was an old friend of Rockefeller Hospital days. There I visited every department and heard at least one lecture by each professor. Another good friend, Arthur Ellis, was then professor of medicine at the London Hospital Medical School, and my visits there were also very profitable and interesting. I spent a week in Scotland. In Edinburgh, where my friend, J. C. Meakins from Montreal, was professor of experimental medicine, I met a number of the leading members of the faculty. I enjoyed my visit to Edinburgh University especially, as it was there that most of the early American teachers were educated in the eighteenth century. The medical school has maintained the highest educational standards from those days to the present time. Several days were given to a memorable trip to St. Andrews in Scotland to visit Sir James Mackenzie, whose book, published twenty years before, had stimulated my interest in studies of the circulation. He had retired from London and was conducting a unique institute for medical research with which most of the practitioners of the town cooperated. I was not prepared for the rather typical Scottish welcome he gave me, which was prompted by some correspondence we had had relative to the drug digitalis. When I announced myself at the door of his large office, he shouted from across the room, "Come in Robinson. You are all wrong about digitalis." This brought us close together in a moment, and we spent two days in almost constant talk. When he took me home to lunch, he remarked to Lady Mackenzie, "I am quite hoarse from listening to Dr. Robinson talk." Mackenzie 168

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was particularly happy over the Vanderbilt plans which I explained to him. He saw that they offered very favorable conditions for the integration of the various fields of medical knowledge, which he considered to be one of the great needs of modern medicine. Another of Mackenzie's ideas was that medicine was being weakened by the use of laboratory procedures that were taking away from the physician his skill as a trained observer of the patient. I had cause for wonder, therefore, when just before Christmas 1923, I received a letter from his chief assistant to say that he was sending me an instrument of precision, but to remember Sir James' dictum that such instruments could never take the place of the trained senses. It was with surprise and delight that I opened the package from Scotland to find a golf club—a new type of putter that had been developed at that great center of the game, St. Andrews. Sir James Mackenzie had long been an inspiration to me, and one of my most prized photographs shows him standing before the ancient clubhouse on the famous golf course at St. Andrews. It always brings to mind the rugged Scotsman who combined a love of his native sport and a delightful humor with original, concentrated thinking and great intelligence and tenacity in medicine. Also of much significance to me were visits to Oxford and to Cambridge. I went up to Oxford at the invitation of an old friend and fellow-student, Billy Francis, a cousin of Sir William Osier and his literary heir. He was living in the home of Lady Osier, and it was a great event to visit the house of the teacher whom I so much admired, filled with his incomparable collection of books, and to be in the gracious home that had welcomed medical men the world over in days gone by. Lady Osier arranged for me to spend the evening with Professor J. S. Haldane, a great physiologist and one of the pioneers in the study of blood gases. He was deeply interested in medical education and we had a long and, for me, an illuminating discussion. The following day under the guidance of Billy Francis I made a grand tour of the university, which of course included the famous Bodleian Library in which Osier had taken great interest. I went to Cambridge as the guest of A. E. Clark-Kennedy, then a fellow of Corpus Christi College, who divided his time between physiology at Cambridge and clinical studies at the London Hospital. During two days among the beautiful old build169

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ings I gained a lasting and delightful impression of Cambridge University. I dined with the noted physiologist, Joseph Barcroft, at the high table of the Dons of Corpus Christi College; lunched with Sir Frederick Gowland Hopkins of vitamin fame; called on the regius professor of medicine, Sir Clifford Allbutt; and met a number of other distinguished members of the university faculty. We sailed f o r home on the Adriatic on November 25. I was much refreshed and invigorated by five months abroad, and felt quite ready to plunge into all the problems in store regarding the Vanderbilt Medical School. Planning and Organizing the Vanderbilt School By the beginning of 1923 a number of basic principles had been settled that determined the size and character of the medical school and how it should ultimately be organized. It was agreed that the $8,000,000 available to finance it should be divided approximately into $8,000,000 f o r building, $3,000,000 as endowment of the medical school, and $2,000,000 as endowment of the hospital. Medical school funds would be augmented by students' fees, and receipts from patients would defray a portion of the hospital expenses. The medical school was to have a student body of two hundred, with fifty students in each of its four classes. The subjects to be taught and the curriculum to be followed were well standardized at that time by the better schools, and these standards determined the departments making up the school and the number and training of the men who would be required to form the faculty. It was decided not to start the organization of the new faculty until the building program was well under way, although inquiries regarding possible appointments were begun at once, thought being given continuously to this problem. During the first half of 1923, the building plans were completed; contracts f o r the building were let in September; and ground breaking ceremonies were held on October 22, 1923. I t is not feasible to attempt a description of the large and complex structure that f o r the first time in this country had been planned to assemble under one roof the departmental laboratories and a teaching hospital of a medical school. However, it may be of interest to discuss some of the features of the plant designed to apply certain principles of medical education. In the first place, 170

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the medical school was located on the main campus of the university so that it could benefit by the general cultural atmosphere of the university and be in a position to cooperate with the departments of chemistry, biology, physics, and psychology in education and research. A new educational feature was the provision of space and facilities for research in the clinical departments, so that investigation related to the study of patients could be closely correlated with the preclinical departments. In order to foster research that would not be confined to a single department, thought was given to correlating the teaching and research of the laboratory and the clinical departments. Thus, in the department of medicine, the laboratory of clinical bacteriology adjoined the department of bacteriology; the laboratories of medical chemistry and physiology led into the departments of biochemistry, pharmacology, and physiology; and the laboratories of surgery were next to the departments of anatomy and pathology. These spatial arrangements were intended to break down barriers between departments on the theory that the influence of the medical sciences would be felt constantly by the clinical staff and students throughout their course, and that the knowledge and training gained in the laboratories would be carried into medical practice. This sort of correlation also serves to keep laboratory teachers aware that the ultimate aim of medical education is the application of their sciences to the practice of medicine. Since the library was located in a central position on the first floor, almost like the hub of a wheel, and was convenient to all departments, provision for extensive departmental libraries did not seem necessary. In the hospital special consideration was given to the relation of the outpatient department to the wards, the medical outpatient clinics being placed immediately under the medical wards, and the surgical outpatient service occupying the first floor of the surgical wing of the hospital. The idea was to break down the distinction of "out-" and "inpatients" from the point of view of staff and students. The same patient was treated at times in the outpatient service and at other times in the wards, and had a unit record wherever he was treated. This feature of hospital organization was new at that time and has since been generally adopted. The hospital had 208 beds, distributed as follows: medicine 60, surgery 66, obstetrics and gynecology 27, pediatrics 30, and 171

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private patients 25. The number of beds was restricted by lack of funds not only for construction but especially for hospital maintenance. Even with this restriction, financial difficulties were encountered after the hospital was in operation. However, plans for hospital expansion were provided in the design, and were carried out some years later when the General Education Board made other substantial contributions to the resources of the medical school. The portion of the building housing the medical school contained the departments of anatomy, biochemistry, pathology, pharmacology, physiology, bacteriology, and preventive medicine and public health; laboratories for the medical and surgical clinics; rooms for the school administration; and quarters for the laboratory animals. The total building extended 458 feet from north to south and 337 feet from east to west and contained 3,390,000 cubic feet. It was a simple brick structure with limestone trim in the "collegiate gothic" style. The carved stone decoration was confined to the hospital entrance toward the east and to the medical school entrance in the center of the north court facing the other buildings of the university. The architectural design and the details of engineering were carried out with intelligence, good taste, economy, and fine understanding by the architect, Henry R. Shepley. His work at Vanderbilt was the beginning of his very important contributions to medical school and hospital design which culminated about eight years later in the magnificent buildings of the New York Hospital and Cornell Medical College. During 1923 and 1924 the reorganization of the faculty was the absorbing and highly significant task, as it was fully realized that the men who were to be the future heads of departments would decide the ultimate success of the undertaking to create new standards of medical education in the South. Much thought and feeling had to go into every move. Care was necessary, first of all, in seeking reliable advisers, as their recommendations often determine the quality of men selected for academic posts. The process of selection required numerous conferences, first to ascertain the men available, and then to analyze their various attributes to determine the one best suited for each post. It is common practice to formulate at least in one's own mind all the qualifications a prospective appointee should have, and then to find that there "just is no such animal." One of my friends once 172

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told a group of his colleagues, among whom was Dr. William S. Halsted, that he had advised a faculty committee to get a man like "Popsy" Welch to fill a certain chair. On hearing this Dr. Halsted, who greatly admired Dr. Welch, quietly asked: "Why didn't you tell them to get two or three?" As academic posts must be filled by the men available at the time, the choice may be distinctly restricted. At the time of filling the posts at Vanderbilt, however, two favorable conditions seemed to have prevailed. There were a number of well-trained young men qualified for professorships, and the idea of a new school with excellent facilities in which the faculty would determine the educational policies was attractive to them. With good advice and under these conditions, the appointments that were recommended and carried through had favorable consequences. By the fall of 1924 the following new professors were appointed : anatomy, R. Sydney Cunningham; biochemistry, Glenn E. Cullen; pathology, Ernest W. Goodpasture; preventive medicine, Waller S. Leathers; and as associate professors: C. Sidney Burwell and Hugh J. Morgan in medicine, James M. Neill in bacteriology, and Horton R. Casparis in pediatrics. Cunningham was an associate professor at Johns Hopkins, where he had worked especially with the brilliant professor of histology, Florence R. Sabin. Cullen had been associated for some years with Donald Van Slyke in the Hospital of the Rockefeller Institute, where he had developed a special interest in the biochemical problems related to disease in patients and had recently been appointed associate professor of research medicine at the University of Pennsylvania. Goodpasture had been on the faculties of Johns Hopkins and Harvard. He had served as professor of pathology in Manila, and had then become director of the Singer Memorial Laboratory in Pittsburgh. Waller S. Leathers was dean of the medical school of the University of Mississippi and was the executive officer of the Mississippi State Board of Health. Burwell, who had served with me at Johns Hopkins as resident physician, had remained in the medical department there with Longcope; Morgan was on the staff of the Rockefeller Institute Hospital; Neill also served there in bacteriology under Oswold Avery; Casparis was a member of Howland's pediatric department at Johns Hopkins. Of this group Goodpasture and Morgan were natives of Tennessee and had graduated from the college of Vanderbilt University. 173

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By the fall of 1924 several professorships remained to be filled, and most of those who were appointed later missed the rare opportunity offered the early appointees. Through a special grant from the General Education Board, five of those appointed in 1923 went abroad to study in Europe. Goodpasture, Cullen, Burwell, Morgan, and Casparis resigned from the positions they were holding as of July 1, 1924, to spend a year in Vienna, Copenhagen, Berlin, Munich, and London with leaders of their choice in their respective fields. Neill was provided with a fellowship to work at Harvard with the distinguished Hans Zinsser, not only to learn more about bacteriology and immunology, but to gain experience in a teaching department. Leathers was given a travelling fellowship by the International Health Board of the Rockefeller Foundation which enabled him to travel extensively in Europe, visiting many departments and institutes of public health in various countries. In the fall of 1924 I moved with my family to Nashville, to occupy a house belonging to the university and situated on the campus. By that time the new plant was well under way, and constant attention was needed regarding details of equipment, organization of the hospital, and provision of the facilities the faculty would require when they finally assembled during the following year. There were still important positions to be filled, and it was essential to study the faculty and organization of the existing school to gain an opinion of its individual members and to learn their aspirations and qualifications for future positions. In November a statement was published on the future policies of the school of medicine which precipitated a revolt among the members of the old medical faculty, comprising practically all of the outstanding physicians and surgeons of Nashville. It is recounted to illustrate the problems that have to be faced in a period of academic reorganization, even under conditions as favorable as those at Vanderbilt, when new men are imported to take places of authority. This published statement included the plan for an advisory council, subsequently designated the executive faculty, to be composed of the chancellor and the heads of the major departments, which would make recommendations to the board of trust. This was interpreted by members of the faculty as depriving them of a means for expressing themselves regarding the conduct of the school and placing all authority 174

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in the hands of the newly appointed professors. Resentment of this proposal was expressed in a statement to the chancellor signed by all but six faculty members stating that under the proposed organization, they wished to have no connection with the reorganized school. The president of the board and the chancellor decided that I should call a meeting of the entire faculty to discuss their objections. This was a critical situation, as it could mean that practically the entire medical profession of Nashville would be actively opposed to the new medical school, creating very difficult conditions. One of the faculty leaders, renowned as a public speaker, was especially anxious to meet me face to face before his colleagues, and to express in no uncertain terms the obligations of the medical school to its faculty. Every member of the faculty was present at the meeting, and as soon as it was called to order, the orator took the floor to voice the dissatisfaction of the faculty with the proposed plan of administration. In a few minutes, I found myself in a heated debate before the assembled faculty. This gave me an opportunity to explain that the proposed executive faculty would be composed of the heads of departments, who would represent all members of the faculty, and would include some members of the present staff. This relatively small group, representative of the entire faculty, would have the responsibility of administering the internal affairs of the school. My arguments did not convince my opponent, who withdrew from the meeting with considerable show of emotion. Thereupon, a much respected member of the faculty spoke, saying that he had come to the meeting feeling that the gloom of night was descending over the medical school, so dear to their hearts. After listening to the new dean he saw instead the early glow of the morning light ushering in the dawn of a new day. With such phrases he changed the atmosphere, and the meeting ended with a vote of confidence. The situation was saved. During 1924 professors of surgery, pharmacology, physiology, obstetrics and gynecology were appointed to complete the list of department heads. Barney Brooks was brought from Graham's department in Washington University as professor of surgery, and Paul D. Lamson, who had been associate professor of pharmacology at Johns Hopkins, under John J. Abel, was called to fill that chair. Walter E. Garrey was appointed 175

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professor of physiology, being called from the professorship of physiology at Tulane University in New Orleans. He had previously been on the teaching staff at the University of Chicago, had served as professor of physiology in the Cooper Medical School in San Francisco, and had been associate professor at Washington University under Joseph Erlanger. Lucius E. Burch, dean of the Vanderbilt school for a number of years, was appointed head of the department of obstetrics and gynecology with Sam Cowan, one of the younger men on the old faculty, in charge of obstetrics. Practically all the members of the existing clinical departments were incorporated into the faculty to serve under the newly appointed heads of departments, and a number of full-time men, recommended by the new professors, were appointed. In the spring of 1925 two young men who had been classmates at Johns Hopkins came to Nashville to serve as the resident physician and the resident surgeon and were put to work in the old Vanderbilt Hospital to get it ready for the move into the new plant. They were Tinsley R. Harrison and Alfred Blalock, a great pair who worked strenuously throughout the hottest summer Nashville had known for many years, and went on not only to do much in the internal organization of the hospital, but to achieve brilliant academic careers as professors in future years. The full-time faculty members in the clinical departments were not formally restricted as to remuneration from private practice, the available funds being insufficient to allow higher salaries for the professors of medicine and surgery than for professors in the laboratory departments. There was an understanding, however, that those receiving full university salaries would confine their practice to Vanderbilt University Hospital. The members of the faculty who continued in private practice were designated by the term "clinical" in the titles of their appointments. The arrangement for the full-time staff operated successfully, as all those so appointed were taken up so fully with their teaching, research, and administrative functions that none of them, at least in the early years, had any interest in outside medical practice, and no rivalry ever existed between those in practice and those giving their full time to the university. Early in 1925, Clarence P. Connell, a Vanderbilt graduate in engineering, was appointed superintendent of the hospital. He was ably assisted by Augusta K. Mathieu, who had had 176

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extensive experience in hospital administration at Washington University. The main burden of equipping the hospital, its outpatient department, food service, and other accessories was carried by them and by Edith P. Brodie, the superintendent of nurses, who was also imported from Washington University and who organized the nursing service. Other administrative officers were retained as far as possible from the old school, and the hospital house staff was organized. Opening

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On September 15, 1925, the hospital was opened, and the medical school began its new life in the completed buildings. It was naturally a happy event to see this great undertaking come to life after five years of gestation; the dreams of many months came true through the whole-hearted cooperation and enthusiasm with which all those forming the human structure pitched in to create the splendid spirit in which the new Vanderbilt Medical School was launched. Irving B. Parkhurst, who had been the clerk of the works representing the university during the construction of the buildings, made a remark that has remained in my memory. He said: "You have built more than a building; you have created a spirit which I am sorry to leave." This expressed our hope. Nineteen hundred and twenty-five was a banner year for Vanderbilt University; it marked its fiftieth birthday, and the opening of the medical school on its campus coincided with the semicentennial celebration which had long been planned. Delegates assembled in Nashville from October 15 to 18 representing 167 American universities and colleges, 9 foreign universities, and 26 national foundations and societies; there was an outpouring of alumni, attracted not only to pay their respects to the university but also to do honor to its great leader, Chancellor Kirkland. Besides the assemblies and dinners at which a number of speakers gave felicitous and stimulating addresses, there were conferences on academic and medical education at which distinguished educational leaders reviewed the past and pointed the way toward the future. At the medical conference Simon Flexner, director of the Rockefeller Institute, spoke on medical education and research, and William H. Welch, then the director of the Johns Hopkins School of Hygiene and Public Health, discussed the relation of medical science to medical practice. Both 177

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speakers expressed enthusiasm and encouragement regarding the prospects before the school and the influence it should exert on medical education and practice in the South. As soon as the excitement of the semicentennial celebrations and the dedication of the medical school had quieted down, the teaching according to a curriculum revised to take advantage of the new facilities was begun. The organization of the various departments by their respective heads was developed and research activities were initiated. Sydney Cunningham brought into the department of anatomy Frank H. Swett and Karl E. Mason. Special studies were soon begun on certain cells of the connective tissue, experimental embryology and regeneration, and nutritional aspects of sterility; in cooperation with the department of medicine a study of blood changes in tuberculosis was started. Before long younger assistants and several medical students were participating in the research work of this active department. In biochemistry Glenn Cullen added J. H. Johlin and two younger assistants to his staff, and they embarked on physicalchemical studies of basic interest in physiology, dealing especially with the chemical properties of the blood. Walter Garrey, the professor of physiology, had as his associate Charles C. King, who had been the professor in the old faculty, and two research assistants were also added. The research activities of his department were concerned particularly with the investigation of the control of the heart by the nervous system, blood pressure studies, and study of various factors causing changes in the leucocyte composition of the blood. Since Garrey had not been available for European study before the medical school opened, he was granted a leave of absence during part of the first year and spent a number of months in Europe, refreshing his outlook on physiology in several European laboratories. In the department of pharmacology, Paul Lamson added two associates to his staff—one well-trained in chemistry, Lawrence G. Wesson, and five full-time research workers. Lamson's work soon attracted sufficient attention to obtain special grants for its support. He was especially interested in research on certain drugs used for the treatment of diseases caused by animal parasites, to which the International Health Board of the Rockefeller Foundation granted support. The liver and the damage to its functions by certain drugs were also widely studied. Lamson 178

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took much interest in the equipment and development of the technical apparatus shop, which he directed for the benefit of all departments, and in which an ingenious and skillful mechanic could construct special equipment needed for research and teaching. Ernest Goodpasture, serving not only as professor of pathology but also as the pathologist of Vanderbilt University Hospital, was responsible for all autopsies and other pathological examinations (except surgical pathology) for the hospital. Arthur W. Wright was assistant professor, and two instructors in pathology lived in the hospital. Special emphasis was given to the study of diseases caused by filterable viruses, an important field of medicine in which Goodpasture was a pioneer and in which he became ultimately an outstanding leader. James Neill, with Roy C. Avery as his associate, and with four student assistants, taught bacteriology with the cooperation of the departments of public health, medicine, and pediatrics. The bacteriology department soon became active in studies on immunity with special reference to diphtheria and pneumonia. The organization of the department of preventive medicine and public health by Waller Leathers was especially noteworthy. He brought Henry E. Meleney, who had special training in diseases caused by animal parasites, into his department, and later added another full-time member. He attached to his staff ten part-time teachers of public health, most of whom were on the staff of the Tennessee State Department of Health, and its director, E. L. Bishop, was appointed an assistant professor of public health. Preventive medicine was developed as a major subject in the curriculum and was given a more prominent place than in any other American medical school at that time. Leathers was especially well prepared to lead in this field, as he had been not only the dean and professor of physiology and hygiene at the University of Mississippi Medical School but also the director of the State Department of Health in Mississippi. He was one of the public health leaders in the South before coming to Vanderbilt, and with this unique experience behind him he developed a department that was integrated with the official public health work of the State and the City of Nashville, an arrangement of much benefit both to the medical school and to the health departments. He was also interested and successful in correlating preventive medicine with medical practice and cooperated with 179

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the departments of medicine, pediatrics, and bacteriology in teaching and in research. Leathers had a broad view of medicine and a fine quality of leadership which enabled him to make conspicuous contributions to medical education. He was very successful as the second dean of the Vanderbilt Medical School, and took a leading part in obtaining needed additions to the plant and to the resources of the school. The clinical departments had a more complicated task in getting the hospital services organized, in developing a new teaching program, in assimilating the members of the old faculty into their departments, and in starting new activities in research. Barney Brooks, professor of surgery, was a skillful surgeon and an excellent teacher much interested in surgical pathology and experimental surgery. Although rather small in stature, he was a true Texan, a man of courage, with strong and sound convictions as to what a university department of surgery should be. I recall that my attention was especially directed to him by William S. Halsted, the master surgeon at Johns Hopkins, whose standards and ideals of surgery were of the highest. He gave a brief, rather reticent, but thoughtful answer to my inquiry concerning the possibilities for the professorship at Vanderbilt by saying: "Why don't you get little Brooks. He recently sent me some of his work and it was very good." Brooks had served a year's internship under Halsted after graduating from Johns Hopkins, and these words from the highest surgical authority I knew made a lasting and effective impression on me. Brooks was an excellent university professor, always a stimulating and somewhat exacting teacher, and constantly encouraging the members of his department to undertake well-considered research problems. He soon added Isaac A. Bigger from the University of Virginia to his department, and he also had Blalock who started as his first resident surgeon in the hospital. Blalock developed splendidly and although he had to take a leave of absence for over a year because of illness, he continued as the associate of Brooks until called to the chair of surgery at Johns Hopkins where he continues a brilliant career. Beverly Douglas, a native of Nashville who had been on the faculty of Yale and had just received a Doctor of Science degree from the University of Lyons in France, joined the surgical staff, devoting himself to plastic surgery. In 1926 he was appointed assistant dean and held that position for many years. The surgical specialties and 180

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the x-ray department under Brooks' direction were initially headed by Nashville specialists who had been on the old faculty. The departments of obstetrics under Sam Cowan and gynecology under Lucius Burch, part-time teachers with limited hospital services and facilities, carried on the teaching of these subjects in a very satisfactory manner. A year or so after the school opened, Abraham Flexner suggested strengthening the department of gynecology by sending a promising young man abroad for study, and offered to provide a fellowship for this purpose. John C. Burch, the son of the professor, was selected and spent a year in Breslau and in other German university clinics studying particularly the relations of endocrinology to gynecology. He returned to improve the department and to correlate its research activities with workers in other departments of the school. After the new school opened I was largely freed to give concentrated thought to the department of medicine, as the administration of the school was comparatively simple after so many willing heads and hands had joined in the work of committees and cooperated with vigor and soundness in directing the affairs of the school. I was particularly fortunate in having Sidney Burwell and Hugh Morgan as the two associate professors of medicine, both splendidly trained in the art and science of medicine, in teaching, and in research. The major duties of the department were divided between us, and we had a human dynamo in Tinsley Harrison to head the initial house staff and to show much vigor and keenness in teaching and in research. I took charge of the outpatient service, where the teaching of fourth-year students in medicine was conducted, to assure that this service would not occupy the subordinate place it had in many hospitals, and left the ward services to Burwell and Morgan. The integration of the two services, brought about by placing the wards directly over and connected with the outpatient department, made it possible for the staff to know all patients admitted either to the inpatient or to the outpatient service, and created favorable conditions for the development of group practice in which all members of the department participated. In two years John B. Youmans, an unusually able administrator and physician, was added to the staff and became the director of the outpatient service in charge of the teaching there. The research laboratories of the medical department consisted 181

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of the physiological division under Burwell, the infectious disease division under Morgan, and the chemical division under Harrison; each hospital assistant resident devoted half of his time to one of the laboratories. This plan of organization attracted excellent young men to the hospital staff, as it afforded opportunities for training in clinical medicine and in research which were at that time rarely available in the South. Studies were conducted on the mechanism of heart failure and on the action of drugs on the output of the heart, observations being made both on patients and, with the cooperation of the surgical department, on experimental animals. Problems of the physiology of the blood were studied in cooperation with the department of anatomy; long-term studies on latent syphilis were initiated; and arthritis, thyroid disease, and other metabolic disorders were investigated. A fine spirit of teamwork quickly developed in the department which was stimulated by weekly clinical conferences in the wards and staff meetings for the discussion of medical literature and research, attended by the part-time as well as the full-time members of the staff. The splendid professional and personal qualities and the fine leadership of Hugh Morgan and Sidney Burwell contributed greatly to bringing about a spirit of cooperation and broad interest in the department and gave it a happy and stimulating atmosphere in which the younger men seemed to thrive. The resident physicians, first Tinsley R. Harrison, then John S. Lawrence, and then Charles P. Wilson were excellent leaders of the house staff, and had subsequently outstanding careers. Harrison, after remaining on the Vanderbilt staff for some years, was appointed professor of medicine in the Bowman Gray School of Medicine when it was reorganized in Winston-Salem. He later became dean and professor of medicine in another new school, the Southwestern Medical School in Dallas, and finally was appointed professor of medicine in the Medical College of Alabama in Birmingham, the city of his birth. John Lawrence, a University of Virginia graduate with extensive hospital training in Boston, returned there when he left the Vanderbilt faculty in 1928. A year later he was appointed associate professor of medicine at the University of Rochester, New York, and in 1947 became professor of medicine and chairman of the department at the University of California in Los Angeles. He has also done distinguished medical work in relation to atomic energy. Carl 182

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Wilson returned to his native Portland, Oregon, to practice medicine, and has served for years as a professor of medicine in the University of Oregon Medical School. Pediatrics, neurology, psychiatry, and dermatology were subdivisions of medicine, but only pediatrics was headed by a new appointment to the faculty. Horton Casparis, beginning as associate professor of pediatrics, developed a small but efficient department with Katharine Dodd as his associate, and with two assistants. This small staff had to devote much of its time to the care of patients in the outpatient service and in its wards, but studies were conducted on early tuberculosis in children, various manifestations of allergy, and the influence of external heat on children. In three years, pediatrics was made an independent department and Casparis was appointed to a full professorship. His promising career was cut short by his early death. The library of the medical school was energetically developed by Eileen R. Cunningham and her associate, Pearle C. Hedges. An active group of investigators and teachers naturally had to have many books and especially journals for their work, and the efficient library service was a great help to all of us. Mrs. Cunningham has developed the library very effectively and has become a leader among medical librarians, travelling to South America and to various parts of Europe on library missions and to attend international gatherings. A small department of illustration was developed by Susan H. Wilkes, a pupil of the famous Max Brodel, in which both graphic and photographic illustrations were skillfully made for publication and teaching as needed by the various departments. The school of nurses, organized by Edith P. Brodie, was integrated with the medical school and hospital, and through the cooperation of the college of arts and sciences of the university, offered a combined course in nursing and academic work leading to the degree of Bachelor of Science in Nursing. Financial Problems

The foregoing account of the activities that were undertaken in the medical school in the first years after it opened on the campus of the university indicates the great strain that was put on its limited finances. Chancellor Kirkland was much concerned when deficits raised their ugly heads, and he had to importune the General Education Board and the Rockefeller Foundation 183

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for special grants. He wrote: "The whole atmosphere of the school is charged with the spirit of expansion, publication, and investigation. No one seems to appreciate our limited resources or the necessity of living within our means." I was not deeply concerned as I felt sure that when the medical school began to show the results which had been the expectations and hopes from the start, Vanderbilt would receive a larger share of the $50,000,000 that had been provided by John D. Rockefeller for medical education. At first the response to the financial needs was through special grants, such as $100,000 from the Rockefeller Foundation for the support of the school of nurses for five years, and $7,000 a year to develop public health nursing in conjunction with Peabody College for Teachers. Grants were also made for the support of the department of preventive medicine in which the International Health Board of the foundation was interested. These and other grants from the General Education Board and the Carnegie Foundation amounted to $141,000 a year, including $25,000 a year for the support of the hospital. In 1929 the General Education Board made a grant of $5,500,000 to the endowment of the medical school which more than capitalized its previous grants, and in 1935 the board appropriated $2,500,000 for an addition to the hospital building and for endowment. Although the amount of support given by the General Education Board eventually reached and surpassed the amount our original estimates called for, it required a number of years and considerable anxiety, especially on the part of Chancellor Kirkland, before this was accomplished. Perhaps it was a sound procedure and a strong incentive to require the school to show what it could do before investing more money in the enterprise. However, had we felt satisfied to take what we had and cut everything down to a reasonable, safe, and sound level, it is doubtful if the demonstration could have been carried out that stimulated the outstanding support given eventually to the Vanderbilt University Medical School. The problem of obtaining additional endowment for the hospital was harder to solve, because there were no foundations to be called upon for this purpose. As the hospital was of great service to the community from which support would naturally be expected, a board of hospital managers, made up of twelve leading citizens, was formed to present the hospital to the people of Nashville as a worthy recipient of their bounty. The members 184

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were interested, attended meetings regularly, listened to reports, and made some well-considered suggestions. They served as visitors who could be counted on to give the hospital a respectable standing in the community, but had no responsibility for its support, and did not function as trustees. It was a number of years before the hospital or the medical school had any substantial local financial support, in contrast to the situation in St. Louis where the far richer community provided the major support for the Washington University Medical School and its affiliated hospitals. The

Spirit of

Vanderbilt

A fine spirit pervaded the medical school, and the members of the faculty were good friends, showing a remarkable cooperation in their work and in the school as a whole, and this spirit of comradeship extended to the members of the families of the faculty. Life was pleasant—happily industrious and stimulating, and everybody seemed to feel he was in the right place. Perhaps it was this delightful environment and the teamwork that made Vanderbilt such a good training ground for deans. Among the original or early members of the faculty, Burwell was called to Harvard as dean of its medical school; Cunningham went to the Albany Medical College to serve as its dean and reorganizer; Youmans became dean of the University of Illinois College of Medicine in Chicago, and Harrison dean of the Southwestern Medical College in Dallas. Leathers was called to be dean of another school, but in spite of strong financial inducements declined to leave Vanderbilt. Glenn Cullen was taken away by the well-endowed department of pediatrics at the University of Cincinnati; Bigger left the department of surgery to become professor of surgery in the Medical College of Virginia in Richmond ; and Neill accepted the call to be professor of bacteriology at Cornell. Goodpasture was the resistant hero, as he was offered the professorship of pathology at Harvard, Johns Hopkins, Cornell, and two or three other leading universities, and refused all of them in order to stay in his native state and continue his important research on the filtrable viruses, undisturbed by new problems of administration and adjustments to a new environment. For a number of years Vanderbilt seemed to be the first place to which people turned to fill a vacancy in a medical school. Of course, everyone was glad to see the younger 185

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men appointed to responsible and well-supported positions in other schools, but to lose the head of a department was disturbing. The problem of leaving Vanderbilt was first presented to me at a meeting of the Association of American Medical Colleges in October 1925 in Charleston, South Carolina, when Walter Niles and John Hartwell from the Cornell University Medical College unfolded a great plan for bringing the medical school and the New York Hospital together, and asked me if I would be interested in directing this project. My immediate answer was that I had no intention of leaving my baby on the doorstep, and that seemed to close the matter. However, a year later, just before I left for a meeting in Cleveland, I received a letter from Mr. Edward W. Sheldon, president of the New York Hospital, asking me to come to New York for a conference after the meeting. I met with him, President Livingston Farrand of Cornell University, and Mr. Payne Whitney, who was much interested in the merger of the hospital and medical college and was ready to support it very generously. A great plan was described for which land had already been purchased adjacent to the Rockefeller Institute, and I was asked to undertake the direction of this project, serving as director of the New York Hospital-Cornell Medical College Association. Here was a question that was to disturb my peace of mind for some weeks to come. I had many reasons for remaining at Vanderbilt, where I was happy and where I had obligations to many friends who had joined me in an undertaking that was well on the way toward realizing the plans and aspirations to which I had given years of thought and effort; I had many strong personal and professional ties to hold me in Nashville. On the other hand, it seemed that I was being offered a very large and responsible opportunity for which much of my previous experience had been an unusual preparation; I would have another chance to play a creative part in advancing medical education from which I should not draw back. It was a hard decision which some of my most dependable advisers thought I should make in favor of this new undertaking. And so I came to feel that not to accept the New York position would show lack of courage—choosing the pleasant and personally comfortable way instead of going on to a difficult battle in the arena of New York. Another point in favor of going was that the plans were already being drawn for the new plant of the New York Hospital and the Cornell Medical College by the architectural 186

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firm of Coolidge, Shepley, Bulfinch, and Abbott of Boston, and Henry R. Shepley, with whom I had collaborated so happily on the Vanderbilt plant, was in charge of the New York undertaking. I decided to accept the directorship of the New York HospitalCornell Medical College Association as of July 1, 1927, with the understanding that I would remain at Vanderbilt for another year, cooperating in the architectural and other planning in New York as needed. Adjustments were made by Vanderbilt University to allow me to carry out this program for a year. Waller S. Leathers was appointed associate dean in preparation for the deanship, and John B. Youmans was brought from the University of Michigan as an addition to the medical department. Later C. Sidney Burwell succeeded me as professor of medicine. Hugh J. Morgan was appointed professor of clinical medicine and eventually succeeded Burwell as head of the department. We left Nashville with many regrets in June 1928 to begin a new adventure in medical education in the autumn of that year in New York. At the time of our departure the faculty of the Vanderbilt Medical School adopted a resolution in which the educational accomplishments of the school were set forth as an expression of those who had taken part in their initiation. Since it is an opinion from the inside, it is quoted as a fitting close to the Vanderbilt adventure: "The plans provided for the construction of the medical school and hospital were developed so that there would be a coordination between the teaching of preclinical and clinical subjects. It was a fundamental conception of the plan that the laboratories for anatomy, physiology, biochemistry, bacteriology, pathology, and pharmacology should be related to the hospital, so as to afford opportunity for the members of these departments and the teachers of clinical subjects to correlate their instruction. This was to enable the students to apply better, in the wards of the hospital, the information obtained in the preclinical subjects. "The building which has been provided for this purpose is regarded as a conspicuous success. The close coordination of all departments of the medical school and hospital is sure to prove an important factor in the future of medical education. The fact that the students spend all of their time in one great building, housing not only all the facilities of their entire course 187

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but also a hospital and out-patient department and laboratories for research, creates a new condition in medical education which is of distinct value. The students are thrown into close contact with the faculty as a whole; they obtain a grasp early in their course of the ultimate aim of medical education; they see the coordination of the laboratories and hospital wards and soon learn to appreciate their mutual dependence. The students are also exposed to the spirit of research and are afforded opportunity to catch the spirit, which it is hoped they will carry into their future work."

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THE NEW YORK HOSPITAL-CORNELL MEDICAL COLLEGE ASSOCIATION -< 1 9 2 8 - 1 9 3 4 κ

T

HE New York Hospital and Cornell University Medical College became organically associated on June 14, 1927, when an agreement was signed by Edward W. Sheldon, president of the hospital, and by Livingston Farrand, president of the university, to form the New York Hospital-Cornell Medical College Association. The Association and Its Resources

The idea of combining the medical college and hospital into a medical center had been under consideration for a number of years and was finally made possible by Payne Whitney, whose interest in each institution led him to support the project and take part in working out the methods of association. He had inherited a large fortune from his uncle, Colonel Oliver Hazard Payne, the original benefactor of the Cornell Medical College, and was a governor and vice president of the New York Hospital. Mr. Whitney joined with Mr. Sheldon and President Farrand in formulating plans for the merger and purchased land adjacent to the Rockefeller Institute on the East River as the future site of the combined institutions. In May 1927 a serious blow fell. Payne Whitney died suddenly, leaving Mr. Sheldon to carry alone the heavy responsibility on the part of the hospital. Mr. Whitney had, however, made very generous provisions in his will, both for the hospital and for the medical college, to finance the plan of the association. He bequeathed approximately 189

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$12,400,000 to the hospital, $6,200,000 to build and endow a psychiatric clinic as part of the projected center, and $2,800,000 to the university for endowment of the medical college. A t about this time, the General Education Board appropriated $7,500,000 to Cornell University to provide the new buildings of the medical college; somewhat later $6,000,000 were contributed to build and endow the Women's Clinic which was to replace the Lying-in Hospital. To this fund J. Pierpont Morgan, Jr. contributed $2,000,000; an equal amount was given by the Laura Spelman Rockefeller Foundation; and George F. Baker, senior and junior, each contributed $1,000,000. The New York Hospital also absorbed the Manhattan Maternity and Dispensary, and its assets became available f o r the building of the Children's Clinic. The potential resources of the hospital and medical college were estimated to be approximately $60,600,000 at that time, although some of this amount was not actually in hand. The two institutions amalgamated in the N e w York HospitalCornell Medical College Association had each taken a significant part in American medical education. The hospital was the second voluntary hospital founded in colonial America, and the first in N e w York. The medical college was established over a century later, in the early days of the modern era of medical education which began at the turn of the present century. The History of the New York Hospital The N e w York Hospital was granted a royal charter by King George I I I of England on June 13, 1771, following a movement started by Dr. Samuel Bard who "eloquently urged on the community the crying need f o r a general hospital not only f o r the care and relief of the sick, but also as affording the best and only means of instructing students properly in the practice of medicine." This plea was made by Bard at the graduation of the first two medical students of King's College, in which he was professor of medicine, before a notable gathering in Trinity Church on May 16, 1769. His address evoked an immediate response, resulting in the raising of funds and the formation of the "Society of the Hospital in the City of N e w Y o r k , " as it was originally called, and in a f e w years a hospital was erected on Broadway opposite Pearl Street. I t was practically completed in 1775 when its interior was consumed by fire and, as a news190

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paper of the day reported, "this beautiful structure, at once the pride and ornament of the City, became a ruin." The hospital was rebuilt, and in July 1776, its first patients were American soldiers wounded in the defense of New York at the beginning of the Revolutionary War. The city soon fell into the hands of the British troops, who used the hospital as barracks and hospital for their own soldiers. It was not until 1791 that the building was restored to its original purpose and the New York Hospital began its long medical service to the community. The governors of the hospital have never forgotten the plea of Samuel Bard that the hospital be a facility for the instruction of medical students, and its outstanding contributions to medical education were emphasized in an address by its president, Edward W. Sheldon, at the exercises in 1921 celebrating the 150th anniversary of the founding of the New York Hospital. He said on that occasion: "Immediately on the opening of the Hospital for patients in 1791 the medical staff became a medical faculty, and organized for clinical lectures and general instruction of students. These students in large numbers attended the clinics and used the library and other facilities of the Hospital. . . . Some idea of the extent of this educational work may be gained when we recall that at the old Broadway Hospital 300 students regularly attended the clinics in the main hospital building and 300 more those held in the newer South building. In volume certainly this will bear comparison with the performance of any medical school in the country. . . . To aid the staff and medical pupils further, a medical library was established in 1796 which grew steadily until it was the largest and best in the country. Being open to the public it was consulted by thousands of students and practitioners." On another occasion in 1932, Mr. Sheldon related that William H. Welch had spent all the spare hours, day and night, of his medical student life in New York in the library of the New York Hospital "and that Dr. Welch had more than once expressed his grateful appreciation to the Hospital for that . . . opportunity." Mr. Sheldon added that Dr. Welch "has abundantly repaid any possible obligation on that score by the wise counsel and constructive suggestions which he has given to the Hospital from time to time during the last fifteen years in the development of its plans." It may be confidently assumed that Dr. Welch encouraged the hospital to strengthen its position in medical 191

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education and exerted his weighty influence in the discussions that brought about the association of the hospital with the Cornell University Medical College. By 1870 it became evident that the hospital should move from the congested district of the city, where land had become very valuable and the surroundings unsuitable for a hospital. Plans to move were consummated in 1877 when the hospital occupied its new building which extended from 15th to 16th Streets west of Fifth Avenue and which embodied the best facilities of that day. Its staff continued to be composed of the leading physicians and surgeons of New York, and the hospital maintained the highest professional standards, being looked up to throughout the nation as a leader in the advancement of medical and surgical practice. When the Cornell University Medical College was founded in 1898, its faculty contained several members of the New York Hospital staff, and Cornell students received medical instruction there according to the traditions of the hospital. In 1913, however, a formal agreement was reached allowing the medical college to nominate half the hospital staff, and allotting medical and surgical services as clinical teaching facilities for Cornell students. Thus, a definite relationship was begun which led to the organic association fourteen years later. Besides occupying a prominent place in medical education, the New York Hospital has also been a leader in the advancement of psychiatry. As early as 1816, one of the governors, Thomas Eddy, presented a memorable report advocating a radical change in the treatment of mentally disturbed patients, setting forth the ideas of Philippe Pinel in France and of William and Samuel Tuke in England, whose humane treatment of patients he had observed. This report stimulated the Society of the New York Hospital to establish a separate psychiatric department. The Bloomingdale Hospital was built in 1821 on a spacious site on Morningside Heights, beyond the borders of the rapidly growing city; in 1894 the hospital was moved further from the city, to White Plains, where the Society of the New York Hospital now conducts one of the leading psychiatric hospitals in this country. The History of Cornell Medical

College

The Cornell University Medical College was founded in 1898, its inception being the result of a disagreement which 192

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caused part of the faculty of the New York University and Bellevue Hospital Medical College to resign and organize a new school. Those who withdrew from the Bellevue school were men of high standing in the community and in the profession, and, especially favorable for the success of their new project, they retained the interest and backing of Colonel Oliver Hazard Payne, a generous benefactor of the Bellevue school before the division of its faculty. Colonel Payne, who had been associated with John D. Rockefeller in the early days of the oil industry in Cleveland, was a wealthy bachelor who had become much interested in the support of medical education through his friends, Lewis A. Stimson and H. P. Loomis. Stimson, a classmate at Yale, and Loomis, Payne's physician, were in the dissenting group, and Payne's interest naturally went with them. In April 1898 the trustees of Cornell University accepted the offer of this group to form the medical college of the university and appointed a faculty consisting of William M. Polk, dean and professor of gynecology; Lewis A. Stimson, professor of surgery; W. Gilman Thompson, professor of medicine; R. A. Witthaus, professor of chemistry and toxicology; Austin Flint (the younger), professor of physiology; H. P. Loomis, professor of materia medica and therapeutics; J. Clifton Edgar, professor of obstetrics; and George Woolsey, professor of anatomy. The professorship of pathology was not filled until the following year when James Ewing was appointed and held a conspicuous place in the school for many years. In the fall of 1898 the college opened with 245 students, most of whom had transferred from the New York University and Bellevue Hospital Medical College. It occupied a rented building on the Bellevue Hospital grounds and used the Loomis Laboratory, which had been given by Colonel Payne to the Bellevue school, and had been assigned by legal action to the dissenting group of the faculty, to become ultimately the property of Cornell University. Colonel Payne's contribution of $1,500,000 to Cornell University at that time and his assurance of further financial support led to the establishment of its medical college. His original gift was for the erection of a medical school building, and in the fall of 1900 the college occupied its new quarters on First Avenue, between 27th and 28th Streets, opposite Bellevue Hospital. The building was designed by McKim, Mead and White, an outstand193

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ing firm of architects of which the talented Stanford White was the chief designer. It provided excellent facilities for the laboratory departments and commodious quarters for an outpatient clinic. Additional laboratory space was available in the Loomis Laboratory near by. Bellevue Hospital, the large New York City public hospital across the street, the New York Hospital about a mile away, and the Cornell Clinic in the school building, provided ample facilities for clinical teaching. In an address on the history of the Cornell University Medical College in 1931, Lewis A. Conner, professor of medicine, said that the two men upon whom the responsibilities and burdens of the new school chiefly rested were Dr. Polk, its dean, and Dr. Stimson. Of the former he said: "Dr. Polk, a native of Tennessee, was the son of the Rev. Leonidas Polk, the famous fighting bishop, and a Major General of the Confederate Army. Dr. Polk had all the courtesy and charm of manner that characterized the gentlemen of the Old South, but behind his handsome presence and his gracious manner he possessed a vigorous personality and an executive forcefulness which watched over every detail of the School's administration and was the mainspring of its every activity." Dr. Stimson, a native New Yorker, had, according to Conner, quite a different personality: "His somewhat reserved manner and cold exterior hid a generous and kindly disposition, which showed itself particularly in his relations with his subordinates. He was guide, philosopher, and friend to the members of his house staff and indeed to every struggling young doctor whom he thought deserving of help." Stimson was not only one of the leading American surgeons of his day, but a scholarly and highly cultivated man with a lucid and penetrating intellect. In 1944 the professorship of surgery at Cornell was endowed in his honor by a gift from his daughter, the late Miss Candace C. Stimson. His son, Henry L. Stimson, who served brilliantly as Secretary of War and as Secretary of State of the United States at times of much stress and strain, added luster to the name. The Cornell University Medical College had an auspicious beginning with two such exceptional leaders on its faculty, a generous benefactor behind it, and academic relations with a progressive and vigorous university. It could, therefore, make a fresh start in medical education, unhampered by traditional and outworn educational methods. Colonel Payne not only pro194

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vided funds to meet the early needs of the medical college, but stood by it during several critical periods and placed the institution on a secure financial foundation by a gift of over $4,000,000 for its permanent endowment. The opening of the new building in the autumn of 1900, was marked with pomp and ceremony, addresses being given by Theodore Roosevelt, then Governor of New York; Seth Low, president of Columbia University; Jacob Gould Schurman, president of Cornell; and Lewis A. Stimson, representing the faculty. Stimson's speech contained a description of the methods of teaching that were common practice a few years before 1900, from which the Cornell school was making a decisive break. The organization of the Cornell Medical College was unique in that the first two years of the four-year course were given both at Cornell University in Ithaca and in New York. As the university was coeducational throughout, women had to be admitted to the medical school. At first they were required to spend the first two years at Ithaca, and only the last two in New York. A few years later, however, all restrictions against women students were removed, and Cornell was one of the first schools to follow the example of Johns Hopkins in coeducation in medicine. During the first ten years of its existence only graduation from high school was required for admission to the medical college, but in 1908 a radical change was made, and admission was restricted to graduates of approved colleges and to college seniors who would receive a bachelor's degree after completion of the first year in the medical school. This change caused an immediate drop in enrollment, only eleven students being admitted, but the college had the assurance of Colonel Payne that he would stand behind the loss of revenue from reduced enrollment. At about this time the faculty was strengthened and the laboratory teaching modernized by the appointment of a number of distinguished scholars as professors. These included Robert A. Hatcher in pharmacology, Graham Lusk in physiology, Charles R. Stockard in anatomy, Stanley R. Benedict in biochemistry, and William J. Elser in bacteriology and immunology. Dr. Polk and Dr. Stimson were the dominant figures in the school for the first twenty years of its existence. They took the lead in bringing about the first formal association of the college with the New York Hospital in 1913, when half of the public 195

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services of the hospital were made available for teaching and placed in charge of the professors of the college. This agreement greatly improved the clinical teaching, as Cornell students could then be regularly assigned to the wards and clinics of the hospital and could study individual patients. By 1918 most of the original faculty had retired. Walter L. Niles was appointed dean, and a number of new appointments were made that put the clinical departments under the control of younger men. These appointments were Lewis A. Conner, professor of medicine; Charles L. Gibson, professor of surgery; George Gray Ward, professor of obstetrics and gynecology; Oscar M. Schloss, professor of pediatrics; and George H. Kirby, professor of psychiatry. These professors and others appointed earlier in the laboratory departments, constituted the faculty at the time the hospital-college association was formed. In 1921 the medical college inaugurated the Cornell Pay Clinic, a project of sufficient significance in medical practice and education to deserve a place in the annals of American medical history. Its aim was to provide a high quality of medical service for persons of moderate means who were unable to pay the fees usually charged by highly trained physicians and specialists, but who did not wish to accept free public or charitable medical service. The operation of the clinic required an economic classification of patients by medical social workers to determine eligibility for the service. This classification was based on income, size and responsibilities of families, and cost of the type of medical service that would be required. A large staff was organized to furnish all types of medical services, a complete group medical practice was conducted in the college building, and the staff was paid moderate salaries derived from patients' fees. Well-run laboratories and an x-ray department were included and the clinic was organized to provide facilities and clinical material for teaching and research as well as to render a high quality of medical service. Successful efforts were made to overcome the antagonism of practicing physicians in New York, who thought in the early years that the clinic created unfair competition with private practice. This same complaint had been voiced over the years in all parts of the country against the dispensaries operated by medical schools which lacked adequate hospital teaching facilities. The Cornell Pay Clinic did much to cure this chronic medical-social complaint by making 196

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efforts both to protect and to cooperate with practitioners of medicine. The clinic treated close to 20,000 patients during its first year at a cost of about $232,000. It showed a deficit of about $50,000, half of which was met by outside social agencies interested in the Cornell Pay Clinic as an experiment in the improvement of medical care and in the reduction of its costs. In later years the clinic was self-supporting and was carried on successfully until it was transferred to the New York Hospital in 1932. George Bigelow, the first director of the Cornell Pay Clinic, summarized in his first annual report the problems and objectives of the clinic by saying that a high quality of medical service is the one permanent essential to success, and if in addition the clinic could contribute to medical instruction and research, could be made self-supporting, and could be so managed as to eliminate the unfavorable so-called "charity" atmosphere commonly associated with clinics, much would be gained. It is interesting to note that important changes took place in the Cornell University Medical College every ten years after it was established in 1898. In 1908 the college became a university graduate school through the requirement of a bachelor's degree for admission into the second year of the medical course. Its faculty was strengthened at about that time by the appointment of several scholarly professors as heads of laboratory departments. By 1918, most of the members of the original faculty had retired, and at that time a new dean and new professors in charge of the clinical departments were appointed. By 1928 the college had become organically associated with the New York Hospital. The Organization

of the

Association

During the years in which the New York Hospital and the Cornell Medical College had been associated in medical education, a sympathetic understanding of their mutual objectives and a harmonious spirit of cooperation had developed between them. The situation was favorable for the establishment of a complete and perpetual partnership in an undertaking which had as its purposes the care of patients, the training of physicians, the fostering of scientific and spiritual ideals in medicine, and the acquisition and dissemination of new medical knowledge. Each institution had come to realize that alone it could achieve these objectives only in part, while in combination an unusually favor197

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able opportunity for the development of these lofty purposes would be established. It was on the basis of these ideas that the New York Hospital-Cornell Medical College Association was formed. The formal agreement signed by the officers of the hospital and of the university in June 1927 was the culmination of negotiations carried on for several years to find a plan acceptable to both institutions which would permit their organic association and at the same time preserve their respective rights and privileges, as well as their respective obligations. The preamble of the agreement stated that "the Hospital is impressed with the importance of rendering a larger and more important service to the sick of the community and to medical science through a more intimate and organic association with the Medical College. . . . The University wishes to associate itself organically with the Hospital . . . for the purpose of developing the Medical School on advanced and steadily advancing university lines. In the teaching of students and in the development of medical research it is the common purpose of the two institutions to be in a position to offer opportunities which will attract to their staff and faculty the ablest teachers, investigators and physicians that are anywhere procurable." This statement indicated that the hospital would participate fully in the educational program of the association, that the faculty and staff would be organized on a true university plan, and that both the clinical and laboratory departments would be established on a full-time basis. The agreement stipulated that the hospital would erect a new general hospital "with all the usual equipment and accessories, including a suitable out-patient department, ample pathological and research laboratories and other facilities as needed, and on plans approved by representatives of the University, accommodations for the instruction of medical students." The university would be granted every facility for teaching and research within the hospital consistent with the welfare of patients. The university agreed to build, maintain, and conduct new medical college buildings as part of the combined program, and to confer the degree of Doctor of Medicine only on students educated in accordance with the requirements of the association. The agreement defined the joint undertakings by the hospital and the university, which would continue their independent cor198

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porate existence and control. The therapeutic and educational work of the institutions was to be conducted under the New York Hospital-Cornell Medical College Association, directed by the Joint Administrative Board composed of three governors of the hospital, three trustees or other representatives of the university, and a seventh member elected by the six appointed members. This board was not incorporated and held no funds in its own name, but authority was delegated to it by the two incorporated bodies, Cornell University and the New York Hospital. The agreement specified that the functions of the board were to supervise the association and to appoint a director. The director was to serve as the executive officer of the board and of the medical faculty, to act as dean of the medical college, and to represent the educational and research interests in the hospital. He was responsible for coordinating the work of the school with the activities of the hospital in such a way as to avoid friction and promote harmonious and effective cooperation in teaching, research, and the care of patients. The expenses of the office and salary of the director were to be borne equally by the hospital and the university. The original Joint Administrative Board was composed of Edward W. Sheldon, Frank L. Polk, and William Woodward representing the hospital, and Livingston Farrand, J. DuPratt White, and Walter L. Niles representing the university; J. Pierpont Morgan was elected the seventh member. Mr. Sheldon, the chairman, carried much responsibility during the period of building and organizing. A graduate of Princeton and of the Columbia Law School, he devoted himself to finance, insurance, and public service, being president of the United States Trust Company and a director of thirteen insurance companies, and of several other large corporations. He served as a trustee of Princeton University, of Barnard College, and of the New York Public Library, had been a governor of the New York Hospital for over twenty years, and was a trustee of three other hospitals. He belonged to a number of important clubs and legal associations, including the Grolier Club—a sign of his interest in book collecting and in his own splendid library. Mr. Sheldon was a quiet, thoughtful man, with an impressive sincerity. He was unusually reticent and it was necessary to be satisfied with his carefully considered decisions rather than with conclusions reached after discussion. His reticence 199

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made collaboration somewhat difficult; the other members of the board considered him their spokesman, and as a result I was never entirely certain of the resources of the New York Hospital, which was to pay the major share of the great expenditures being planned. He was always interested in providing ample facilities of high quality, but did not in the beginning place definite limits on the funds that would be available. My association with Edward Sheldon was a happy and valuable experience, although I regretted that we could not have had more freedom and lightness in our conferences, which were sometimes held at his dignified dinner table in an atmosphere of formality that was unexpected in a confirmed bachelor. Livingston Farrand, the president of Cornell University, was quite different. He had an outgiving and attractive personality and was a talented public speaker. Like Sheldon, he was a Princeton man, and had graduated in medicine in 1891 from the College of Physicians and Surgeons of Columbia University. Instead of following a career in medicine, Farrand became an anthropologist, serving as professor at Columbia University from 1903 to 1914. During most of that time he also filled the position of executive secretary of the National Tuberculosis Association and took a leading part in its early development. He was president of the University of Colorado for five years and headed the American Red Cross for two years before being appointed president of Cornell in 1921. His wise diplomacy was an important factor in bringing the medical college and the hospital together to form the association. My relations with Farrand were always very pleasant and cordial, and it was a matter of much regret that his office was in Ithaca, over two hundred miles from New York, so that we could not frequently confer. Walter Niles had been dean of the medical college for nine years and had also taken part in bringing the college and hospital together. His experience was valuable to the board, but he naturally deferred to Farrand in regard to matters concerning the university. J. DuPratt White, a trustee of Cornell University, was a senior member of one of the largest Wall Street law firms. Frank L. Polk, a governor of the New York Hospital, was the son of Dr. William M. Polk, the first dean and a leader in organizing the original Cornell Medical College. He was naturally much interested in the association, but was a busy Wall Street lawyer with many other interests. William Woodward was the 200

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president of an important bank and the well-known owner of some of America's finest race horses. J. Pierpont Morgan had taken a leading part in bringing the Lying-in Hospital into the association and had made a large financial contribution toward this end. However, he attended none of the early meetings of the board. It is evident that no member of the board was in a position to give the sort of leadership to this complex and comprehensive project that had been given by William H. Welch at Johns Hopkins, by Simon Flexner at the Rockefeller Institute, by Robert S. Brookings at Washington University, and by James H. Kirkland at Vanderbilt. Planning

and

Building

I was appointed director of the association in March 1927, to take office on July 1, with the understanding that during the first year I would remain at Vanderbilt University, but would collaborate with the architects on the building plans and go to New York for meetings of the Joint Administrative Board. My family moved to New York in September 1928, and I took over the office of the dean in the Cornell Medical College at First Avenue and 28th Street from Walter L. Niles, an old friend. By the time I assumed the office of director, the basic program of the association had been defined by the agreement between the hospital and university, and the Joint Administrative Board had been organized. The two major problems before us were to plan and to build a plant providing facilities for the two combined institutions and to organize a unified professional staff qualified to conduct teaching and research on a high university level and provide patients with outstanding medical care. These physical and human components of the total project had to be developed separately up to a certain point and then joined together. It was realized that the character and adequacy of the physical facilities would be an important factor in attracting to the faculty and staff the ablest teachers and physicians anywhere procurable, an objective on which the hospital and university had agreed. It was also realized that the department heads should have an opportunity to decide certain details of plans and equipment of the departments which they would direct. It was obvious, however, that the basic principles of designing the plant—location, size, general architectural arrangements, and coordination of 201

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facilities—would have to be carried on by a small, closely cooperating group, and that the collaboration of the future department heads would have to wait until the staff was organized. Architectural studies had been started in 1924 by Coolidge, Shepley, Bulfinch, and Abbott, and preliminary plans had been made for a hospital in the block between 68th and 69th Streets extending from York Avenue to the East River on land that had been purchased by Payne Whitney for the New York Hospital. These studies were further developed in 1926. In the spring of 1927, the second block was acquired. It extended from 69th to 70th Streets and included the east end of 69th Street, which was bought from the city and closed off. New plans uniting the hospital and medical school on one piece of land were then begun. By this time Henry R. Shepley was the architect in charge of the planning, and we conferred in Nashville in April 1927, outlining a general scheme for the building of a medical center. Mr. Sheldon and Mr. Whitney approved the scheme and expressed the wish to have the plans developed as rapidly as possible. Marc Eidlitz and Son were selected as the builders, an excellent choice not only because of the fine quality of their work, but also because of their valuable experience in recently building the great medical center on the upper west side of New York City, combining the College of Physicians and Surgeons of Columbia University and the Presbyterian Hospital. Winford H. Smith, director of the Johns Hopkins Hospital, was engaged as consultant in hospital design. The group that worked closely together on the planning was Harry Shepley and his job captain Truelson, George Brown representing the builders, and myself; Winford Smith met with us from time to time and reviewed the plans as they were developed. Shepley and I had worked together on the medical school and hospital at Vanderbilt University, and our previous association was of much value in the New York project. We were already in agreement on how a medical school with an integrated hospital should operate and on how various activities should be correlated. Although the Vanderbilt plant was a smaller and simpler project, the same principles could be applied to the larger New York project, and we frequently called upon our experience at Vanderbilt in solving intricate problems of planning. George Brown, who had been directly in charge of the Columbia-Presbyterian building operations often informed us of the way certain 202

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features of its plan had worked out, and sometimes cautioned us on the basis of that experience. Winford Smith decided matters related to hospital administration, the required capacity and design of kitchens, and many other questions having to do with the operation of the hospital as a whole. During the first year of planning many changes had to be made. As more land was acquired north of 70th Street, the original limit of available land, plans were developed for the nurses' residence and school of nursing, the power plant, and other services. New projects, including the Women's Clinic, the Pediatric Department, and the Payne Whitney Psychiatric Clinic, also had to be incorporated in the plans. By February 1928 a promising scheme had been devised which provided separate buildings for private patients and for staff quarters. However, not enough land was available to accommodate these separate facilities, and they had to be incorporated in the main building. This was accomplished by adding six floors for private patients over the central portion of the building, and above them the living quarters and recreational space for the resident professional staff, raising the structure to a height of twenty-seven stories. Following this change, the final general plans were agreed upon in April 1928 and were approved by the Joint Administrative Board. The architects then began their working drawings; over a year was needed to bring them sufficiently near completion so that construction could begin. Ground-breaking ceremonies were held on June 17, 1929. The plans were developed without definite limitations' being placed on the cost of construction and equipment. It was correctly estimated that the contemplated plant of the New York HospitalCornell Medical College Association would cost, including land, buildings, and equipment, $30,000,000. These estimates were made in the halcyon days of finance during the boom that preceded the stock market crash of October 1929, which ushered in the dreadful depression that changed the outlook in every direction and created serious difficulties for this great medical project. Early in the process of planning, three principles were agreed upon. The first was that each department of the medical college and of the hospital should be as far as possible a self-contained institute or clinic incorporating all the facilities needed for its own use, and that these units should be correlated with one 203

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another so as to encourage natural cooperation and intellectual intercourse. The second principle was that facilities should be provided for a relatively small body of medical students and that extensive opportunities should be offered for research by the staff and by graduate students in order to cultivate the university spirit in all departments of the hospital and medical school. The third principle was that each clinical unit should provide space for the number of patients which teaching experience had shown to be the optimum for a well-conducted university clinic. It was decided that the western end of the available land along York Avenue should be occupied by the buildings of the medical school and by the nurses' residence and school of nursing in order to retain the East River view and openness for patients. The main hospital was to occupy the center part of the area, dominating the group of buildings. Separate divisions for obstetrics, pediatrics, and psychiatry were to be erected on the eastern part of the land overlooking the river. After the location of the various divisions of the plant had been determined, each had to be developed with the idea of creating coordinated facilities that would provide conditions as nearly ideal as possible for patients, staff, teachers, and research workers. The central hospital building was planned to contain in wards extending toward the south 167 beds for medicine, 292 for surgery and the surgical specialties, and above them, 100 rooms for private medical and surgical patients and accommodations for 114 members of the resident staff. The Women's Clinic was to contain 179 beds, including 33 private rooms; the Pediatric Clinic was to contain 100 medical ward beds, 23 surgical ward beds, and 10 private rooms; the Psychiatric Clinic was planned to accommodate 114 patients. Including the beds in the accident and receiving wards, the total capacity of the hospital was 987 patients. The nurses' residence was planned to house 500 nurses. The medical college was to occupy four buildings extending out to York Avenue and providing space for the departments of anatomy, public health, bacteriology, pathology, physiology, biochemistry, and pharmacology. A connecting building, facing York Avenue, contained the college administrative offices, the medical library, and the auditorium; the pathological laboratories, above, were connected with the main hospital on all floors. The central hospital was a long building running from 204

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east to west, terminating in the Pediatric Clinic toward the River and in the medical college toward York Avenue, with two wings on the south side for patients and two wings on the north side, one for the medical and surgical outpatient departments and the other for the x-ray, physiotherapy, and other special departments. The administrative offices of the hospital were to occupy the first floor, the medical clinic the second to fourth floors, the surgical clinic the fifth to ninth floors, the operating rooms the tenth and eleventh floors. The twelfth to seventeenth floors contained rooms for private patients. Living quarters with recreational facilities for the resident staff occupied the eighteenth to twenty-fourth floors, and above that was space for elevator and other machinery. The central kitchen, storerooms, record room, and other facilities were located in the basement and subbasement. The three clinic buildings along the river front were provided with their own outpatient departments, staff living quarters, and facilities for research and teaching. On the north side of 70th Street, east of the nurses' residence, was the powerhouse unit, which included boilers, dynamos, refrigerating plant, laundry, shops, garage, and living quarters for employees—a complicated problem of planning. The development of the plans for this great medical center required long and concentrated effort over several years, as it was probably the most specialized building project ever erected at one time. There were many special problems to be solved, not only in its design and in the specification of materials, but in providing the mechanical services. Careful consideration had to be given to a great number of individual units which had to be correlated in correct proportion to each other and in the most advantageous location in relation to the plant as a whole. During the planning process very little consideration was given to exterior appearance; only Tightness of plan and orientation of parts were studied. From these studies emerged a mass, the proportions of which could be but slightly altered without causing the plan to suffer. Keeping in mind the particular limitations of plan and equipment, the architects then turned their attention to the character of the architectural form. Eventually, Henry R. Shepley evolved a magnificent design employing long, pointed arches, suggested by the Palace of the Popes at Avignon. The beauty of the structural form was emphasized by the use of light gray variegated bricks above a gray limestone base that 205

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extended up to the second floor. The great structure rising majestically above the East River, became one of the finest buildings in the City of New York, where the foremost American architects have vied with one another in designing the world's greatest collection of monumental buildings. The building was acclaimed by architects in this country and abroad, and the Architectural League of New York awarded its gold medal for 1933 to Henry R. Shepley for "the orderly arrangement of the many and varied parts of an unusually complex problem, and the excellence of the plan and originality of the design." A fine and somewhat poetic tribute was paid to the building by Henry E. Sigerist, who saw it in 1932 during his first visit to America. At that time he made an extensive tour of this country and on returning home to Leipzig, where he was professor of the history of medicine, Sigerist wrote a book on American medicine. He later spent many years at Johns Hopkins as professor of the history of medicine. During his tour he was much impressed by the New York Hospital-Cornell building and described it in his book* as the last link in the chain of hospital evolution. He wrote: ". . . it is a dignified independent building of really overwhelming beauty. At first glance, and seeing the great pointed arches which are frankly reminiscent of the Palace of the Popes at Avignon, one may feel taken aback and inclined to wonder what the Gothic has to do with New York: why these sacerdotal associations ? Has not New York a rhythm and a style of its own? But at a more prolonged view the building casts a spell; we find ourselves coming back to look again. Gradually we become aware of the meaning of the building, its profound symbolism, the great humanistic idea which it embodies in stone. At the center of medicine is the sick human being, the sole reason for its existence. The center of the building contains the hospital, with the two departments of medicine and surgery, which rise towards Heaven like a prayer for healing. From medicine and surgery the specialties developed; and from the central building the specialist clinics branch out as separate wings. Medicine is based on anatomy, physiology, pathology, and pharmacology. These departments are located on the ground floor of the building and enclose in their midst the library, that room where the wisdom of centuries has been stored for the benefit of future *Henry E. Sigerist. American Medicine. New York: Norton, 1934. 206

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generations. Mental diseases have a place apart in the system of medicine and here, too, the psychiatric clinic has a separate building. And the pointed arches? Is not medicine immortal, a dispensation given to men in all times? Did not the Middle Ages bequeath to us our most complete expression of the unity of medicine and the divinity of the physician's mission? Greek science and Christian charity are the ground in which our Western medicine is rooted. In this building the snake of Aesculapius twines, not around a staff, but a cross. I t is a fine thing and gives us confidence in the future to find such a monument today, in the twentieth century, in a city like N e w York." The Development

of the Professional Staff

As the plans f o r the buildings were being developed, the problem of organizing a unified staff and faculty was being given serious consideration. From the beginning, it was understood that the hospital as well as the medical college would be organized and conducted on a university basis, and that each division of the hospital would be headed by a chief-of-service who would also be the professor and head of the department in the medical school. Appointments to these positions were to be made with the understanding that the heads of all major departments would give their full time to the hospital and medical college without financial dependence on private practice, and that adequate salaries would be provided to make this possible. The hospital was designed as five university clinics which would provide facilities adequate in every way not only f o r the care of both bed patients and outpatients, but also f o r teaching and f o r the conduct of research. These five clinics were medicine, surgery, obstetrics and gynecology, pediatrics, and psychiatry. It was a matter of paramount importance to secure as heads of these clinical departments men capable of carrying the heavy responsibilities which these positions entailed, both from the viewpoint of directing the service to patients and of fulfilling the functions of a university professor. I t was essential to fill these posts with outstanding men trained f o r and interested in an academic career and willing to forego the advantages of private practice. Another condition bearing on the appointments at the time of reorganization was the decision by the Joint Administrative Board that members of the faculty should retire at the age of 207

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sixty-five. Three of the professors of the clinical departments, Lewis A. Conner, Charles L. Gibson, and William L. Russell, professors of medicine, surgery, and psychiatry, respectively, had already reached the age of retirement and could not, therefore, be considered as heads of these clinics. There were, however, two younger members of the faculty who were eminently fitted to head a hospital service and to continue in their professorships on a full-time basis. They were Eugene F. DuBois and Oscar M. Schloss. DuBois was appointed professor of medicine and physician-in-chief of the hospital; Schloss was appointed professor of pediatrics and pediatrician-in-chief. Eugene DuBois, a well-trained and scholarly physician entirely devoted to the academic aspects of medicine, was the director of the large medical service in the Cornell Division of Bellevue Hospital. He had been an associate professor at Cornell since 1919 and had served since 1913 as medical director of the Russell Sage Institute of Pathology. The institute had been sponsoring medical research in the field of metabolism under the scientific direction of Graham Lusk, the Cornell professor of physiology. A metabolic laboratory, including one of the first calorimeters in this country, had been established in the Cornell Division of Bellevue Hospital. There DuBois had carried on metabolic studies of widely recognized value and had trained a number of young men who became leaders in this field of research. When DuBois was appointed to New York Hospital, the Russell Sage Institute of Pathology was transferred to a specially designed laboratory in the new hospital's medical clinic, and the trustees of the institute agreed to continue support in the amount of about $12,000 a year so that this important research could continue under the direction of DuBois. Oscar Schloss had been professor of pediatrics in the Cornell school for two years when, in 1920, he accepted an appointment at Harvard Medical School, where he served as professor of pediatrics for three years. Returning to New York in 1923, he resumed his Cornell professorship and served as director of the children's service in New York Nursery and Child's Hospital. He was much interested in research and in teaching, and the academic life appealed to him so strongly that he was willing to retire from a large private practice in order to accept the professorship in pediatrics. These appointments and those of Charles R. Stockard as professor of anatomy and of Stanley R. Benedict as professor of 208

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biochemistry were confirmed by the Joint Administrative Board in January 1930. Stockard had been professor of anatomy since 1911. He had made a number of contributions to the science of embryology and to studies of the problems of growth and development, and was a leading anatomist. Benedict had been at Cornell since 1910, specializing at first in chemical pathology, and was appointed professor of chemistry in 1913. Among his scientific interests were chemical problems related to cancer; he had devoted part of his time to the direction of the chemical laboratory of the Memorial Hospital, the cancer hospital affiliated with Cornell, but relinquished this post to become a member of the reorganized faculty. It was planned that persons appointed to the reorganized faculty would participate in the direction of the future medical school. The first four professors—DuBois, Schloss, Stockard, and Benedict—formed a curriculum committee and undertook a study of the educational programs of four medical schools which had recently introduced new features into their plans of teaching. These were the medical schools of the University of Chicago, Harvard, Johns Hopkins, and Yale. Not only were their published curricula studied, but a member of the committee visited each school to confer with its dean and faculty members. On the basis of this study certain educational principles were agreed upon to be followed in the revision of the Cornell curriculum. Later, this same group became the committee on development and considered educational policies, appointments, and other matters, and made recommendations to the Joint Administrative Board. As other department heads were appointed, they were added to this committee, and from it evolved the executive faculty of the medical college. The appointment of former full-time professors of the Cornell medical faculty to positions on the reorganized faculty presented problems. James Ewing, professor of pathology, and Graham Lusk, professor of physiology, two eminent members of the faculty for many years, would reach retirement age in 1931, so that new appointments had to be made to these important posts. Ewing was one of the leading authorities in the field of cancer and other tumors. He had long devoted part of his time to directing cancer research at the Memorial Hospital and became full-time director there. He continued his connection with the department of pathology as professor of oncology. Gra209

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ham Lusk retired when the medical school moved in 1932. William J. Elser, who had served for a number of years as professor of bacteriology, was also the pathologist of the New York Hospital, where he had devoted himself largely to the problems of pathology related to clinical diagnosis and to the laboratory study of patients. He was appointed professor of clinical pathology and bacteriology and director of the general clinical laboratories of the hospital. William C. Thro, who had taught this subject and had conducted the clinical laboratory of the Cornell Clinic, was attached to the department of clinical pathology. John C. Torrey, since 1916 professor of hygiene, was appointed professor of public health and preventive medicine and head of an independent department with its own laboratory and research facilities. Robert A. Hatcher, who had been professor of pharmacology since 1908 and who held a prominent place among American pharmacologists, was near the age of retirement, but agreed to continue in his professorship for a few years and to organize the department of pharmacology in the new buildings. Professorships of pathology, physiology, bacteriology, surgery, obstetrics, and psychiatry were filled by appointing men from other institutions. Eugene L. Opie, appointed professor of pathology, was called from the University of Pennsylvania where he was professor of experimental pathology and director of the Henry Phipps Institute for the Study, Treatment, and Prevention of Tuberculosis. Opie was at that time one of the leading pathologists in this country, with a wide experience in medical education and holding an eminent position in medical research. After six years in the Johns Hopkins department of pathology under William H. Welch, he had become one of the original staff of the Rockefeller Institute for Medical Research with Simon Flexner. As a young man he had gone to Washington University in 1910 when its medical school was reorganized and had served as dean when the new school was being developed. During his thirteen years in St. Louis he had taken a leading part in establishing high university standards in the Washington University Medical School, and his concepts of medical education, so well expressed in his address at the ceremonies dedicating the new school in St. Louis, coincided closely with the ideals we hoped to develop in the New York Hospital-Cornell Medical College Association. 210

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Opie's appointment carried with it the position of pathologistin-chief of the New York Hospital, a place from which he could exert an important influence in maintaining high standards of scientific work and research. He was older than any of the other newly appointed professors and was thought of as an elder statesman in medical education who would be a leader and an example of the university spirit that it was hoped would permeate the institution. Herbert S. Gasser, appointed professor of physiology, was called from Washington University where he had been for ten years professor of pharmacology. Gasser had entered the field of physiology after graduating from Johns Hopkins in 1915 and had not shifted his main scientific interests during his years as professor of pharmacology in St. Louis. During this time he had collaborated with the professor of physiology, Joseph Erlanger, in carrying out brilliantly conceived studies on the conduction of nerve impulses, for which they were awarded the 1941 Nobel prize in medicine. The professorship of bacteriology and immunology was filled by the appointment of James M. Neill, who had shown much promise as an investigator and teacher while serving as a professor in the Vanderbilt University Medical School. Neill received a Ph.D. degree from the Massachusetts Agricultural College in 1921. He had worked with Oswold Avery at the Rockefeller Institute for several years, and was one of the youngest men appointed to the faculty of the reorganized Vanderbilt school in 1925. The professorship of surgery was an especially significant one because of the difficult problems involved in coordinating the New York Hospital staff and the members of the Cornell faculty with a group of surgeons to be appointed on a full-time basis to conduct the teaching and hospital services. The department included not only general surgery but also the various surgical specialties, such as ophthalmology, laryngology, orthopedic surgery, and urology. The situation with regard to urology was complicated by the existence of the James Buchanan Brady Foundation, which had been established in the New York Hospital by an endowment from James Buchanan Brady with the understanding that Oswald S. Lowsley would be its director. In order to carry out the provisions of this endowment and at the same time provide a urological division that was an integral 211

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part of the department of surgery, the ninth floor of the hospital was designed to accommodate two urological services. One independent service under Lowsley's direction fulfilled the requirements stipulated in the endowment; the other service under the direction of the professor of urology was part of the university surgical clinic. George J. Heuer, appointed professor of surgery, was called from the University of Cincinnati, where he had developed a splendid surgical department during his ten years as professor of surgery there. Heuer had graduated in medicine at Johns Hopkins in 1907, and had had an extensive training under William S. Halsted. He was one of Halsted's outstanding disciples, having spent fourteen years in his department. His excellent training and experience eminently qualified him to organize and conduct a surgical clinic of high order and to serve as a university professor. The professorship of obstetrics and gynecology was filled by Henricus J. Stander, who was associate professor in the department of J. Whitridge Williams at Johns Hopkins. Stander's educational experience was quite unusual. A Boer from the South African Transvaal, he had become interested in chemistry in early life, and wanted to pursue his studies in an English university. His father, however, still smarting from the distress of the Boer War with England, would not permit him to carry out this plan. Stander, therefore, came to this country with practically no resources, but by a stroke of good luck, found a place at Harvard where he could study chemistry and also earn enough to live on. There he conducted research in the chemistry of substances derived from tar and invented a process which led to a well-paying position in a subsidiary firm of the Du Pont Company, located in the Southwest. He obtained a M.S. degree in 1916 at the University of Arizona and accumulated enough money to enable him to enter Yale to study medicine. He obtained his doctor's degree in 1921, interned at the New Haven Hospital, and in 1922 went to Johns Hopkins where he was appointed to the staff of the department of obstetrics. During his industrial career he had developed considerable experience in administration and leadership and was strongly recommended by Whitridge Williams as the best man he knew to undertake the organization of the Women's Clinic of the New York Hospital and to serve as professor of obstetrics and gynecology. In this position Stander had the task of taking over the service of the old Lying-in Hos212

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pital which had been amalgamated with the hospital-medical school association, and of providing for members of the Lying-in Hospital staff. The appointment of professor of psychiatry and psychiatristin-chief of the Payne Whitney Psychiatric Clinic was the final step in a project that had long been contemplated to establish a psychiatric service in New York City which would correlate the operations of the general hospital with Bloomingdale Hospital, its psychiatric division in White Plains. William L. Russell had been especially concerned with this project and had stimulated Payne Whitney to provide generously in his will for its support. Dr. Russell had been the medical superintendent of Bloomingdale Hospital for fifteen years and had greatly improved the institution during that period. In 1926, when the association with Cornell was contemplated, he was appointed general psychiatric director of the New York Hospital, to devote himself to broadening its psychiatric program. In 1928 he was appointed to the Cornell faculty as professor of psychiatry, but as he had reached the age of retirement before 1932, it was necessary to find a successor who would also be the chief of the new psychiatric clinic, built under Russell's direction. Russell, however, retained his position as general psychiatric director of the New York Hospital, and much dependence was placed upon him to find the man to lead the development of the new clinic. It was decided that the search should be conducted abroad as well as in this country, and for this purpose Dr. Russell and I went to Europe in June 1930 to visit the leading psychiatric clinics in Great Britain, Holland, Germany, and Switzerland. Our first objective was to discuss the professorship with the Scotsman, D. K. Henderson, professor of psychiatry in Glasgow, who had been on the John Hopkins staff with Adolf Meyer. Since Henderson had served as the first resident psychiatrist in the Henry Phipps Psychiatric Clinic, taking an important part in its organization, and also since his wife was American, we had hoped that he might be interested in returning to the United States. Henderson was at that time one of the leading and advancing British psychiatrists and could not be persuaded to leave again his native land. A few years later he was appointed to the professorship in Edinburgh, the highest psychiatric post in Scotland. Although we were disappointed in our first objective, Russell 213

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and I visited twenty-three psychiatric hospitals and university clinics, met a number of the leading European psychiatrists from whom we sought advice regarding equipment and methods of organization, and became acquainted with several new psychiatric developments. The trip with Russell was of much value in orienting me in the field of mental and nervous disorders, and both Russell and I were better prepared to guide the development of high university standards in the new psychiatric clinic. After our return from Europe, George S. Amsden was appointed professor of psychiatry. A Harvard graduate, Amsden had been appointed in 1905, soon after receiving his M.D. degree, to the laboratory staff of Bloomingdale Hospital; he later became one of its physicians under Russell and served there until 1924. He was then appointed professor of psychiatry at the Albany Medical College where he served for five years; at the time of his Cornell appointment he was professor of psychiatry in the New York Post Graduate Medical School and also engaged in private practice. In 1931 William S. Ladd was appointed associate dean of the medical college and took a very helpful part in organizing educational and student programs in the new plant. He was a Columbia graduate and was in its department of medicine when appointed to Cornell. He had also served on the Johns Hopkins medical staff. By the end of the academic year, in June 1931, the thirteen professors had been appointed as heads of the departments of the medical college, to take up their full duties in the fall of 1932 in the new plant. Early in 1932 the executive faculty was organized, consisting of the heads of the various departments, the director, and the associate dean; the president of the university acted as presiding officer. During this year consideration was given to the organization of the hospital staff around a core of full-time teachers, assisted by a large group of physicians and surgeons in private practice who would devote part of their time to the hospital and medical school. This part-time group would conduct much of the outpatient service and would form the staff of the Cornell Division of Bellevue Hospital. It would consist mainly of the members of the old Cornell faculty and members of the former staffs of the New York and Lying-in Hospitals. The organization of the large 214

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resident staff posed a problem for the chiefs of the services, as the graded system of residents (interns, assistant residents, and resident physicians and surgeons) was to be introduced. This system, originated by Osier at Johns Hopkins, was then generally recognized as the best method of training leaders in medicine, and ample staff quarters had been provided for this purpose in the new hospital. The School of Nursing The development of a strong school of nursing was a project in which the New York Hospital Nurses' Alumnae Association was much interested. In 1929 a committee on nursing organization was formed with Miss Mary Beard, the president of the alumnae association, as its chairman. The other members were Miss Lydia Anderson and Miss Anna Reutinger, with Miss Annie W. Goodrich, director of the Yale School of Nursing, and Miss Minnie H. Jordan, superintendent of nurses at the New York Hospital, as honorary members. The governors of the hospital authorized the committee to conduct studies on the organization of the school of nursing and the nursing service in the new hospital and provided funds for the support of these studies. The committee engaged Miss Ethel Johns as the full-time director of studies, and she served in this capacity for two years beginning in September 1929. Miss Johns, a Canadian nurse, had a broad international view of nursing, having recently spent four years on the Paris staff of the Rockefeller Foundation. The studies were planned to be of sufficient breadth and thoroughness to make a lasting contribution to the education of nurses and to hospital nursing service. Miss Johns had the collaboration of Miss Katherine Tucker of the National Organization for Public Health Nursing, and of Miss Alice S. Gilman, an authority on planning facilities for schools of nursing and nurses' residences. I collaborated closely with Miss Johns and the committee, as their studies were important to the future operation of the hospital, and a frequent exchange of ideas was essential. The committee was concerned with the improvement of nursing education, formulation of the hospital nursing service, and determination of the financial requirements to meet the program they advocated. Emphasis was placed on the establishment of a university school of nursing, with Cornell collaborating 215

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with the hospital in an educational program leading to a bachelor's degree. The standards of education were to be acceptable to the university so that students completing two years of college work in addition to the course of the school of nursing would be granted a degree by the university. The committee estimated that such a school would require an endowment of $2,000,000 to place it on a sound financial basis. This endowment would relieve the school from the need of depending on services rendered by student nurses in the hospital to offset the costs of its operation—the basis on which most hospitals operated their nurses' training schools—and it would allow the school to utilize the hospital's nursing service primarily for its educational value to students. The committee recommended that the school of nursing be related to the hospital and the university through the Joint Administrative Board, that the director of the school also direct the hospital nursing service, and that all nurses appointed to higher positions on the staff be qualified to participate in the educational program. These recommendations were approved in principle by the board in 1931, but no funds could then be secured for a separate endowment of the school, and the proposed relations with Cornell University could not be consummated at that time. However, an advanced nursing program had been formulated on the sound and thorough studies of the committee, and it was decided to carry out this program as far as existing conditions would allow and to appoint a director of nursing who would be qualified to organize the school and the nursing service along the line projected by the committee. Miss Anna D. Wolf was appointed director of nursing, effective October 1, 1931, allowing nearly a year to complete her organization before the new hospital opened. Miss Wolf had an exceptional educational record, being a college graduate and holding a master's degree from Columbia University. After graduating from the Johns Hopkins School of Nursing and serving on its staff, she had been appointed superintendent of nursing in 1919 at the Peking Union Medical College in China, where she organized the nursing service and a school of nursing. After returning home in 1925 and spending a year at Columbia University Teachers College, she was appointed director of nursing in the university clinics and associate professor of nursing at the University of Chicago, where she developed courses in teaching 216

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and administration for nurses. With this outstanding experience Miss Wolf undertook the organization of the school and the nursing service of the New York Hospital, contributing much energy, skill, and understanding to the task. She and her staff played an important part in putting the hospital in readiness for its opening. In December 1932 the entrance requirements of the school of nursing were increased to two years of college work, and the quality of the curriculum was elevated in order to make a graduate eligible for a bachelor's degree from the college in which she had completed two years of study. However, as the financial depression was severe at this time, these advanced requirements proved impractical, and in 1934 it was necessary to reduce the admission requirement to high school graduation and to make other changes to effect economies of operation. It was not until 1942, two years after Miss Wolf had resigned to become the director of nursing at Johns Hopkins, her alma mater, that the original plan of a university school was finally put into effect. The Cornell University-New York Hospital School of Nursing was then established, and its graduates were awarded the degree of Bachelor of Science in Nursing by Cornell University. Miss Wolf deserves much credit for the part she played during those difficult times in laying a sound foundation upon which an exceptionally fine school of nursing was ultimately built. The Medical

Social

Service

Another project in which I was much interested was the development of a department of social service which would be an integral part of the hospital organization and would be conducted by a professional staff of well-qualified social workers. I was convinced that a high quality of medical social work would not only create a service of great value to the patients of the hospital, but would also make important contributions to medical education. A strong department of social service would, in my opinion, stimulate the interest of the staff and especially of the medical students in the personal problems of patients which would be of much value in the education of the physician. In the design of the hospital, adequate facilities for a central social service department had been provided, and space had been allotted for social workers in the various outpatient clinics. An extensive plan was drawn up for the organization of a coordinated 217

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department to operate in all the clinics. It was found, however, that the traditions of the hospital presented obstacles to the inauguration of this plan, as the social service of the hospital had for years been operated by a committee of women, who raised the funds for its support, made appointments to its staff, and directed many of its activities. When the plan I had formulated was presented to the committee, it was received with something less than enthusiasm, indicating as it did that medical social service should be conducted by a professional staff occupying much the same place in the organization of the hospital as the medical and nursing staffs. The committee was composed of a group of fine, outstanding women who had rendered splendid service over the years to the hospital, and it was obvious that whatever was done would have to have their cooperation. Under the existing conditions it was not possible to inaugurate the type of social service department I had envisioned. The Administrative Staff

The organization of the administration of the hospital and medical college was a large and complicated undertaking, shared by the heads of various administrative departments, who were appointed a year or more before the buildings were ready for occupancy. John R. Howard, Jr., appointed superintendent of the hospital in February 1931, took an active part in building up the administrative staff. Mr. Howard had served for several years as the superintendent of the New York Nursery and Child's Hospital, which was merged with the New York Hospital in 1935. Dr. William Howell and Dr. William Spiller, superintendents of the old New York Hospital and of the Lying-in Hospital, joined the administrative staff when these hospitals were transferred to the new buildings. W. W. Downey was appointed chief engineer and worked closely with the engineers installing the power plant and the elaborate mechanical equipment, which he operated with much efficiency after the hospital was opened. Miss S. Margaret Gillam was brought from the University of Michigan Hospital as chief of the nutrition department and was remarkably successful in organizing the personnel, kitchens, storerooms, and the various other facilities involved in supplying food to patients, staff, and employees. Wallace Lund, who had served as assistant to the director in the medical college, was appointed its business manager in April 1932, following the 218

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death of J. Thorn Willson, who had filled that position since the medical college first opened. The Opening of the Medical Center During the last months before the hospital opened, many new people were engaged and trained in the services that had to be ready for operation when the hospital received its first patients. Other personnel were prepared for their transfer from the old hospital and medical college. Consideration of equipment was begun in the fall of 1930, and Myers, Minot, and Company, a firm of equipment engineers experienced in equipping hotels, institutions, and ships, was employed. This firm served as adviser and purchasing agent after all equipment had been approved by Mr. Shepley, the architect, Mr. Augustine J . Smith, a governor of the hospital, and me. Heads of the departments of the medical college as well as of the hospital were consulted regarding equipment, and Dr. Winford Smith, consultant on hospital design, gave much valuable advice and direction. Mrs. McMillan, an interior decorator, served as an adviser to the architect, and her excellent judgment and good taste regarding colors, fabrics, furniture, and hangings contributed greatly to the beauty of the interior of the hospital. The hospital was opened on September 1, 1932, at 10 A.M., when the first patient was admitted to one of the surgical wards. It is difficult to comprehend the innumerable details that had to be arranged before the hospital was ready to render efficient professional care to patients; the fact that it was able to receive the sick with so little disturbance and difficulty was a lasting tribute to all those responsible for the administrative and professional details. A particularly heavy burden fell upon the director of nurses, Miss Wolf, and her associates. They did much toward smoothing out the work of the medical staff, which had been brought together from various places and had not previously worked together. The laboratory departments and the library of the medical college had been transferred during the summer months, so that all was ready when instruction began in the new buildings on September 26, 1932. Financial Problems The course of events during the years the medical center was being constructed and organized greatly changed its finan219

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cial condition and markedly affected the program that had been anticipated. Construction had been begun in June 1929, during an unprecedented financial boom; the entire scope of the project had been determined; contracts for the buildings had been let; and many commitments had been made. What seemed to be a sound fiscal plan had been adopted, dividing the financial responsibilities between the hospital and the university. By this plan, the medical college supported fully its laboratory departments and the college administration, while the college and hospital shared equally the support of the departments of medicine, surgery, and pediatrics, and the office of the director. This division had been agreed to because the hospital wished to share in the educational program of these departments, and it was impossible to separate the educational functions of the staff from the care of patients. The departments of obstetrics and of psychiatry were financed entirely by endowments that were secured after the association had been formed and were intended to support the educational program as well as the services to patients. The hospital had much greater financial responsibilities than the medical college and sustained the more serious loss from the economic depression. It was obliged to liquidate a large portion of its investments to pay for the construction of the buildings, and securities had to be sold when the stock market was much depressed incurring an estimated loss of about $15,000,000. The anticipated endowment of the hospital was thus diminished to that extent. This created a situation in which economies were imperative and operating deficits seemed inevitable, especially since the depression had decreased patients' ability to pay for their medical care. As a means of reducing the cost of operating the hospital, the number of beds to be put into use was cut by about 300, and the equipment of several floors was omitted. Restrictions had to be placed on departmental programs, and the financial situation created at the hospital the general feeling of insecurity which prevailed everywhere during the early days of the depression. It was an unfortunate time to launch a great medical project for which many people had high hopes and great expectations. There were, naturally, disappointments; administrative decisions had to be made that were hard to accept for those on whom financial restrictions had to be imposed. 220

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Chairman

After the hospital had been in operation for a year or so, the financial difficulties became more obvious, and a spirit of unrest and tension became evident. During 1933 Edward W. Sheldon, who, as chairman of the Joint Administrative Board, had been its stalwart leader, had to relinquish much of his activity because of illness, and Wilson M. Powell, then the attorney of the New York Hospital, became more active in hospital affairs, and was elected to the board of governors. In February 1934 Mr. Sheldon died, at the age of seventy-five, and Mr. Powell succeeded him as president of the Society of the New York Hospital and as chairman of the Joint Administrative Board. Mr. Sheldon was greatly missed; he had maintained a staunch optimism throughout the difficult times we were encountering and he always gave me full support and confidence while he was active in the affairs of the association. Mr. Powell was a trustee of a number of institutions and was especially interested in Swarthmore College, being the president of its corporation. His appointment as chairman of the Joint Administrative Board had a definite effect upon my position as its director. While Mr. Sheldon, through his reticence, did not always keep me informed of situations I ought to have known about, Mr. Powell investigated and planned without consulting me. He soon effected a radical change in the business administration of the hospital by replacing the superintendent, John R. Howard, by Murray Sargent, a manufacturing executive of wide experience, as executive director of the hospital. Mr. Powell also conferred directly with the heads of the clinical departments regarding the administration of their clinics. Such activities were probably justified by the serious financial problems the hospital was facing, but they served to weaken my position as director, not only with the hospital staff but also with the heads of departments in the medical college. Salary cuts had to be made, and departmental budgets had to be reduced— measures which generated a sense of insecurity new to men holding academic posts. Deterioration of the high spirit of earlier days set in. Early in 1934 it was decided that the hospital would have to cut drastically its support of the departments of medicine, surgery, and pediatrics, and that it would not be able to share equally with the college in supporting these departments after the year beginning July 1. This created a serious condition for 221

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the medical college, as it meant either that these departments would be badly disorganized or that all departmental budgets of the college would have to be reduced in order to help support these clinical departments. I brought this situation to the attention of Alan Gregg of the Rockefeller Foundation, and through his good offices and understanding the foundation made a grant of $100,000 to Cornell. Arrangement

for

Retirement

This temporary relief of the financial state did not change the emotional state of some members of the executive faculty, who began to create a situation in which my position as director soon became untenable. Mr. Powell seemed to concur in the position taken by these members of the faculty, while President Farrand was sympathetic and friendly to me throughout this difficult time. Farrand was, however, also sympathetic to those who opposed me and did not take a strong position in the controversy, partly because of his desire not to disturb the relations of the medical college and hospital. Arrangements were made by Powell and Farrand, acting for the Joint Administrative Board, for my retirement on October 1, 1934. It was difficult to accept with equanimity retirement from the institution I had directed throughout its development and to which I had devoted strenuous effort requiring much thought and many difficult decisions. Even though a moderate pension and other helpful conditions for retirement were provided, and though my resignation was not called for, the situation created serious personal problems. However, my immediate concern was for the spirit of the medical school for which I had had such high hopes. I had looked forward to an institution that would maintain high spiritual as well as intellectual standards through the collaboration of the leaders of the faculty and staff. Under the strain of disappointment and dispute, some of the more aggressive leaders of the faculty became particularly concerned with the attainment of selfish objectives and seemed to disregard the good of the medical school as a whole. Their state of mind and feelings were, I thought, unfavorable for the creation of an environment in which medical students should develop, and I regretted leaving when signs of a demoralized spirit were apparent. As my last official action, therefore, I sent a letter to each member of the executive faculty, setting forth my ideas 222

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regarding the influence of environment on medical students. This letter, presenting what I believe to be an important educational principle, was as follows: "On retiring from the post of Director of the New York Hospital-Cornell Medical College Association, I cannot refrain from addressing a few final words to those on whom rests the responsibility for the education of the students of the Medical College. I wish to emphasize the opportunities and serious responsibilities each one of you has individually and all of you have collectively in relation to the students. Young men and women, of the best type in this country available for the medical profession, are placing themselves in your hands, coming to you after a long and successful educational process, and embarking on a course of study often entailing not only severe discipline, but also material sacrifices on the part of their families and themselves. The objective of each member of the faculty must be to make of these students the finest possible members of the medical profession. "I feel called upon to say as convincingly as I can that the responsibility toward the students is not fully discharged by thorough instruction in each department. The aim of the faculty must be directed beyond giving the students a sound knowledge of medicine and a safe, efficient technical training. The teaching must include the cultivation of industry and of thoroughness in thought and action, and above all the inculcation of an earnest desire to be a life-long student of medicine. "But the ideals of the Medical College should not stop there, and must extend to the molding of character as well as the development of mind. From the very first day the student enters the Medical College he must be exposed to those qualities of mind and heart which will teach him how to act with sincerity, courage, independence, and goodwill toward his fellows of whatever rank. The standards of professional life are largely set by the examples which are placed before the students in their plastic and formative years, and every teacher in the medical college should carry constantly in his thoughts the realization that he has about him young people whose future lives he may profoundly influence. The future medical graduate has a world to face in which there are many temptations to lower professional and spiritual standards, and each one should be equipped with an armor to enable him to resist these temptations. The greatest help that can be given him comes from the example of his teachers, who will be 223

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for years the moral and intellectual guides in his professional life. "The members of the faculty and especially the heads of departments have the possibility of creating a type of medical graduate from Cornell and from the New York Hospital which will be distinctive, not only for the standards of scholarship and technical training, but also for leadership in right behavior, in sincerity, in civic righteousness, and in the sort of highmindedness so much needed in the profession of medicine. These qualities may be developed in all students, regardless of their intellectual attainments, but only if there is a spirit in the laboratories and hospital which constantly influences the students toward these qualities in every nook and corner of the institutions. "I am called upon to express these ideas because I have felt that so far there is something lacking in the spirit of the student body which the faculty should earnestly endeavor to supply. This lack can only be supplied by the sincere effort of every teacher to cultivate the highest attitude of thought and action in himself and in relation to the students, as the student cannot be expected, as a rule, to go out of the College with higher professional and personal ideals than he has found in the College. "The environmental influences in medical education are stronger, I believe, than most teachers are apt to realize, and I am sending you a reprint of a paper in which are set forth some ideas on this subject. I should be grateful if you would give this paper your consideration. The Medical College and Hospital have a beautiful physical setting. Students are surrounded by buildings and equipment which have been planned to awaken their esthetic sense and to stimulate their better selves. They should be encouraged to appreciate their surroundings and to treat them with respect and devotion. But above all, it is the general atmosphere and spirit of the place, created by the attitude and real character of the faculty, which will leave the lasting imprint on the graduates of Cornell. My final words to the members of the Executive Faculty are to guard carefully their own spirit, as well as their intellectual activities, if they truly desire to do their best for the young people who are entrusted to their care." During the last months before my retirement, William S. Ladd, the associate dean, was prepared to take over the deanship 224

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of the medical college, but no plans were made for filling the directorship. Problems of

Administration

My situation was confused and difficult during this time, and as it was the most disturbing adventure I have had, a brief discussion of this episode should not be omitted. Under the conditions then existing it was difficult for anyone so closely involved to place blame fairly or to justify his own course of action, but in looking back after a period of twenty years, I can see the weakness in the original plan of administration of the New York Hospital-Cornell Medical College Association. The top of the organization failed to hold together under the strain of a serious financial crisis because authority and responsibility for the association as a whole was not centralized. The director of the association was responsible for the educational activities and the administration of the medical college, but had no authority or responsibility for the administration of the hospital and took no part in its financial operations. The two corporate bodies, the hospital and the university, delegated authority to the Joint Administrative Board, of which the director was not a member. He served only as secretary of the board; though he attended monthly meetings, he had no vote. The greatest weakness in the early days of the organization was, it seems to me, insufficient knowledge of the financial situation on the part of those who had the responsibility of planning and organizing the project. When Mr. Powell took over the leadership of the Joint Administrative Board and tried without consulting me, to solve the serious financial problems then existing, my position as director was much weakened and our relations soon became strained. Lack of harmony at the top of the organization gave an opportunity to the members of the faculty, who were especially disturbed and resentful, to bring forward relatively small but emotionally exaggerated disagreements—a situation which made my position as director untenable and led to my retirement. The position of director as defined in the original agreement between the hospital and the university was not filled after my retirement, and the close tie between the medical school and hospital became weakened. William S. Ladd continued to serve as the dean of the school until July 1, 1941, when he was obliged to 225

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retire because of ill health; Walter L. Niles returned to the office as acting dean. His service was cut short by his death in December 1941, and Joseph C. Hinsey, the professor of anatomy, was appointed to the deanship. Murray Sargent continued to direct the administration of the hospital, and up to 1947 the administration of the school and hospital were not connected. By 1947 the weakness of the organization was recognized, and it was agreed that the entire association should be placed in the hands of one fulltime officer who would have over-all responsibility and authority. To this end the original agreement was amended to provide for the appointment jointly by the university and the hospital of a professionally qualified person to give his full time to the presidency of the Joint Administrative Board. Stanhope Bayne-Jones was appointed president of the board in 1947, being called from Yale where he was dean of the medical school and professor of bacteriology. He had gone from Johns Hopkins to the University of Rochester as professor of bacteriology before his Yale appointment and had had extensive experience in medical education, administration, and research. Under his leadership many problems were solved, and harmony was brought to a confused situation. After the retirement of Bayne-Jones in 1953 the agreement between the hospital and university was again amended. At this time the associated institutions were officially named the New York Hospital-Cornell Medical Center, of which the Cornell University-New York Hospital School of Nursing was an integral part. The directorship was reestablished, and its functions were defined more specifically and broadened. The director was then given full authority as the administrative officer of the entire center, including the preparation and administration of the annual budgets. In 1953 Joseph C. Hinsey, dean and professor of anatomy, was appointed director of the New York Hospital-Cornell Medical Center by the governors of the hospital and the trustees of the university, on recommendation of the Joint Administrative Board. Under his direction the center is making splendid progress. The Center

I spent two weeks in February 1956 and had my cherished hopes had developments that have

in

1956

the New York Hospital as a patient in an opportunity to learn that many of become realities and to see the recent gone beyond my early dreams. The 226

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New York Hospital-Cornell Medical Center stands proudly in one of the greatest groups of institutions for medical research, education, and patient care that can be found anywhere in the world. Adjoining it on the south is the Rockefeller Institute for Medical Research, where new buildings were being erected in 1956 to provide for its recently inaugurated program of advanced education in the medical sciences. On the west, across York Avenue, is the center for the study and treatment of cancer and allied diseases composed of the Memorial Hospital and the Sloan-Kettering Division of the Cornell Medical College—both affiliated with the New York Hospital-Cornell Medical Center. On the north, along the East River, the new Hospital for Special Surgery has recently been built to continue the work of the old New York Hospital for Ruptured and Crippled, and now serves as the department of orthopedic surgery of the New York Hospital. Directly across York Avenue from the medical college stands the latest addition to the group, Olin Hall, a spacious residence providing accommodations for 285 students and attractive facilities for their social life. It was opened in September 1954. I was glad to hear from Dr. Hinsey that although the struggle with hospital deficits has continued through the years, the problem is nearing solution, and that the financial situation is much improved. Large resources for research are now available through special grants for the support of scientific work in the hospital as well as in the medical college. These grants have been made in recognition of the quality of the research being conducted at the medical center. The supervisor of one study, Vincent du Vigneaud, professor of biochemistry, was recently awarded the highest honor, the Nobel prize in medicine. I was much interested in the program of comprehensive medicine in which a number of departments are correlated in the care of patients and in hearing how this program is used extensively in teaching. The coordination of psychiatry and public health with the more general aspects of medicine, and the active participation of the medical social workers in the coordinated work of the various departments was very gratifying, as it indicated that an interest in the emotional and social aspects of the individual patient pervaded the clinics to an unusual degree. My visit to the New York Hospital in 1956 was a happy occa227

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sion, not only because I received excellent surgical care, but especially because I had the opportunity to see some results of the effort I had put into planning and organizing years before. I left the hospital with the feeling that, after all, a solid foundation had been laid, and I was pleased to hear Dr. Hinsey say that the medical center had been organized soundly and without compromise. All my former antagonists had left the field, as I had outlived most of them, and I was warmly and cordially received. This visit to the hospital removed all the hurt I felt at the time of my retirement years ago.

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VIII

THE PEIPING UNION MEDICAL COLLEGE -< 1 9 3 4 - 1 9 3 5

y

HEN the Cornell class of 1934 had graduated in June, my activities in teaching and administration were ended, although I was to remain in the office at the New York Hospital until October 1. Another adventure in medical education had come to a close; at the age of fifty-six, I faced the problem of a new start, this time without an academic post. It was with a feeling of loneliness and disappointment that I went to our summer house at Peconic on the eastern end of Long Island. There, in an isolated spot overlooking Long Island Sound, we had a peaceful camplike place, where I enjoyed swimming in the Sound, working in the woods and on the beach, reading good books, and especially sharing fine and inspiring talks with the members of my family. These surroundings, gratifying letters from friends, and the balm of nature all played a part in soothing the hurts of the last few months. That summer was a time when stock-taking of the past and a calm view of the future were needed to reorient a shaken career, and I find in the journal which I wrote at that time, that I settled some important matters with myself. I decided that I wanted in the future to devote myself to the spiritual values of medicine, and that in order to do this I must endeavor to get back to a teaching position where I would be directly concerned with the relations of students and patients. Before many weeks had passed, a way was opened to a new adventure which was to be one of the most interesting, medically 229

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profitable, and diverting experiences of my life, and which was to take me far away from the scene of my recent turmoil. In September I received an invitation from Roger S. Greene, director of the China Medical Board, to serve as visiting professor of medicine at the Peiping Union Medical College for a period of five months beginning January 1, 1935. He wrote that the professor of medicine, Francis R. Dieuaide, was to take a leave of absence, and asked me to serve as head of the department of medicine in Dieuaide's place until the end of the academic year. After a conference with Mr. Greene, who was then in New York, I accepted with enthusiasm the invitation of the China Medical Board, which included provision for Mrs. Robinson to accompany me. A few days after our conference, Roger Greene returned to Peiping, where he served as resident director of the medical college, and his presence there added much to the interest and pleasure of our visit. The Voyage to China

The weeks that followed were filled with exciting arrangements, which included plans for taking our two children with us. Our twenty-one-year-old daughter Margaret was at Bennington College, and as soon as the authorities agreed, in their liberal spirit, to allow her a leave of absence to visit China, her college course was shifted to give her some understanding of the Orient. Our eighteen-year-old son Boise was at boarding school at Avon Old Farms in Connecticut. The head master agreed with us that a trip to China was too good an opportunity for Boise to miss, especially as he had already shown the artistic talents that later led him into architecture. Our itinerary to China and back was soon planned with Cook's to take us across Europe to Naples, there to embark for Shanghai via the Suez Canal; the return was across the Pacific by way of Japan. During the busy weeks of October we visited the Orientalia bookshop in the Greenwich Village district of New York, where books proved so irresistible that I had bought fifty-six volumes on the history, people, and traditions of China before I realized that this was more than we could carry with us and certainly more than we could read before arriving there. However, we took along a fine selection and posted the rest to Peiping, so that we were well supplied with reference material. Conversations with friends who had lived in China and with 230

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some of the officers of the China Medical Board all served to stimulate our interest and heighten our anticipation. We sailed from New York on November 1 on the HamburgAmerican liner Deutschland, and after a pleasant voyage arrived in Paris via Cherbourg on November 8. Our trip across Europe took us to Lucerne, Lake Como, Milan, Florence, Rome, and Naples, and seventeen days were crowded with the high lights of scenery, galleries, and historic places. It was a joyous beginning of a grand tour. Especially exciting was Italy, which we had never before visited. The Bay of Naples in the sunset backed by smoking Vesuvius, the visit to Pompeii, the drive from Amalfi along the cliffs above the blue Mediterranean on a day of rare beauty, left memories to be forever cherished. On November 25 we sailed from Naples on the Japanese steamer Fushimi Maru and embarked on a month at sea in the company of passengers representing fourteen different nationalities: nine western countries and Japan, China, Ceylon, India, and Thailand. In this international house party atmosphere conversation flourished, and discussion was spiced by varying points of view and interests. Our first stop was Port Said, where a group of us disembarked to visit Cairo while the ship was passing through the Suez Canal. Here, on Thanksgiving Day we had a typical turkey dinner at the famous Shepheard's Hotel, since destroyed by fire; visited the great pyramids and the Sphinx, almost in the suburbs of Cairo; and best of all, saw in the museum the relics from the tomb of Tutankhamen, among the most beautiful works of ancient art in all the world. After an evening drive across the starlit desert, we spent the night and next morning in the intriguing city of Suez and joined our ship, which had emerged from the canal, after noon. This was the first of the delightful trips ashore, followed by brief visits to Colombo, Singapore, and Hong Kong, arriving at Shanghai on Christmas Day 1934. At Shanghai we were met by Harold Morris, who had been a resident at the Pennsylvania Hospital with me, and we spent four delightful and interesting days with the Morris family in the great Chinese metropolis. He was professor of medicine in the medical school of St. John's University and physician-in-chief of St. Luke's Hospital where Joe McCracken, another old friend of Pennsylvania Hospital days, was the surgeon-in-chief. In their school I saw for the first time the admirable work and teaching conducted in China by American medical missionaries. During 231

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my stay I met a number of American, British, and Chinese doctors, and attended a medical society meeting of high order at the Lester Institute. At this British-endowed institute for medical research I learned that modern medicine and research were carried on in China in the same spirit and with the same methods and objectives as in Europe and America. I was impressed with the idea that modern medicine serves as one of the first steps toward the development of Western culture in countries we think of as backward, and was amazed to find it to be a strongly unifying force around the world. I visited the medical school that had been recently organized by the Chinese National government under the direction of the American-educated F. C. Yen. This school was one of the first official efforts to promote modern medical education in China, independent of support and direction from the Western world. I was surprised and much pleased by the excellence of the Chinese students and the high quality of their work, as judged by my first impressions. This was the beginning of an admiration which was to grow steadily during the next few months. We left Shanghai on December 28 on the famous Blue Express and, after a comfortable trip in a European-built sleeping car, arrived in Peiping forty-two hours later, on December 30. We were met by Roger Greene and my old friends Francis and Mrs. Dieuaide and Henry Houghton, who welcomed us at the destination toward which we had been travelling for two delightful months. The trip by train afforded an interesting view of northeastern China, a highly cultivated land dotted with innumerable compact little farming villages and now and then a sizable city. Among our many surprises along the way were the careful guarding of the railroad by soldiers, the expanse of ground taken up by the rounded hill-like graves which are said to occupy almost a quarter of the otherwise arable land of China, and the basketball fields beside each village school. The day after we arrived in Peiping we moved into the house of Harry B. van Dyke, the professor of pharmacology, who had returned to America on a leave of absence. It was a comfortable, American-built house, located in the South Compound, one of two compounds built by the China Medical Board. Each compound contained about a dozen houses, and, since most of the foreign professors of the medical school lived there, we soon found ourselves in very agreeable society. With the house came 232

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six servants: an English-speaking number one boy, who ran the house and who was paid a weekly sum for meals; a cook; an old fellow known as the cleaning boy; an amah or lady's maid; and two rickshaw boys, who waited at the compound gate to transport us most comfortably at a jog trot wherever we wanted to go. My first visit to the Peiping Union Medical College was a significant event for me; there, at last, I was again to take up the teaching of medicine and the study and care of patients. The beauty of the buildings was astonishing. Their high, curving roofs of jade-green glazed tiles and the lovely Chinese decoration of their eaves and entrances made a lasting impression. Within these architecturally oriental buildings were modern facilities for the study of medicine and for the care of patients that were in accordance with the highest Western standards—symbolizing the way in which benefits of the healing art were being brought directly to the Chinese people as a lasting contribution of the world-wide development of science and technique, the careful training of men, and the humanitarian concepts of Christianity. The plant was complete: it consisted of a modern medical school, a 345-bed hospital, commodious laboratories for research and teaching, and a fine, comprehensive medical library. What a surprise to find such a school among people who were then just learning to appreciate the benefits of modern medical science and of medical practice built upon this science. The Development

of the Medical

College

The development of the Peiping Union Medical College was the most conspicuous consequence in foreign lands of the great awakening in American medical education at the beginning of this century; it holds a significant place as part of the veritable revolution that followed this awakening because it was, in reality, an extension of the great American movement. The idea of bringing modern medicine to China originated in the mind of Frederick T. Gates, the man who had previously conceived the idea of the Rockefeller Institute for Medical Research in New York. The establishment of a medical school in China was one of the first projects to arouse the interest of the Rockefeller Foundation. Mr. Rockefeller had long been interested in church missions in the Far East, and Mr. Gates, when he undertook the organization of the great philanthropies that the mounting 233

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Rockefeller fortune made inevitable, induced Mr. Rockefeller to finance a commission to study the educational problems of China. This study was based on the idea that the establishment of a university in China following the concepts of the University of Chicago would be a great benefaction—a dream that proved impossible to realize. However, interest in China remained, and a few years later the question of strengthening medical education in China was raised and was warmly supported by President Eliot of Harvard, who had had personal experience in establishing the Harvard Medical School in Shanghai in 1911. Backed by a number of authorities on the Far East, Gates suggested that a commission be appointed to determine where and in what manner Western medicine, surgery, and public health could be effectively stimulated in China. In January 1914 the Rockefeller Foundation appointed a commission composed of Harry P. Judson, president of the University of Chicago; Francis W. Peabody, who had recently gone from the Rockefeller Institute to the Peter Bent Brigham Hospital and Harvard Medical School; and Roger S. Greene, United States Consul at Hankow. After an extensive trip through China, studying many universities, medical schools, and hospitals, the commission submitted a full report. It recommended that the foundation approach China through the field of medicine, that it concentrate on the development of medical schools of high standards in Peking and in Shanghai, and that teaching, at least in the beginning, be in English. It also recommended that fellowships for foreign study be made available to selected Chinese students, to enable them to assume some of the teaching responsibility in the new schools. Following this report, the Rockefeller Foundation established the China Medical Board as a subsidiary organization, with Wallace Buttrick, president of the General Education Board, as its director. At the same time Roger S. Greene was appointed resident director of the board in China. The property of the Union Medical College of Peking was acquired from the London Missionary Society, and the new medical school was eventually built there. The original plan of establishing another school in Shanghai was abandoned, largely because the economic disturbances of the First World War had so elevated costs that it seemed wise to restrict the initial efforts to the Peking school. In order to investigate the technical aspects of the China 234

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project another commission was appointed consisting of William H. Welch, Simon Flexner, Frederick L. Gates, the doctor son of the originator of the idea, and Wallace Buttrick. They spent five months in China in 1915 obtaining valuable information that confirmed and extended the findings of the previous commission and enabled the foundation to make a more adequate estimate of the magnitude of the project. This is a good example of the careful study by the best available people that has always been given to the undertakings of the Rockefeller boards. One of the conclusions reached by the 1915 commission was that premedical education in various Chinese universities would need to be strengthened to provide good training in the English language and in the natural sciences as preparation for admission to a first-class medical school. The support given ultimately by the China Medical Board to the leading universities for this purpose served to improve the teaching of these subjects in China. The commission also recommended that an objective of the new institution be to put responsibility for medical education in the hands of the Chinese themselves at the earliest possible time. It emphasized that a medical school of the highest possible quality should be established in order to set new standards of medical education in China comparable with those of the best European and American schools, and to create, as Simon Flexner said, "the Johns Hopkins of China." A primary objective of the school would be, as Buttrick stated, to train young men and women "capable of studying the medical problems of China, of producing a medical literature, and themselves becoming the teachers of the next generation of Chinese in the very best that modern medicine can offer. To that task we propose to set ourselves." My interest in this project was sharply stimulated by a telegram from Simon Flexner in April 1916, asking me to come from St. Louis to New York to confer with him and Wallace Buttrick. They told me of the Peking project in some detail and asked me to consider going to China as the medical director of the school. At that time I was deeply involved in the developments at Washington University and had a son born only a week before the conference. I therefore decided to decline this far-off post, but the offer aroused a continuing interest which was greatly heightened when I arrived in Peiping eighteen years later. In 1916 Charles A. Coolidge of Boston, a leading American 235

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architect, was sent to China with Franklin McLean, the newly appointed director of the college, and Roger S. Greene, its resident director, to study building problems. In October Coolidge submitted a comprehensive report on the situation in Peking in which he discussed the style of architecture that should be used; the problems of construction; the use of Chinese and imported materials; the provision of various general services such as water, heat, power, and sewerage; and estimates of costs. He submitted a preliminary plan for the buildings which was, in the main, finally adopted. The planning of the buildings was begun by an American firm of architects with representatives in China, but after numerous difficulties of construction, the project was placed in the hands of Coolidge and Shattuck, the Boston architects who carried it to completion. The entrance of the United States into the First World War in April 1917 created discouraging complications, and although the cornerstone was laid in September 1917, the plant was not completed until September 1921, when it was fully opened and formally dedicated. The plant of the Peking Union Medical College was one of the finest in the world, comprising fifty-nine buildings on twentyfive acres of land. It included laboratories for anatomy, physiology, chemistry, and pharmacology; a pathological building; a teaching hospital with provision for clinical research and a large outpatient department; a nurses' training school and residence ; a hospital administration unit with quarters for resident physicians and interns; an animal house; dormitories for students ; and faculty residences in two walled compounds. In addition to these facilities, a powerhouse had to be constructed, and facilities for water and sewerage, usually supplied by municipalities in Western countries, had to be provided. The cost of the buildings was $8,283,000. The educational activities in China, centered in the medical school, were financed originally by the China Medical Board, appointed in 1914, to which the Rockefeller Foundation made annual appropriations. Nearly all of those appointed to the original board were members of the board of the foundation. A board of trustees was also appointed on which there were representatives of the six British and American missionary societies that had supported the old Union Medical College. This board of trustees, which included a number of Americans with special interest in and knowledge of China, apparently served in an 236

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advisory capacity and formed a link between the China Medical Board and the old missionary medical school. By 1935, when I was in Peiping, the board of trustees, which then had limited control over the administration of the medical college, was made up of distinguished Chinese leaders and educators and a few Americans who resided in China. It was hoped that the trustees would form a strong link with the Chinese people and would encourage them to assume an ever-increasing responsibility for the medical college. The original program of the China Medical Board extended beyond the support of the medical school in Peking, and during its first fourteen years it appropriated approximately $5,300,000 to other Chinese medical schools and hospitals and to colleges to strengthen their premedical teaching. Grants were also made to promote medical education and research in China in other ways. In 1928 the China Medical Board was reconstructed and incorporated as an independent body. The Rockefeller Foundation transferred to it the ownership of the land and buildings in Peking, granted it $12,000,000 as an endowment, and pledged further contributions if necessary over a five-year period. There were annual calls on the foundation thereafter for further support, although from that time on the medical college was the major project of the China Medical Board. In 1929 the name of the school was changed to the Peiping Union Medical College, following the change in the name of the city from what in English means "Northern Capital" to "Northern Peace." This change followed the transfer of the seat of the National government to Nanking, and was made at a time when no one realized how inappropriate the name Northern Peace would be, in the light of events that began a few years later. In December 1941, following the Pearl Harbor attack, the institution was taken over by the Japanese, but continued to function until February 1942, when its work was brought to an end and all staff contracts were cancelled. Of the few American faculty members remaining, all were exchanged during the course of the war except Henry Houghton, the acting director, and Trevor Bowen, the comptroller, who were interned by the Japanese in Peiping. During the war, the China Medical Board supported medical and nursing education in Free China, especially in the West China Union University at Chengtu. Here the nursing school of the P.U.M.C. was kept intact, and support was 237

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given to former students of the college to enable them to complete their medical course. By the end of 1945, the Peiping Union Medical College was returned to its rightful owners, and the task of rehabilitation was begun. The institution had, fortunately, suffered relatively little structural damage, and the clinical records and library were intact. Practically all equipment had, however, disappeared or been destroyed; the interior was in bad repair; and the power plant had been so misused that a drastic overhauling was necessary. During the progress of rehabilitating the plant, certain buildings were used by the American commission headed by General George Marshall that endeavored to arrange peace between the Nationalists and the Communists. The commission occupied these buildings from January 1946 to the early summer of 1947. In 1946 the Rockefeller Foundation sent to China Alan Gregg of its staff; C. Sidney Burwell, dean of Harvard Medical School; and Harold H. Loucks, former professor of surgery in the college and representative of the China Medical Board, to study, on the ground, the problem of the development of medicine and public health under post-war conditions. This commission reported that the major needs of China were peace, economic stability, better communications, and the improvement and extension of education at all levels. One of the most important needs of the Chinese people would be met by the professional education of doctors, especially for work in public health and preventive medicine. The commission therefore recommended that the Rockefeller Foundation contribute to the support of medical education in China by further appropriations to the China Medical Board, and that most of this support be directed toward reestablishing the Peiping Union Medical College and operating it as a medical school of high quality especially devoted to teachertraining and to promoting preventive medicine and public health. It further recommended that the China Medical Board be sufficiently endowed to make it entirely independent of the foundation, psychologically and morally as well as financially. These recommendations were approved, and in 1947, a capital grant of $10,000,000 was made to the board by the foundation. The grant was accompanied by a statement from the president of the foundation, Raymond B. Fosdick, indicating that this was a terminal contribution and that the foundation was withdrawing completely from the support of medical work in China to which it 238

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had contributed $44,944,665—the largest contribution the foundation had ever made to a single objective. In his letter to the board Mr. Fosdick expressed on behalf of the trustees of the foundation their belief in the Peiping Union Medical College and in its promise for the future. "It has behind it," he wrote, "a magnificent record of performance. Its graduates have introduced modern medicine into many parts of China. . . . It has earned a unique name for itself in all the countries of the Far East." The trustees of the foundation "would take this occasion to rededicate it to the new generation of China in the firm belief that the light which it started in modern medicine will not be allowed to die out." In the fall of 1947 the Peiping Union Medical College resumed its work on a small scale, under the directorship of C. U. Lee, a Chinese member of the faculty who had shown conspicuous administrative ability during the war years. It was hoped that full-scale operations could be attained by 1951. The post-war political turmoil in China, which ended in its control by the Communists and the withdrawal of the Nationalist government to Formosa is a well-known part of modern history. For a time after Peiping fell under the Communist control the college was able to continue with its old spirit, but in January 1951 came the government order that it was to be "nationalized," which meant that it was from then on to be under Communist control. This action not only ended the college's support by the China Medical Board, but severed all direct communications with the outside world. Very little has been learned about the fate of this great institution since it has been hidden from the West behind the "Bamboo Curtain." The Organization

of the

College

The establishment and operation of the Peiping Union Medical College was a great American adventure, carried out with conspicuous success. It represented an enormous investment of funds by the Rockefeller Foundation and these contributions, made through the China Medical Board, were instrumental in spreading the knowledge of modern scientific medicine to a large part of the world sorely in need of improvement in public health and in the medical care of its inhabitants. The foregoing account of the development of the Peiping Union Medical College fails to tell the story of the human prob239

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lems that were encountered in creating a great medical center in China. The significance of its accomplishments does not· depend upon its magnificent buildings and facilities, but upon the quality of the men who worked there and upon the establishment of rapport with the Chinese people and with existing medical and educational institutions whose cooperation and collaboration were essential. How Americans could develop an advanced medical school which would fit congenially and constructively into the environment of China was an important matter to which the 1915 commission gave special consideration. It was indeed fortunate that two members of the commission, Wallace Buttrick and William H. Welch, were past masters in the art of diplomacy and were accomplished ambassadors of good will. Buttrick had the difficult task of harmonizing the plans of the China Medical Board with various extensive missionary activities in medical education and in hospital work. He had been a Baptist minister and knew thoroughly the temperament and concepts of missionaries; it was for this very reason that he was urged by Gates to go to China. Welch, of course, had great influence with medical men the world over and succeeded admirably in stimulating interest and good will toward the new project among those engaged in medical research, teaching, and practice. Simon Flexner, who was also a member of the 1915 commission, gives a delightful account of the trip to China in his biography of Welch* and shows how effective Welch was in interpreting the ideas of the new school to the people of China. At a meeting of the students at Yale-inChina in Changsha, one of the more advanced missionary schools, Welch gave a splendid exposition of what the new school would mean for China. He said that for generations the Chinese had trained themselves by reading and being told about things; they learned by committing texts to memory, page after page, sometimes being able to repeat whole books by rote. Indeed, the Chinese were just emerging from the Middle Ages into the modern period, when speculation and hypotheses were tested by experiment. He said: "You need power of independent observation, to make experiments and draw inferences, to see with your own eyes, and touch with your own hands, and hear with your own ears. You need to go over for yourselves the processes •Simon Plexner and James Thomas Plexner. William Henry Welch and the Heroic Age of American Medicine. New York, Viking, 1941. 240

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by which natural knowledge was first acquired. This point of view I believe to be of fundamental importance for education in China... . That is the kind of knowledge that gives power and should bring some measure of wisdom with it." This is an example of what Welch preached as a missionary of seience in China. His words expressed his conception of the medical school the Rockefeller Foundation should establish, and as he was the most influential medical adviser of those directly concerned with the project, his statement was the keynote regarding the quality of men who would be sought to form the faculty of the future school. The initial appointment to be made was that of medical director of the college, the man who would have the task of incorporating the conception of a research-centered institution into the plant and faculty of the future medical college. Leadership in scientific work, both in the laboratories and in the hospital, was essential for the director, and this position was filled by a young man of twenty-eight with a brilliant mind and an outstanding record of accomplishments, Franklin C. McLean. McLean had graduated from Rush Medical College in Chicago in 1910, and after an internship in the Cook County Hospital, was appointed by the University of Oregon as professor of pharmacology, the medical science in which he had worked during his student days at the University of Chicago. He studied in Graz and Vienna during his professorship and obtained a Ph.D. degree from the University of Chicago in 1915. From 1914 to 1916 he served as an assistant resident physician in the Hospital of the Rockefeller Institute, where he was directly under the eyes of Rufus Cole and Simon Flexner, and was well known by Welch, then the president of the board of the institute. One day in 1916 McLean was called over from the hospital by Simon Flexner, the director of the institute, for a pleasant chat with him and Wallace Buttrick; on returning to the hospital, McLean remarked to a friend: "I've had the once over for China." No doubt he made a good impression as before long he was offered, and accepted, the directorship of the Peking Union Medical College and the professorship of medicine there. McLean was an excellent representative of the new school of clinical medicine which the Hospital of the Rockefeller Institute played a leading part in developing. He had a thorough training in pharmacology and chemistry combined with experience in the 241

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study and care of patients, which equipped him for a career in academic medicine at the university level and for leadership in clinical research. He served as director from 1916 to 1920 during the building of the plant and the organization of the staff of the medical college and hospital. He deserves great credit not only for the splendid manner in which this institution was developed up to the time its buildings were dedicated in 1921, but also for the high scientific standards that were established and for the excellent quality of work and teaching that subsequently prevailed. McLean served as the professor of medicine until 1923, when he accepted the position of professor of medicine at the University of Chicago and director of its university clinics, a post in which he participated in planning the buildings and organizing the new clinical departments of the university medical school. In 1933 McLean shifted his interests from clinical medicine to become professor of pathological physiology in the university, a position he held until his recent retirement. The list of his activities in the university, in military service, in civilian service, and in race relations, is long and marks him as a conspicuous leader in recent American academic medicine and medical research. He is one of the outstanding figures among those who took modern scientific medicine to China. Most of the original faculty of the Peking Union Medical College were Americans. A number had had previous experience in China, some at the old college, and they were given fellowships for study in the United States or in Europe before taking up their new duties. It was a strong faculty, and the college began to function with high university standards and an excellent hospital and teaching staff. As time went on more Chinese were added to the staff. Some of them had had foreign training initially ; others had graduated from the college and continued their studies abroad, usually in the United States. One of the basic considerations in planning the Peking Union Medical College was to provide conditions for work and for living that would attract to its faculty men of the highest quality, often from across the sea. This was evidenced not only by the excellence of the laboratories and hospital, but also by the comfortable houses in attractive, walled compounds, where the faculty members could live with their families in a delightful social atmosphere. Isolation from the centers of medical learning was 242

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forestalled by a liberal plan of furloughs for the foreigners and a systematic program of foreign study for the Chinese faculty members. Visiting professors from Europe and America were regularly invited to stay long enough to participate in teaching and research. While I was in Peiping I enjoyed my association with Walter B. Cannon, the Harvard professor of physiology, who was there with his family for several months; his visit served to stimulate the scientific and cultural activities of the school. Among the Americans who, as visiting professors, refreshed the school by their personalities, experience, knowledge, and ability were David L. Edsall, L. Emmett Holt, William G. MacCallum, Alfred E. Cohn, Eugene L. Opie, Anton J. Carlson, and Donald D. Van Slyke. In 1935, when I was in Peiping, the general political situation appeared highly satisfactory. Chiang Kai-shek had built up what seemed to be a strong central government in Nanking; it occupied an impressive group of new buildings and had the support of the intellectual class in China, many of whom had been educated in American universities. Even then, however, friction with the Japanese was evident, and there were newspaper accounts of efforts by the Japanese, who then occupied Manchuria and Korea, to spread drug addiction among the people of Peiping. Only two years later, in 1937, fighting broke out with the Japanese outside of Peiping in the so-called incident of Marco Polo Bridge; but in 1935 China was in her modern heyday. It was a favorable time to be there. The medical college was a strong, well-directed institution. Roger Greene was nonmedical director, and professional authority was vested in the committee of professors. This committee was composed of sixteen department heads, the director, and the vice-director. There were eight Americans, six Chinese, one British, one Dutch, one German, and one Swiss, making up a truly international group. The American professors were Francis R. Dieuaide in medicine, Harold H. Loucks in surgery, Chester N. Frazier in dermatology, Nicholson J. Eastman in obstetrics, John B. Grant in public health, Chester M. Van Allen in thoracic surgery, and Harry B. van Dyke in pharmacology. Among the Chinese, J. Heng Liu, a Harvard graduate, was at that time the director (in absentia) of the P.U.M.C. as well as minister of health in the National government; the Scottish-trained Robert K. S. Lim was professor of physiology, who served afterwards as surgeon general of the Nationalist army. 243

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Hsien Wu, professor of biochemistry, had formerly been on the teaching staff at Harvard, and the other Chinese faculty members had worked in leading American medical institutions. There were about thirty students in each class of the fiveyear course. The first four years were quite similar to those of the best American schools; the fifth year was spent as an intern in the college hospital and was a requisite for graduation. All students spoke and wrote English fluently, and there was no language barrier in the teaching, even when a lively discussion was carried on with a large class. The students were without exception well educated and well prepared for the study of medicine. They were an alert, industrious, and technically welltrained group, and it was a pleasant and gratifying experience to teach these delightful, understanding, attractive young men and women. The professor of medicine, Francis R. Dieuaide, was a 1920 graduate of the Johns Hopkins Medical School and had served as a medical intern in the Johns Hopkins Hospital. During 19211922, when I was there as acting professor of medicine, he was on my staff, working with Edward F. Carter in the cardiac laboratory. I admired at that time the high quality of work of this quiet, reticent young man, and was impressed by his mental ability. Although I had seldom seen him in the intervening years, I was not surprised to find that his department was excellent. He not only directed his large department very well, but was an intellectual leader in the college, serving until 1938 as physicianin-chief of the hospital and as professor of medicine. On his return to the United States, Dieuaide was appointed assistant professor of medicine at Harvard and was made a member of the staff of the Massachusetts General Hospital; in 1946 he became the scientific director of the Life Insurance Medical Research Fund in New York and was appointed professor of clinical medicine at Columbia University. The author of an admirable book on civilian health in war-time, published in 1942, Dieuaide has attained a high place in academic medicine. After orienting me in the ways of the medical school and hospital during my first two weeks in Peiping, Dieuaide left for the United States, and I took over the department of medicine. And what a splendid department it was! There were thirty-two full-time teachers, ranging in rank from professors to assistants. The department included pediatrics, neuropsychiatry, and der244

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matology, as well as general medicine. Six professors were Americans. They were, besides Dieuaide and Frazier, Claude E. Forkner, then specializing in hematology; Richard S. Lyman in neuropsychiatry; Arthur P. Black and Ann G. Kuttner in pediatrics. A review of the Chinese members of the department indicates the quality of their training, their special fields of work, and the general excellence of the medical department which was characteristic of the entire school. Richard Sia was a medical graduate of Western Reserve University and had special training in the infectious diseases with two of our leading medical bacteriologists, Oswold Avery at the Rockefeller Institute and Alphonse R. Dochez at Columbia. C. U. Lee, a graduate of Glasgow University, had spent four years in the London School of Tropical Medicine and was engaged in studies on kala -ΣΙΖίΙΓ) Q, tropical disease that had recently invaded North China. H. C. Chang, in charge of metabolic studies, had spent two years with George Harrop and others at Johns Hopkins, and S. H. Liu, head of the chemical laboratory, had worked for a year or more with Donald Van Slyke at the Rockefeller Institute Hospital. C. L. Tung, a medical graduate of the University of Michigan, had returned there from China to work for a year with my brilliant former associate, Frank Wilson, and while I was in Peiping C. J. Wu returned from a sojourn with Hans Zinsser at Harvard. This group was ably supported by the house staff of the department, which numbered twenty-five and included medical students taking their internship in medicine. The resident physician, Charlie Bien, was a delightful fellow and my right-hand man on the wards. He did much to guide me quietly in Chinese customs and acted as my interpreter with the patients. I also look back with gratitude to the excellent secretary Dieuaide had left for me, a mature man with a thorough knowledge of English, of stenography, and of typing. My teaching was largely with the ward patients, whom I visited every morning at nine o'clock—three days a week with the students, and once a week with all the staff when we had "grand rounds" in the various divisions, at which different staff members demonstrated and discussed cases of unusual interest. Once a week I gave a clinical lecture to the combined third- and fourth-year classes, and I took part in the course for second-year students that initiated them into the study of patients. I also delivered a number of general lectures, open to all students, that 245

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dealt with medical ethics and with the history of medicine. Every two weeks the college medical society met, and research work conducted by the staff was presented and discussed. Toward the close of my visit I recorded my impressions of the medical department in a letter to Alan Gregg. I wrote that "the routine ward service is excellent, both regarding the variety and interest presented by the patients and especially regarding the way the patients are studied. I have never seen them better studied anywhere. Practically all data that any case requires for diagnosis are speedily and accurately collected, and a high degree of intelligence is exercised in conducting the ward routine. The clinical material is abundant and is more than enough for the training of the third-year clinical clerks. "The various members of the staff who act in rotation as attending physicians impress me as being well trained and energetic. All members of the department, including the resident staff, are carrying on laboratory problems, and I have been much impressed not only with the variety of interests in the department, but with the good quality of their research. "I feel justified in saying that the department is splendidly organized and staffed with a group of men who have had excellent training and show much interest. Dr. Cannon came to staff rounds a couple of weeks ago and told me he was astounded by the way the cases were worked up and presented. [To astound Walter B. Cannon in China, familiar as he was with the best medicine of Boston, was quite an accomplishment.] "I have found every member of the staff cordial, cooperative, and very agreeable. It is excellent too, the way the other departments, such as bacteriology and parasitology, cooperate in furnishing data on patients. To sum up, the medical clinic is as well organized as any I have seen, and I can only express enthusiasm for it. Dieuaide deserves great credit for the present status of the medical clinic." It was a rare privilege to participate in this great medical enterprise that played such an important role in the rapid awakening of one of the most ancient and, at certain historical periods, one of the most highly developed civilizations in the world. It was a privilege as well to enjoy the stimulating intellectual atmosphere of the college community. Almost daily gatherings at tea and dinner fostered friendships with interesting Chinese and with people from other lands. From some of them we learned 246

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about old Chinese medical customs based on ancient traditions— the curious drugs that were administered and the "treatments" that had no relation to actual disease processes. Public Health in China

China's battle against ignorance, poverty, disease, and social disorganization was just beginning, and it was of great interest to meet some of the leaders in this battle and to see their work. One of these was Marion Yang, a woman doctor with qualities of greatness. A graduate of a London medical school, she had taken special training in obstetrics at Johns Hopkins and was conducting an extraordinary campaign against maternal and infant mortality. Her principal effort was directed at training midwives who would know how to prevent such complications as tetanus, which she estimated attacked 50 percent of the babies born in a region near Peiping where the old custom still prevailed of putting earth on the navel of the newly born to prevent bleeding. Dr. Yang's campaign, sponsored by the National government in Nanking, and her school for midwives in Peiping were outstanding examples of the work of this progressive Chinese; her courage, energy and sincerity made us feel that she was one of the great people of China at that time. Another remarkable person was James Yen. We saw his great accomplishments at Tinghsien, a county about a hundred and fifty miles southwest of Peiping, where the mass education movement under his direction was introducing modern methods of education, medicine, agriculture, and sociology. Jimmie Yen, a graduate of Yale, had gone to France during the First World War as a social worker among the two hundred thousand Chinese coolies who worked behind the lines of the Allied Armies. He was distressed at the widespread illiteracy among these homesick boys—most of whom could neither write home nor read letters from their families. He devised a simplified language, based on one thousand Chinese characters, which many of these coolies soon learned to read and write. After the war, Yen studied at Princeton and received a Ph.D. degree in the field of education in preparation for a campaign in China against ignorance, poverty, disease, and social chaos. He chose Tinghsien, a county with a population of about 400,000 people living in 475 villages and with a progressive, cooperative local government. There he was developing a new form of society for the country people. 247

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He had gathered together a notable group of colleagues, most of them graduates of American universities. They included a Ph.D. in sociology from Columbia, a Wisconsin University graduate who specialized in agriculture, a Harvard graduate who directed dramatics (an effective form of popular education), and a graduate of the University of Paris who was in charge of translating Chinese literature into the simplified language the country people could easily learn to read. The medical work at Tinghsien was organized to reach all the people in the numerous villages of what we would consider a densely populated rural county. In the central town there was a forty-five-bed hospital, built by funds contributed by the Milbank Memorial Fund. The hospital was headed by C. C. Chen and had a medical staff of nine doctors, most of whom were P.U.M.C. graduates. They not only conducted the medical work at the hospital, which served as the medical center, but also visited the villages, usually on bicycles. There they treated the sick and injured in simple clinics and conferred with the health workers trained at the hospital. The training of these health workers was an interesting and effective project. Young men were selected from the various villages to attend a two-week training course at the hospital. They were taught how to record births and deaths in order to develop vital statistics, how to build sanitary wells, how to vaccinate against smallpox, and how to use about six simple drugs for the relief of common ailments. When they returned home they brought together the patients of their villages to be seen by the doctors and nurses during their visits to the village once or twice a week, and as far as they could, inculcated the simpler rules of public health among the villagers, who respected them and learned to depend on their advice. In the center of the reception room of the hospital at Tinghsien stood a mammoth wheelbarrow filled with medical literature, supplies, and appliances. It was wheeled out to fairs and other popular gatherings in the county as an exhibition in health education. Another somewhat unusual adjunct to the hospital was the row of bathhouses. It was amusing to see schoolchildren lining up for their weekly shower baths, provided by water from rows of oil drums on the bathhouse roofs. As we travelled in rickshaws from village to village, we were amazed to see the improvement in pigs, hen's eggs, cotton, and 248

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other farm products that had been brought about by modern methods at the experimental farm. We were much interested in the out-of-door schools where older children taught classes of youngsters of pre-school age, and in the wayside reading rooms stocked with popular and instructive literature cheaply printed in the simplified language that Jimmie Yen had invented. I have a vivid memory of this visit to Tinghsien as one of the most interesting and stimulating experiences I have ever enjoyed. The Departure and the Journey Home After a burst of delightful social activities, we left Peiping with much regret on May 28, 1935. According to Peiping custom about forty of our friends were at the railroad station to see us off. We were especially touched by the care given us by our number one boy, Gow, who planned so thoughtfully for our departure, and by one of our rickshaw pullers, who appeared at the station with lovely flowers for my wife. It was the last evidence of the grace and charm of the Chinese, possessed by all strata of their society, which makes them the delightful and attractive people we were leaving with feelings of affection and gratitude. Our train took us through Tientsin to Taku, where we boarded a small comfortable Japanese steamer. After a trip across the China Sea and through the picturesque Inland Sea of Japan, we landed at Kobe. A week in Japan was filled with daily rounds of sightseeing in Kyoto, Nara, Tokyo, and Nikko. In Tokyo I inspected the American St. Luke's Hospital, and visited the public health center supported jointly by the hospital and the Tokyo City Health Department. There I met Dr. Kiyoshi Saito, who explained the complete organization of the center, which had recently received a grant from the International Health Board of the Rockefeller Foundation for new buildings. We had an illuminating discussion regarding the attitude toward public health of the overcrowded medical profession in the vicinity of the health center, where the opposition of the doctors to state medical insurance reminded me of home. We sailed from Yokohama on June 8 on the Canadian Pacific steamer Empress of Asia. With a one-day stopover in beautiful Honolulu, gorgeous with June flowers, we reached Victoria, B.C., on June 21. There we had a pleasant visit with my sister and her daughter at their charming summer house with a view of 249

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sea and mountains that was one of the loveliest we had seen around the world. The trip through the Canadian Rocky Mountains added the last touch of grandeur and beauty to our happy and memorable trip. Arriving in New York on June 29, we experienced a thrill of homecoming as we rolled along the Hudson and entered the Grand Central Station. The China Medical Board After returning home, my interest in China and in the Peiping Union Medical College continued; in January 1936 I was elected a member of the China Medical Board. During my service on the board until my automatic retirement in 1945, many problems were encountered as a result of the Japanese invasion which closed the college in 1942. How to take care of the displaced faculty and student body was a difficult question. During this period I served on the executive committee of the board with Edwin C. Lobenstine, its president, and John D. Rockefeller, 3rd, and financial assistance was given to reorient the faculty either in Free China or in this country. Claude E. Forkner, a former member of the P.U.M.C. faculty, went to West China as the representative of the board and struggled manfully with complex problems in Chengtu, where the board gave financial assistance to the medical school of the West China Union University and to other medical institutions in Free China. A t the end of the war, when the property of the P.U.M.C. was regained from the Japanese, the China Medical Board faced the serious problem of restoring the medical center so that its work could be resumed. This was accomplished by 1947, when the board was incorporated as an organization entirely independent of the Rockefeller Foundation. The medical college was reopened under a Chinese director, C. U. Lee, as has been related, with a plan to assume full operation by 1951. However, by 1950 the Communists controlled the government of China, and the China Medical Board adopted a new program. Up to that time practically all the resources of the board, which included an endowment of about $30,000,000, had been devoted solely to the support of the P.U.M.C. Although the present board retains its original name, its articles of incorporation allow greater scope than the support of medicine in China. It now supports no work there; neither has it appropriated funds for China for any purpose since that country has 250

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been under Communist control. Its present program encompasses aid to medical and nursing schools in the Far East and in the United States. The activities of the board have extended to Japan, Formosa, Hong Kong, Korea, the Philippines, Indonesia, Malaya, Thailand, Burma, and Ceylon. In many of these countries it has supported travelling fellowships for medical study abroad and visiting professorships in local medical schools; it has given assistance for medical libraries and for the dissemination of scientific publications. In the United States appropriations have been made to sixteen university schools of nursing and to a number of universities to support special programs in their schools of medicine and of public health, and for the publication of work in medical education. The China Medical Board is composed of a strong group of men, some of them with medical teaching experience in China and some with business and other kinds of experience in the Far East. Joseph C. Hinsey, director of the New York HospitalCornell Medical Center, is the present chairman of the board; Harold H. Loucks, for years a member of the P.U.M.C. faculty is director of the China Medical Board, and Miss Agnes M. Pearce has served as its secretary for many years. The continuity with the Peiping Union Medical College is therefore retained through its administrative officers. Through the medium of the China Medical Board, the Rockefeller fortune has made a noteworthy and beneficent contribution to the health of the people of the world. With rare foresight, courage, and intelligence, modern medical science, education, and practice have been spread to an ancient and noble race sorely in need of the contributions of advancing science for their physical and social welfare. Although the march of events seems to have brought disappointment and frustration to those desiring to see the medical work in China go forward along the lines they had planned and directed, there can be no doubt that seeds were sown by the Peiping Union Medical College which will not fail to bring forth harvests of human betterment. This great project was a successful investment, and now that the funds are being more widely used, the benefits of the China Medical Board are still reaching many people much in need of encouragement and beneficent support for the betterment of health and human welfare. 251

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THE SOCIAL ASPECTS OF MEDICINE •« 1 9 3 6 - 1 9 4 1

y

N returning from China in 1935, I had decided to devote myself to the study of the social aspects of medicine and to endeavor to demonstrate that the personal and social problems of patients constitute an important factor of illness which was being largely neglected, both in the care of hospital patients and in the teaching of medical students. The rapid expansion of medical science had led doctors to specialize to such an extent that interest in the patient as a person had become submerged. I was convinced that emotional disturbances, which frequently cause illness, were not receiving adequate consideration, and that a systematic study was needed to demonstrate the validity of this conception.

O

Early Interest in Social Problems This idea had been on my mind for many years, in fact since my days at the Pennsylvania Hospital thirty years before when I became interested in the social problems of patients. This was in the days before the establishment of a medical social service department at the Pennsylvania Hospital, but the personal problems of patients were there, and now and then protruded above the routine of medical care. I can recall instances when personal difficulties seemed to dominate the medical situation, and my desire to understand them led me to visit the homes and families of a few patients. However, at that time there were practically no organized social services available to assist these families, 253

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and my visits revealed difficulties I did not know how to relieve. During my seven years at Washington University, I was earnestly interested in medical social service in association with Julia C. Stimson, the first director of the social service department in the St. Louis hospitals. Working closely with Blanche Renard, the social worker in the medical outpatient department, and taking an active part in the development of a workshop for the handicapped and a school of occupational therapy, gave me a variety of experience in medical social service. In 1921 at Johns Hopkins I said at a meeting of medical social workers that it should be the outspoken ideal of each hospital and of all connected with it to endeavor to have every patient who enters its doors leave the institution a better person, not only physically but also intellectually and spiritually. My ideal was that efforts should be made constantly to influence patients so that on discharge from the hospital they would be more efficient and cooperative and would have a better idea of just and right relations with other people than they possessed on admission. Personal improvement would be a side issue in some cases, while in others it would have a direct bearing on the future health of the patient. Every hospital should consider the time spent by a patient in its wards or even in its outpatient clinics as an opportunity to do all that can be done for the person. To approach the fulfillment of this ideal, a mechanism must be established for dealing adequately with each patient as an individual, and in this mechanism all—administrative officers, doctors, nurses, and employees—must participate, and the medical social worker must take a prominent part. This idea was borne in mind over the years and exerted an influence on the planning and organization of the hospitals that I directed. It was especially a motive for action in tuberculosis hospitals when, years later, I had the opportunity to influence their management. In an address before the Southern Medical Association in 1924 on the influence of environment on medical education, I formulated a program of study: "Problems in social diagnosis and social treatment are constantly before us in our hospitals and dispensaries, and for the sake of our students' training and our patients' welfare, they should not be ignored. But in the complexities of hospital practice, replete as it is with scientific problems, is not the inner man submerged? Whose duty is it to under254

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stand the human problems which surround but are apart from disease? Who is to study with a true sympathy and friendliness the troubled spirit? We all know that the recovery of many patients can be hastened by clearing away mental doubts, by relieving worry that may be daily wearing down courage; and yet the busy physician, especially when rushed by many patients in the dispensary or when caring for large groups of patients in the wards of a hospital, usually cannot extract from each his or her special need beyond the immediate medical problems." A decade later, when I returned "foot-loose" from China, I decided to study these problems. During my stay in China I had stimulating talks with Richard S. Lyman, who headed the neuropsychiatric department in the Peiping Union Medical College. He was much interested in the integration of psychiatry and general medicine and was convinced that the social and personal problems of patients constituted a field of study worthy of all the effort, time, and thought that could be given it. Our discussions helped to clear my thoughts and propelled me toward the objective I was contemplating. The letters he wrote me after I left China were helpful in guiding the organization of my work toward a sound method of investigation from which reliable deductions could be drawn. The Development

of a Plan of Work

In the summer of 1935 I had opportunities to talk over my vaguely formulated plans with two of my friends who eventually gave much assistance in securing facilities for initiating the plan of work I had in mind. One was Alan Gregg of the division of medical sciences of the Rockefeller Foundation, then a summer neighbor on Long Island. He helped me define the field of work I hoped to develop and later provided funds for its support through the foundation. The other friend was Alan M. Chesney, dean of the Johns Hopkins Medical School, to whom I paid a visit in Deer Isle, Maine. There we began a long and very helpful discussion, recorded in many letters that passed between us, on how the social aspects of medicine should be studied. Alan Chesney was an intimate and cherished friend, and over the years our medical paths had crossed and run together several times. He soon developed an enthusiasm for the field of work I wished to plough and cultivate that was quite equal 255

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to my own, and we deliberated together how the study of the social problems of patients could be integrated into the curriculum of a medical school. I hoped to find an opportunity to work in the Johns Hopkins Medical School and Hospital, where I knew the staff and organization, and where my future work could be naturally related to the School of Hygiene and Public Health. The outstanding department of psychiatry under Adolf Meyer and the admirable department of medicine under Warfield T. Longcope, in which I hoped the project could be centered, were further inducements. At Johns Hopkins a traditional interest in public and social service was combined with high standards of scientific achievement—a heritage especially from Osier and Welch. Although other possibilities were explored at this time, Johns Hopkins presented a very favorable situation, and by the end of the year the project was almost ready to be launched. The introduction into the medical school and hospital of a new field of study centered on social rather than medical problems was given careful consideration by a special committee appointed by the advisory board of the medical faculty, of which Chesney was chairman. Somewhat protracted discussions ensued regarding how such a study could be integrated with other plans that had been proposed, such as a historical study of the social problems of medicine in which Sigerist, the professor of the history of medicine, was interested, and also what its relation would be to the course in preventive medicine, for which a plan had already been formulated. While these discussions clarified our ideas on the way a study of the social aspects of medicine could be conducted by investigating the problems of individual patients, they did not provide a method of integrating such a study into the medical school that was approved by everyone concerned. In January 1936 I submitted a plan which would not require the medical faculty to make any radical decisions, but which would give me an opportunity to demonstrate the soundness of the ideas that had been evolved. I proposed that the medical school provide an opportunity for the study of patients at the Johns Hopkins Hospital in order to determine the nature and extent of their personal problems that were not receiving systematic attention in relation to their medical care. The study would be concerned with emotional disturbances, social maladjustments, faulty physical and mental hygiene, and economic 256

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difficulties, and the relation of these problems to the physical condition, family life, occupation, and environment of the patients. The study would aim to determine the significance of these matters in medical care and to devise methods best suited to reveal and solve these personal problems. It was proposed that the study be conducted as a research project over a period of about five months without further commitments by medical school and hospital. During that time data would be collected and studied to furnish material for evaluating the desirability of further activities in this field. The proposal suggested that an office be provided and detailed a small budget for the salary of a secretary and other expenses. I undertook to secure the necessary funds from the Rockefeller Foundation. This plan was approved by the advisory board of the medical faculty and by the medical board of the hospital. Through the interest of Alan Gregg, a small grant was obtained from the Rockefeller Foundation to support the work f o r five months beginning January 1, 1936. Experimental Studies Although I continued to live in New York, after the beginning of February I spent Monday to Friday of each week in Baltimore initiating my work at the Hopkins. Two small rooms in the medical department of the hospital, adjacent to the outpatient service, were placed at my disposal, and I soon secured a secretary. A f t e r talking over my plans with members of the hospital and outpatient staffs, I selected at random ten patients from various clinics as a "trial run." I soon found problems that needed further study; six out of the ten patients revealed personal problems that were related to their illness. My first patient, a woman with elevated blood pressure and symptoms of heart disease and increased thyroid activity of four years' duration, was of special interest. She worked in the hospital laundry and said that her work was a strain and that recently she dreaded going to work each day. It was a simple matter to look into her working conditions; they were found to entail an emotional strain, as she was responsible for four assistants, young girls who were not interested in their occupation and who amused themselves by annoying their older supervisor. It was arranged to have her work alone on the other side of her ironing machine, where only one person was required. A week 257

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after this change the patient returned to the clinic and said enthusiastically: "A miracle has happened. A big burden has been lifted from me." Her symptoms had disappeared, and she remained well during the three years she was followed. She gained weight, was happy and cheerful, and a significant change in personality was noted, although there had been no reduction of blood pressure. She never stopped talking about the miracle that had been performed by changing her position of work from the front to the back of the ironing machine, which relieved her emotional strain. Another patient of this small group was a man who had been undergoing unsuccessful treatment for several months for intestinal symptoms of four years' duration. Because he was unable to continue as a skilled worker in a shoe factory, he and his family were on public relief. An analysis of his story revealed that his symptoms were initiated and aggravated by bursts of anger, which he managed to control, directed at the man who had become his supervisor shortly before the onset of his symptoms, and who became more irritating to him as time went on. At the end of the second interview, the nature of his illness and its emotional cause was explained to the patient. He responded well, accepted both my explanation and advice, and a week later said that for the first time in months his pain was gone. Although he had transient symptoms for some time and his morale was occasionally in need of support, his rehabilitation eventually was complete. When last seen he was happy, had a good job, and was out of debt. There was also a forty-nine-year-old woman in this group who had made eighty-nine visits to the clinics in the previous two years and who had a long list of medical diagnoses. After talking to her for fifteen minutes, I asked which of her various doctors she knew best. I was surprised when she looked up with a quizzical smile and replied: "I think I know you best." It was evident that no one had been a true physician to her, although she needed most of all some one to help her straighten out her social problems. This incident demonstrated how inadequate the doctor-patient relationship could be in the outpatient department. The findings in this group of ten patients provided convincing evidence that the proposed study had promise, and a report of these few cases served to indicate the desirability of continuing and extending the program. 258

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By the first of May the medical school authorities agreed that "the study of the accessory factors of health," as the program had been designated, should be continued for another year on an experimental basis, so that the various aspects of the subject which had been revealed might be more fully explored and sufficient material might be collected and written up to present definite evidence of the value of the work, both to the members of the faculty and to the officers of the Rockefeller Foundation. I was authorized to solicit the foundation's support with the assurance that the medical school would extend its invitation to me to work there for another year. At that time it was arranged that I should initiate a teaching program in September 1936 as part of a plan of instruction in preventive medicine which had been previously adopted by the faculty but had not yet been organized. This plan included visits by third-year students to the homes of dispensary patients, as the basis for the study of the patients' environment. The Rockefeller Foundation made a grant to the medical school to finance the work for a year. The grant, which was sufficient to provide salaries for a social worker, a secretary, and me, was renewed the following year. A trip to Boston in May provided an opportunity to discuss the proposed program with Ida M. Cannon, director of the social service department of the Massachusetts General Hospital. Miss Cannon was a pioneer in medical social service in the hospital where that work had had its modern American beginning under the stimulus of Richard C. Cabot. She showed much interest in the proposed field of study and arranged a leave of absence for a member of her staff, Josephine C. Barbour, to work with me in Baltimore in October 1936. Miss Barbour was a great help in the Hopkins study and later had a distinguished career as Miss Cannon's successor as director of social service at the Massachusetts General Hospital. While in Boston I visited Joseph H. Pratt's "Thought Control Clinic" at the Boston Dispensary. There, weekly meetings provided encouragement and mutual stimulation for groups of emotionally disturbed patients. I also attended a clinic conducted by George R. Minot at the Boston City Hospital where, with the cooperation of the hospital social workers, patients' problems were presented and discussed with students of the Harvard Medical School. Joe Pratt and George Minot especially encouraged me in the study of social aspects of 259

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medicine, and their activities in this field were stimulating and enlightening. We moved to Baltimore from New York in September 1936, and as I planned to concentrate my work on patients living in the Eastern Health District, my wife suggested that we live in the district. This good idea was carried out by renting a little house on Wolfe Street, back of the Johns Hopkins Hospital and in the block next to the school of hygiene. There we lived for three years among delightful neighbors, including numerous younger members of the hospital staff and their wives. The Program of Work

The Eastern Health District, so designated by the Baltimore City Health Department, surrounds the hospital, the medical school, and the school of hygiene. It contained in 1936 over 100,000 people mostly in the lower economic brackets. The majority of the inhabitants were industrial workers, mercantile employees, shopkeepers, and unskilled laborers; the population contained a somewhat larger proportion of Negroes than the total city, as well as a variety of foreign-born persons. The public health administration of this district was largely carried on by the school of hygiene for which it served as a laboratory for field work and study. Harry S. Mustard, then the administrative officer of the district, was a valuable adviser and placed all facilities and records at our disposal. This district was an excellent field for the study of the social aspects of medicine and public health, as probably more was known about the health conditions of its population than of any other urban community in this country. As I was to be a full-time member of the medical faculty, spending most of my time in the outpatient department, I was appointed lecturer in medicine and director of the medical outpatient department. I was also to supervise the teaching and medical administration. This appointment gave me authority in the medical clinics to make some improvements in organization which pleased the staff, and provided an opportunity to meet with all the students assigned to the general medical clinics and to give general direction to their work. Before the beginning of the academic year three problems had to be considered. The first problem was to formulate the method of studying individual patients that was best suited to eliciting 260

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from them facts in which we were particularly interested; the second was to initiate a systematic study from which reliable conclusions could be drawn regarding the prevalence and significance of social and emotional disturbances as related to medical care; the third was to inaugurate a plan of teaching which would arouse the interest of the students and give them opportunities to study the social problems of their patients in the clinic. It was fortunate that these three objectives could be correlated and that the broad study of individual patients was the basis for all of them. The field of medicine that we endeavored to cultivate was concerned primarily with illness or sickness rather than with disease, and it is necessary to make this distinction clear if the objectives of our work are to be appreciated. Illness or sickness is a disturbance of health recognized subjectively by the patient as symptoms, such as pain or discomfort, which interfere with the usual requirements of living, and which are often augmented by anxiety or depression. Illness is what the patient feels that makes him conscious of loss of good health. When symptoms are sufficiently disturbing to body and mind, most people seek the help of a physician. Disease is an abnormal state of the body, recognized objectively by the physician after due consideration of what the patient relates and after physical and laboratory examinations have revealed abnormalities of bodily structure or functional activities. The doctor endeavors to find the derangements of the body that are causing the symptoms of illness and to make a diagnosis as the basis of the treatment best suited to relieve the patient and to cure his disease. This distinction between illness and disease is important because a person may be ill and yet have no demonstrable evidence of disease. Conversely, a person may have a serious and ultimately fatal disease without feeling ill. When a patient consults a physician the first objective is usually to determine the disease that may be causing the patient's illness. After the patient has described his symptoms, the doctor performs a physical examination, paying special attention to the parts of the body with which the symptoms seem likely to be associated. A diagnosis is made and treatment prescribed. This is what patients expect, and it is the natural beginning of the doctor-patient relationship. Our contacts were made with patients after their medical histories and physical examinations 261

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had been carried far enough by the medical staff to indicate the character and extent of their diseases. Our study was concerned primarily with the components of illness that were not directly attributable to organic disease, but which were related especially to reactions of mind and body to emotional stress and strain, to faulty modes of living, and to poor adjustments to adverse social conditions. In every case there are three interacting components that determine the character, severity, and treatment of the illness: (1) the disease that may be present, (2) the social and environmental conditions surrounding the patient, and (3) the personality of the patient, which determines his emotional reactions to his illness and to his surroundings. These three components and their interactions need to be studied so that the whole person and all aspects of illness may be considered. While giving full cognizance to the presence of disease, our interest was especially in social and environmental conditions and in the personality of the patient as they affected understanding and treatment of illness. The method of study, described below, may be of interest because this was one of the pioneer efforts in a modern medical clinic in which a physician gave his full time to the study of the social aspects of medicine. The first contact with the patient took place in a secluded office, after the record of his medical history, examination, and provisional diagnosis had been reviewed. The first objective was to establish an intimate doctor-patient relationship by explaining the significance of the medical findings. The patient was then encouraged to talk freely about his illness and his problems by allowing him the benefit of an interested and attentive listener who had plenty of time. He was asked to tell about his daily routine and habits, his work, his family and associates, and about anything that was on his mind. The confidential nature of the interview was impressed upon the patient and was rigidly so regarded when the patient had any reason to desire it. Special attention was given to obtaining a detailed account of the symptoms that brought him to the hospital, in order to determine whether they could all be reasonably attributed to the organic disease that had been revealed by his medical study, or whether they were in whole or in part attributable to an emotional reaction, the cause of which should be sought. Practically every patient responded with grateful satisfac262

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tion to the opportunity to discuss his personal problems with a doctor. Some told of episodes and situations that had been shut up within and disturbing them for months or years, often saying that they had never before had a chance to talk to anyone about these problems. Special efforts were made to discern subjects a patient wished to avoid or seemed unable to talk about. All interviews were recorded at their conclusion and problems to be subsequently investigated were noted. Nearly every patient was visited at home, after the purpose of the visit had been explained, and in many instances other members of the family were interviewed. In a large number of cases I came to know all or most of the members of the family. The patient was sometimes visited at his place of work, and information was gathered from various social and public health agencies to which the patient was known. Many conferences were held with workers in these agencies. Whenever a strong attachment was found to a priest or minister, he was visited, and although this opportunity was not often presented, the churchmen were definitely helpful in some cases. Information thus assembled and recorded was analyzed and interpreted to the patient as a means of giving him better insight into the nature of his illness and an understanding of the relation of emotional strain or unhygienic ways of living to his state of health. Efforts were made to teach the patient how to live with any physical disability that he might have, and how to adjust his life to family situations, economic needs, or working conditions. The correction of erroneous ideas and the replacement of harmful thoughts by rational thinking was often successfully accomplished. It was remarkable and often surprising how much light was shed on the true nature of illness by this method of study and how constantly it was of value in the treatment of patients and in the improvement of their ways of living. The first one or two interviews usually required half to three quarters of an hour to reveal the main problems, and the time subsequently devoted to each patient depended necessarily on the complexity of the situations. Most of them were followed for several years by check-ups at the hospital, by home visits, or by letters. We were particularly interested in the continued freedom from symptoms, sense of well-being, and improvement of health which the patients reported, rather than in changes in the signs of disease, although consideration of any chronic disease 263

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was not ignored or neglected. The long-range results were usually very gratifying. The second problem was to plan a systematic study of the social aspects of medicine as a research project from which reliable conclusions could be drawn. It was decided to center the study on patients who were admitted to the general clinics of the medical outpatient department and who resided in the Eastern Health District, and to study all of them without selection until enough data were collected to allow analysis and statistical treatment. By this method facts could be obtained regarding the prevalence and the nature of personal and social problems of unselected patients residing in a defined part of Baltimore, and the relation of these problems to the illnesses that brought them to the hospital could be ascertained. This plan of restricting the study to patients who resided near the hospital was advantageous, both because it encouraged frequent visits to the clinic and because it made home visits convenient. It also kept the number of patients within manageable limits and utilized the clinics where the third-year medical students received their first clinical teaching in medicine. The plan worked well and led to the publication of a voluminous report which will be discussed subsequently. The third problem was to organize teaching to correlate with the clinical work of the third-year students. One third of the class, a group of about twenty-five students, was assigned in rotation to the general medical clinics of the outpatient department for a period of eight weeks. Under the direction of a large staff of physicians, the students were initiated into the study of individual patients, taking their histories and participating in their physical and laboratory examinations. One period of two hours each week was assigned to the "study of the personal, social, and sanitary background of patients." The official announcement read: "Each student during his time in the medical dispensary is assigned one or more patients admitted from the Eastern Health District for the study of their personal, social, and sanitary background. By means of interviews, home visits, and information gained from public health and social service sources, the student learns all he can about the patient as an individual and presents his findings at weekly conferences attended by representatives of public health, clinical medicine, and 264

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social service. Public health, hygiene, occupational, social, and economic problems are discussed as presented by the study of the individual cases." Harry S. Mustard, administrator of the Eastern Health District, and Henry M. Thomas, Jr., chief physician of one of the medical clinics, were associated with me in conducting the course; they participated in the conferences, while I worked directly with students and prepared the conferences. At the conferences students presented cases which they had studied medically and which had been assigned to them for social study. The students were prepared for the conferences by reviewing the interviews that had been conducted, by being taken on home visits, and by discussing privately the social, emotional, hygienic, or public health problems which their patients presented and the relation of these findings to the patients' illnesses. The conferences were attended by the psychiatrist studying mental hygiene problems of the Eastern Health District, by medical social workers, by representatives of outside social agencies interested in the case scheduled for presentation, and by visitors from the City Health Department, the school of hygiene, and other departments of the medical school. Lively discussions took place on the problems presented by patients and the social aspects of several important diseases such as heart disease, tuberculosis, syphilis, diabetes, and other chronic conditions were brought up with each group of students. It was especially advantageous to give the students an opportunity to appreciate the importance of considering the patient as a person at the time when they were beginning their study of individual patients, for it is then that students start to form medical habits and to develop attitudes toward the sick. The response of the students was excellent and the course aroused an increased interest in the social problems of patients that spread gradually throughout the hospital. This plan of teaching was continued for three years under the original conditions, the work being supported by the Rockefeller Foundation for two years and by the John and Mary R. Markle Foundation and the Josiah Macy, Jr. Foundation during the third year. In 1939 the university received a grant from the Rockefeller Foundation to support a new department of preventive medicine in the medical school. The department was started in the fall of that year, headed by Perrin H. Long as 265

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professor of preventive medicine, and the teaching program I had organized was continued as one of the courses in this department. Reports

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Studies

The study of unselected patients admitted to the general medical clinics from the Eastern Health District was continued for nearly two years and served well as a means of correlating the study of social problems with medical care and with teaching. This field of work attracted attention outside Baltimore, and I was asked to present a paper on the significance of adverse social conditions in medical care at the 1938 Annual Meeting of the Association of American Physicians, the leading scientific society of physicians especially concerned with medical teaching and research. This invitation came from George R. Minot, who was the president of the association that year and who was as much interested in the social problems of medicine as in medical research. Minot's outstanding studies in the cause and treatment of pernicious anemia had won for him and his associates the award of the Nobel prize, the highest honor attainable by medical scientists. It was gratifying to have the study of social problems recognized as deserving a place on the program of an association before which much of the best work in medical research is presented. This paper was based on the study of the nature and prevalence of adverse social conditions and the resulting emotional disturbances occurring in a series of 174 patients in the Johns Hopkins Hospital. Adverse social conditions included a patient's personal problems which were significant because they produced emotional disturbances injurious to health or created situations interfering with medical care. In this paper the conviction was expressed that if an intimate personal relationship is established with a clinic patient, more nearly like that existing in the practice of the family physician, favorable conditions are created for the revelation of the extent, nature, and significance of social situations which disturb health. This conception was based on the study which combined a thorough clinical investigation in a modern hospital with a study of the patient as an individual by the methods described above. The results of the study showed that 114 patients in the group of 174, or 66 percent, had adverse social conditions directly related to their illness, and that in 63 266

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patients these conditions were the major precipitating cause of illness. From these findings it was concluded that a large proportion of the patients in the public services of hospitals are confronted with adverse social conditions which cause emotional disturbances resulting in illness. This is an impelling reason for greater consideration and further investigation of the relation of these problems to illness, as much suffering and disability can be relieved or prevented by procedures aimed at the removal of, or adjustment to, social adversity. The case studies of the 174 patients composing the series were subjected to detailed analysis and statistical treatment and, with a summary of each case, were reported in a book published by the Commonwealth Fund in 19B9, entitled The Patient as a Person: A Study of the Social Aspects of Illness. During the process of analyzing the material, Miss Barbour was especially helpful in defining and classifying the social and personal problems encountered and in making a "social diagnosis" of each case. For this purpose, the adverse social conditions revealed by a patient were divided into "deficiencies of subsistence" and "dissatisfactions" ; the first category was defined as maladjustments of the patient to society as a whole and the second as maladjustments between the patient and other persons. Although these two categories of adverse social conditions were often found to be integrated or dependent on each other, they could be distinguished from one another. Deficiences of subsistence were inadequate physical protection, such as poor housing, inadequate financial resources, faulty personal habits injurious to health, or personal inadequacy. The dissatisfactions were related to family life or other group relationships, or were connected with restricted social outlets. Of the total number of persons classified under this scheme, 80 percent revealed some type of adverse condition; of these, 70 percent were problems of subsistence and 50 percent were social dissatisfactions, both types of situations frequently being found in the same patient. For 114 patients (66 percent of the group) the social or personal problems were definitely related to the illness and had to be taken into consideration in making a diagnosis and prescribing treatment. An account of most of the patients in the series was published together with the findings in each case, so that the data from which conclusions were drawn could be scrutinized. The cases were grouped either according to the parts of the body to which symptoms primarily 267

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referred, such as circulatory, respiratory, or digestive organs, or according to general disease, such as diabetes, syphilis, or psychoneurosis. The 40 patients with circulatory symptoms ranged from those diagnosed as having severe heart disease to those with similar symptoms in whom no evidence of cardiac disease could be found. In all but 3 patients with circulatory symptoms adverse social conditions were responsible for the production of symptoms or for creating a barrier to medical care. This study demonstrated that it is essential to separate the manifestations caused by emotional disturbances from those produced by organic heart disease, and to evaluate the significance of each as the basis for treatment and for the management of the patient's mode of living. A case illustrating this concept was a thirty-four-year-old steel worker who had been ill for two years following an automobile accident in which his pelvis had been fractured. The accident produced what he called "nervous shock," and he spent thirteen miserable weeks in a public hospital where he was constantly under emotional strain. On leaving the hospital his doctor, who had discovered a heart murmur, told him he had heart disease and must avoid strenuous exercise. Since then, he had led the life of an invalid, seldom leaving the cheerless firstfloor flat where he lived with his wife and two small children. The family was supported by public relief. When he was admitted to Johns Hopkins because of an acute attack of bronchitis, the diagnosis of valvular disease of the heart was confirmed. Our interview with this patient revealed, first, that his illness was vague and general and that his symptoms had never been characteristic of heart disease; and second, that he had had rheumatic fever at the age of twelve. This had no doubt damaged one of his heart valves and left him with a cardiac murmur; he had been told of the presence of the murmur when he was nineteen years old. In spite of this he had carried on strenuous work for years in the steel industry, had worked as a furniture mover, and had gone through maneuvers with the State National Guard. There was no reason to believe that the condition of his heart had changed recently, and there was every indication that it was not his heart but his anxiety and his attitude of invalidism that required treatment. It took quite a time to persuade him—and also some of the doctors who had examined him—that he was physically fit to work. However, he was finally encouraged and 268

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assisted to get a job in a gasoline filling station, and from there he went on to work as a chauffeur. He was soon able to restore himself to self-support and was freed from the bonds of anxiety that had crippled him and his family. Heart disease is always a serious matter for anyone to face, as it often means restricted living and is thought of as implying an uncertain future. In telling a patient he has heart disease, a doctor must be mindful of the consequences in terms of emotional strain, anxiety, and social disturbances which may be part of the patient's situation. This was illustrated time and again in the study of patients with circulatory symptoms. It was gratifying to be able to relieve patients of these personal problems when a careful study of the circulation showed that their symptoms had no alarming implications. It was observed, however, that some of these patients could not be relieved permanently of their anxiety and emotional disturbances merely by telling them that a careful examination had revealed nothing organically wrong with their hearts. Such reassurance even seemed disappointing to patients whose symptoms were of psychoneurotic origin, and more than reassurance was required. After a search for disturbing conditions in their lives, a convincing discussion of their true situation often gave them a new attitude toward health and put before them the problems related to their illness which they themselves had to solve with the guidance and encouragement of their physicians. Nearly all patients in this group, even those with serious cardiovascular disease, responded favorably to the consideration given to the psychogenic components of their illness. The 49 patients with respiratory symptoms ranged from cases of mild and transient infections (the familiar common cold) to cases of serious lung diseases such as pulmonary tuberculosis. It was interesting to note how a common cold would create disturbing symptoms in emotionally unstable people, and their visits to the hospital opened the way to a helpful discussion of their personal problems from which they received lasting benefit. The social problems of the patients with tuberculosis were especially important, as active pulmonary tuberculosis affects profoundly the life of the patient. When told he has tuberculosis, the person must immediately face two problems, one related to his own welfare and the other concerned with the welfare of 269

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those about him. For his own sake he usually must undergo a long period of treatment under conditions which will probably remove him from his home and work, and which will require him to relinquish temporarily or permanently his responsibilities and opportunities. The patient must also accept the fact that he is a potential source of infection to others and must control his behavior and habits with this consideration in mind. The doctor encounters few situations that place upon the patient as much emotional stress and strain as the diagnosis of pulmonary tuberculosis. Intimate knowledge of the patient as an individual is necessary in order to help him with the problems he has to face. Success in the treatment of tuberculosis is to a large degree dependent upon the initial preparation of the patient for what lies ahead, and he needs to be educated not only in regard to his disease and how to cooperate with his physician, but also in regard to his attitude toward life in general, toward adjustment of his family situation, his occupation, and, in many instances, toward solution of economic difficulties. The interview and home visits, giving family members an understanding of the problems and stimulating their cooperation, are usually important factors in giving the patient the best start toward recovery. As the disease was encountered in our study among the poorer people, it was also necessary to see that all available facilities of the city health and welfare departments and voluntary social services were utilized to meet the needs of the patient and his family. Cases of pulmonary tuberculosis were of special interest also because from them students could learn so much about public health and preventive medicine. Students, accompanied by a public health nurse, usually visited tuberculosis patients at home. In one instance, a student, a nurse, and I visited an elderly colored woman with advanced tuberculosis. In the course of our interview we found that a few months before she had been employed as a nursemaid for a nine-year-old child in an attractive suburb of Baltimore but had given up her work because of her cough. The student was surprised and shocked to find that the little girl the patient had cared f o r was the daughter of one of his intimate friends whose home he often visited. That student learned an unforgettable lesson in public health, and through the action taken by the health department with the family, he saw at first hand some of the operations of a health department. 270

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Patients with digestive symptoms frequently suffer from the effects of emotional disturbances. Everyone knows that the digestive tract is sensitive to fright, anxiety, grief, or anger, as these emotions often cause loss of appetite, nausea, and pains of "indigestion." The relation of stomach ulcers to nervous stress and strain has become common knowledge. All patients with digestive symptoms should be studied in relation to the possibility that social or personal problems are the cause of their symptoms. Among the cases in our series that illustrated this principle was a thirty-seven-year-old police officer, admitted to the hospital for treatment of a duodenal ulcer causing an intestinal hemorrhage. He had had digestive symptoms for about ten years, and they had become worse recently. Although he claimed to be without personal troubles, his sensible wife told us that he was a constant worrier and that his "indigestion" was always worse when he had any emotional disturbance. She said that recently he had been on police duty from midnight until 8 A.M. and that their three children, six, four, and two years old, disturbed him so much in the daytime that he was unable to sleep, that this situation was the cause of constant worry, and that he had dreaded going back on night duty after leaving the hospital. This he admitted when confronted with his wife's opinion, and it gave him the incentive to tell about the various emotional problems he was facing, much to his relief. With his consent, I went to the police captain of the district and convinced him that a change of duty would be very beneficial to this patient when he reported back. After quite an argument, the captain consented to put him on a daytime traffic duty assignment. The news of this decision had a definite effect on the patient, who became brighter, happier, more communicative, and he seemed like a different person. He made a good recovery and when last visited at home, two months after being discharged from the hospital, he was happy in his new assignment, and was entirely free from the digestive symptoms he had had for ten years. This is an example of how cooperation may be gained even from a rather "hard-boiled" police captain, when humanitarian instincts are aroused by reasonable discussion. The education of the patient as to how rational thinking rather than emotional outbursts would help him avoid illness, bid fair to give him permanent improvement of health. Among other types of chronic illness in which patients were 271

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found to need special attention in regard to the personal and social aspects of their lives was diabetes. The treatment of this disease is, like the care of tuberculosis, largely dependent upon the cooperation the doctor can elicit from the patient, as faithfulness in following medical directions regarding diet, injections of insulin, and a method of living is a large factor in the success of treatment. The cases of diabetes mellitus in our series indicated the necessity of knowing not only as much as possible about the severity and treatment of the disease, but knowing also about the character and situation of its victim. It is not enough to be sure that the patient has a clear understanding of what he must do to retain his comparative health; he must also know the difficulties to be faced in carrying out his regime. His intelligence and especially the status of his emotional development must be evaluated, and it must be realized that his ability to carry on successfully in spite of his illness is dependent on the relation of his mental characteristics to the social situation he has to face. In other words, the diabetic patient as a person must be the subject for study and treatment. He cannot manage his disease unless he can be taught or has already learned to manage himself as an individual. Serious difficulties were encountered, involving patients who were unwilling or unable to cooperate in their treatment, and for a few of these patients many hours of sympathetic discussion failed to elicit adequate response. Among other chronic diseases from which patients in our series suffered was epilepsy. People who, almost without warning, have epileptic seizures which may subject them to serious accidents and may cause very difficult disturbances to those around them, need to have their conditions of living and of work carefully considered. The social disturbances resulting from epilepsy have been recognized throughout the history of this ageold disease, and the epileptic has always been more or less an outcast of society. The degree to which such a person must be separated from the usual pursuits and normal modes of living depends, of course, on the severity, frequency, and character of the seizures. Even when epileptic attacks are controlled by drugs, a field of medicine in which recent improvements have been marked, it is difficult to say when and where they may recur, and the life of the epileptic must always be viewed as containing uncertainties and dangers. The facts of epilepsy must be faced, 272

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although they are hard facts, and a sympathetic, honest, and accurate explanation of what the patient has to expect is essential for his future welfare. This explanation must be made to the patient or to the person responsible for him and must be based on full understanding of the situation in which he lives. This effort was made with the 6 epileptics encountered in our study. The 20 patients in our series who revealed no evidence of organic disease often required prolonged study and frequent conferences in the office and at their homes in order to unravel their tangled lives. These patients presented opportunities for clearing away anxiety and depression by tracking down the problems causing the emotional disturbances to which the body reacted with illness. A simple form of psychotherapy, which constitutes an important part of all medical practice, was used; it was based, however, on a more thorough study of the personality and the social adversity of the patients than is usually made in hospital practice. If our study of a patient led us to conclude that his emotional disturbance was part of mental illness, he was transferred to psychiatric care. However, if a patient seemed to have a rational attitude and was not unduly disturbed, we endeavored to educate him to meet his problems more sensibly and to improve his social situation in ways that would lessen emotional stress and strain. This was sometimes a protracted process which took us beyond the conventional field of hospital practice. An example was the case of an attractive sixteen-year-old girl, a high-school student, who complained of drowsiness, headaches, and a pain in her back for which no organic cause was found. She was depressed and presented symptoms suggesting early signs of serious mental illness. The interview with the patient and her mother revealed that she was doing poorly in her school work and was constantly under pressure from her stern, foreign-born father, who was critical of her marks at school. The patient herself recognized the relation of this strain to her symptoms; she said that when her father expressed annoyance over a failure in school and told her not to make excuses, "this got me down and then I was sick." Action was taken in two directions. A long talk with the father threw much light on the family situation and the difficult problems he had 273

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faced, and brought him to see clearly his part in his daughter's illness. He changed his attitude toward her completely. A visit was made to the girl's school, where her situation was discussed with her teachers and with the school nurse. The school authorities thought that the girl was confused and disturbed; her work was so poor that they had decided to drop her from the school at the end of the semester, a few weeks away, a step which would deprive her of further public school opportunities. This would have caused a family tragedy. She had done well in a few subjects and had an aptitude for so-called home economics. With this in mind, the principal of a public vocational school was visited, and after some pleading a transfer was arranged to this school. The patient and her family finally accepted the transfer without ever knowing that she would have been dropped from her high school. The change worked out well. The patient was soon interested in her school work, especially in a course in tearoom management, and in a month reported enthusiasm for her course and her teachers and the disappearance of her symptoms. A month later she and her mother said that the whole atmosphere of the home had changed from a state of tension that seemed to affect the health of all of them, including a sister, to a happy family life beneficial to all. This case illustrates how the study of the patient as a person may lead to the successful practice of mental hygiene. The study of psychoneurotic patients, whose symptoms were unrelated to demonstrable organic disease emphasized the necessity of considering them as total individuals in order to give them adequate medical care. The psychoneurotic patient is a person who reacts excessively to social and personal disturbances, either because of inherent characteristics of personality or because prolonged or repeated adversities have broken down his emotional stability. Often both reasons are present. The first step toward rehabilitating the psychoneurotic patient, after completion of a thorough study of his physical status, is to discover the adverse social conditions in his life and the manner and degree to which he reacts to them. This knowledge is gained primarily by means of the interview that has been described. It is largely on this knowledge that the understanding and treatment of the psychoneurotic individual must be based. The study of the 174 unselected patients admitted to the Johns Hopkins Hospital from a typical urban community fur274

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nished convincing evidence that special consideration of their personal and social problems was highly significant in diagnosing and treating their illnesses. In regard to diagnosis, it was clear that the illnesses of many patients were not fully understood by the highly trained medical staff because inadequate consideration had been given to the emotional disturbances from which these patients suffered. The emotional components of illness were, of course, frequently recognized by the physicians responsible for their medical care, but they were often put aside, especially if organic disease was present, without consideration of their underlying causes and without attempts at tracing the origin of emotional disturbances to adverse social conditions. This attitude was attributed in part to the concentration of interest on the study of disease rather than illness, and in part to lack of time for the rather tedious study of the patient as a person. In regard to treatment, our cases showed that in 124 patients, or 71 percent of the total number, adverse social conditions were a significant factor in medical care, and convincing evidence was furnished that greater knowledge of the total individual was needed in hospital practice in order to improve medical care. This problem is especially significant in teaching hospitals where students observe for the first time the methods and standards of medical practice and where concepts and sentiments are implanted in young and developing minds. Although it is primarily the doctor's responsibility to utilize knowledge of the patient as a person in the treatment and management of chronic illness, he needs assistance in gathering information about the patient's personal and social problems. For this information he must often rely in hospital practice on the professionally trained medical social worker. Our study indicated that there was a definite need for greater development of medical social work and for the cultivation of social workers as close collaborators with physicians in hospital practice. The study also emphasized that an intimate relationship between doctor and patient is a fundamental factor in medical care, and that something has been lost in this respect by the increasing specialization of doctors in university teaching hospitals. The study as a whole demonstrated the value of giving greater consideration to the patient as a person, both in medical care and in teaching, and furnished a useful background for further investigations of the social aspects of illness. 275

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The Study of Industrial Conditions In December 1937 the National Academy of Sciences appointed a committee on "Work in Industry" of which I was a member. The functions of the committee were to review and evaluate scientific studies that had been made or were in progress bearing on the physiological and psychological discomfort and distress of industrial workers and to correlate these studies in order to make them generally available to American industry. The committee was formed at the suggestion of the conference of the National Research Council on industrial labor conditions and was part of the effort being made to improve industrial organization in this country at a time when the world was threatened with a war which in less than a year became a reality in Europe. The chairman of the committee and its leading spirit was Lawrence J. Henderson, professor of biochemistry at Harvard. Other members were W. S. Hunter, professor of psychology at Brown University; Elton Mayo, professor of industrial research at the Harvard School of Business Administration; G. A. Pennock, manager of the Hawthorne Works of the Western Electric Company; and F. W. Willard, president of the Nassau Smelting and Refining Company. In a few months Pennock resigned and was replaced by Harold J. Ruttenberg, research director, Steel Workers Organizing Committee of Pittsburgh. I enjoyed especially my association with L. J. Henderson, one of our most distinguished biochemists and a brilliant medical philosopher, and with Elton Mayo, a bright-minded Australian, who studied the problems of industrial workers with much the same attitude I was using in studying the social problems of patients. It was also interesting to hear labor unions discussed intelligently and with insight by Ruttenberg, and to hear the views expressed by the broad-minded industrialist, Willard, on social problems of industrial workers. Numerous meetings were held in New York either by the committee alone or with members of the National Research Council conference on industrial labor conditions, and at these meetings reports on scientific studies were presented by those directing and conducting them. George C. Homans of the Harvard department of sociology was appointed secretary of the committee and brought together its reports and discussions in a book entitled Fatigue of Workers: 276

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Its Relation to Industrial Production, published in 1941. The various topics that were discussed show the breadth of interest of the committee, which was concerned with what happens to people in everyday life. The first reports were made by D. B. Dill and Ross A. McFarland from the fatigue laboratory at Harvard and concerned the effects of heat and high altitude on industrial workers. I gave the next report on some industrial causes of illness, and discussed some of the cases I had studied in which industrial conditions were a cause of illness. The extensive studies on social factors related to the daily output of industrial workers conducted in the Hawthorne Works of the Western Electric Company were reported by H. A. Wright and his associates, and were especially interesting to the committee. Elton Mayo discussed the value of systematic interviews as a method of conducting psychological studies in industrial plants, advocating much the same procedures as those we were using in our social study of patients. H. J. Ruttenberg discussed selfexpression and labor unions, and Jacob J. Blair of the University of Pittsburgh reported his studies on the methods of determining extra-time allowances for industrial workers. Finally, Chester I. Barnard, who was then president of the New Jersey Bell Telephone Company and later president of the Rockefeller Foundation, led a discussion on industrial organization based on his recent book, The Functions of the Executive. Some of the important conclusions reached in the analyses and the investigations reported were summarized at the end of Fatigue of Workers. The book was a unique contribution to knowledge about fatigue in industry and its relation to industrial production. The Study of Patients with Digestive

Symptoms

During the time interest was being given to the problems of industrial workers, a new study was begun in the gastrointestinal clinic of the Johns Hopkins Hospital. This study was planned with Moses Paulson, a member of the staff of that clinic who was particularly interested in the relation of gastrointestinal symptoms to emotional disturbances. We agreed that he would refer to me all his clinic patients after he had completed the study of their physical condition, and that I would investigate their social and personality problems. Although we knew that emotional disturbances frequently caused digestive symptoms, 277

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we realized that inadequate consideration was being given in the clinic to the separation of psychogenic symptoms from those caused by organic disease. A total of 50 patients routinely assigned to Dr. Paulson was investigated, and we were surprised to find that interviews, home visits, and personality studies revealed that 38 patients or 76 percent of the group had emotional disturbances which were the major cause of their illnesses. There were only 6 with demonstrable disease of the digestive tract and only 13 needing treatment by the special methods of the gastroenterologist. The 38 patients with what we called personality disorders suffered from excessive emotional or hypochondriacal reactions, depression, hysteria, or anxiety attacks; all needed treatment for their psychoneuroses rather than for their gastrointestinal complaints. Nearly all these patients responded favorably when given an understanding of the true nature of their illnesses and persuaded to change their attitudes toward health and to alter their habits of thought. An example of the value of these procedures was a twenty-one-year-old baker, who for seventeen months had suffered from attacks of choking, palpitation of the heart, and difficulty of breathing which came on when he attempted to eat. Recently, the attacks had been so severe as to make him think he was about to die. These were typical anxiety attacks, for which the physical examination, including x-ray studies, revealed no cause. During the interview the patient said with reluctance and hesitation that he feared he had tuberculosis. He then told how he had been unable to put out of his mind the death of a young man who had lived next door to him and whom he had greatly admired. He had seen this young man gradually succumb to tuberculosis and die just at the time his wife had had a baby. The patient's mother had kept this episode in his mind by telling him as he grew up that if he did not take care of his health and go to bed early, he too would get tuberculosis. She succeeded in planting this idea in his mind, and it blossomed forth as a fixed anxiety at the time of his marriage seventeen months before he was seen in the hospital. His symptoms became worse as the time drew near for his wife to have her first baby. He was very unhappy and had been obliged to cease working. The patient was greatly relieved when told that he had no evidence of tuberculosis and was in no danger on that score. His symptoms entirely disappeared after I visited his mother's house and told her 278

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emphatically, in his presence, never to mention tuberculosis again. Two weeks later the baby had been safely born, and the patient was back at work, a changed and happy young man with all symptoms gone. An example of how hypochondriacal reactions can be dispelled was the case of a cheerful looking thirty-five-year-old housewife who had had abdominal discomfort for three years and constant pain during the past year. Her examination, including x-ray studies of the gastrointestinal tract, failed to reveal any abnormalities. After we had become well-acquainted she confessed that she thought she had cancer, but had feared to mention this before, and had made all her funeral arrangements before coming to the hospital—as she thought, to die. She related how her symptoms had begun one Saturday afternoon three years before as she listened to a description of the symptoms of cancer of the stomach included in a radio talk on cancer prevention. Since then she had never missed this weekly program, a so-called health broadcast, and had read all she could find regarding health in the newspapers. She was persuaded to give her thoughts to her garden and chickens in the country where she lived, and to stop ruminating on her death from cancer, of which she had no signs or symptoms. Three months later she wrote that all her digestive symptoms had disappeared and that although she felt "very nervous" at times, our talks had changed her outlook regarding her health and that she no longer worried about it. Both of the foregoing cases show how important it may be to establish an intimate and cordial doctor-patient relationship. Both these patients were reluctant to disclose the emotions which were the key to their illnesses, and did so only after they felt convinced that they could talk to a doctor particularly interested in them as persons. The systematic study of this group of 50 patients clearly demonstrated the frequency with which emotional disturbances cause digestive complaints and the necessity of investigating the personal and social problems of these patients. It also pointed out that if these patients are to receive adequate care, they must be treated by psychotherapy after their difficulties have been identified. Other Studies and

Teaching

Other studies were made on the social problems of tuberculosis patients and also on the personality problems of patients 279

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with asthma, but these were interrupted by a request that I undertake work related to preparations for the impending war. During the years devoted to the study of the social aspects of illness, there were opportunities to disseminate the results of our studies in various directions in addresses and publications. These included a paper on emotional factors causing illness in industrial workers, published in Belgium; a presentation of our teaching methods before the Association of American Medical Colleges; and discussions of the significance of social problems in medical practice before audiences especially interested in medical social work. Discussions of the patient as a person in convalescence, in the practice of public health, and in the outpatient services of hospitals were also presented. I was particularly interested in addressing a large group of potential patients at the Health Education Forum of the Group Health Association in Washington, D.C. This occasion gave me the opportunity to emphasize the value of an intimate doctorpatient relationship and to discuss the attitude the patient should take not only to encourage this relationship but to demand from the medical profession greater interest in the patient as a person. This address was printed by the Group Health Association and distributed to all its members. In a paper on the study of the patient as a whole as training for medical practice, presented in 1938, I stated that if medical students are to understand illness and its treatment in a broad sense, they must be taught to consider the patient as a total individual and they must learn to appreciate the significance of social and environmental problems as a part of medical care. This concept had begun to be widely recognized by medical teachers, and various plans aimed at the development of interest and skill in dealing with the patient as a person were being inaugurated in medical schools. Programs of teaching for the study of the personal and social problems of patients had by then been introduced into the curriculum of at least thirteen medical schools in this country, and various methods for conducting them had been instituted. Since that time interest in this form of education has been greatly extended, and it has always given me a sense of satisfaction to have been among the pioneers in this field of teaching.

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WAR SERVICE AND POST-WAR ACTIVITIES -< 1 9 4 1 - 1 9 5 5

I

N July 1941 my summer vacation on Long Island was interrupted by a telegram from Lewis H. Weed, chairman of the Division of Medical Sciences of the National Research Council, asking me to come to Washington for a conference concerning the blood donor service being organized by the American National Red Cross and the National Research Council. On my arrival in Washington, Lew Weed gave me a brief account of what was contemplated and asked me if I would undertake the organization of the service. This was, of course, before the United States was drawn into World War II; the attack on Pearl Harbor was nearly five months away. The problem at that time was to create an organization that would operate through the Red Cross to obtain enough blood from voluntary donors to provide 200,000 units of dried plasma for the Armed Forces—the estimated amount needed should our country become involved in war. THE

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After conferring with Weed and with DeWitt Smith, vice chairman of the American National Red Cross in charge of domestic services, I accepted the position of national director of the Red Cross Blood Donor Service and took office on July 21,1941. It was thought that about six months would be required to complete this project; and, as it seemed sufficiently important and urgent to require my full time for a few months, I arranged a leave of absence from the Johns Hopkins Medical School. There was 281

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then no indication that I would have to devote myself very actively to this service f o r four and a half years. Pre-War Status of Blood Transfusions The various steps leading to the decision to organize a blood donor service as a preparation f o r war are interesting. It had long been known that blood transfusions were of great value in saving the lives of battle casualties, but it was realized that many difficulties were involved in procuring blood and in giving transfusions under battle conditions. A f t e r war broke out in Europe in 1939, it was clear that this country might be drawn into the conflict. The experience of World War I had shown the need f o r carefully considering the problem of blood transfusions if our armed forces should be fighting f a r f r o m home. During World W a r I the use of blood transfusions to combat shock and hemorrhage among the wounded of the American Expeditionary Forces led to the realization that methods then available were quite inadequate and that the use of stored blood was impractical under conditions of modern warfare. In the interval between the two wars, medical research had made notable progress in the use of blood transfusions. It had been discovered that the condition known as traumatic shock, which frequently follows severe injuries, loss of blood, and burns, is caused primarily by loss of fluid which diminishes the volume of the blood in circulation and leads to collapse and death. I t had also been found that blood plasma or blood serum, the fluid portion of the blood f r o m which the cells have been removed, is often as effective as whole blood in restoring the volume of blood in circulation and thereby combatting the immediate symptoms of traumatic shock. Experience in the field of blood transfusions had demonstrated practical methods of collecting blood from donors, of separating the blood cells from the plasma, and of administering the plasma f o r the successful treatment of traumatic shock, burns, and hemorrhage. In several laboratories the problem of preserving plasma in a dried state had been studied and a method had been evolved by which dried plasma could be preserved almost indefinitely and dissolved in water immediately before being used f o r transfusion. This greatly increased the ease with which blood could be transported and made available under conditions of war. On the basis of this knowledge concerning blood plasma, four 282

WAR SERVICE AND POST-WAR ACTIVITIES coordinated activities were carried on in 1940 which formed the background for the development of the blood donor service. The Army and the Navy each appointed a well-qualified medical officer to devote his full time to the study of the blood and its derivatives and their uses for military purposes. Captain Douglas B. Kendrick was assigned to this duty by the Army, and Commander Lloyd R. Newhouser by the Navy. Milton V. Veldee, chief of the Biologies Control Laboratory of the U.S. Public Health Service collaborated with them in developing methods of preparing plasma and in establishing standard procedures to be followed in procuring blood from volunteer donors. Through its Division of Medical Sciences, the National Research Council formed a committee on traumatic shock under the chairmanship of Walter B. Cannon of Harvard University, which consisted of the leading scientists working on various problems related to shock and its treatment. A subcommittee, of which Robert F . Loeb of Columbia University was chairman, was appointed to study blood substitutes, and another committee, with Cornelius P. Rhoads of the Memorial Hospital of New York as chairman, was formed to standardize methods of blood procurement. The blood donor service was integrated with these subcommittees responsible for promoting research into blood transfusion and for solving the technical problems of the service. A third activity of particular significance was a project in which the Blood Transfusion Association of New York and the American National Red Cross joined in collecting blood from voluntary donors and in processing the liquid plasma for shipment to British troops. From this activity, known as "Blood for Britain," much was learned about methods of collecting and handling blood and about procuring and properly treating donors. At the same time Sharp and Dohme, a pharmaceutical company, was developing methods for the mass production of dried plasma in their laboratories at Glenolden, Pennsylvania. Through the cooperation of all participants, these four projects were successfully integrated, and the foundation was laid for the wartime blood donor service. The War Service The Red Cross Blood Donor Service was inaugurated in February 1941 when the Surgeon Generals of the Army and of the Navy joined in requesting the Red Cross and the National 283

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Research Council to organize a cooperative undertaking for the procurement of blood plasma. This request specified that the Red Cross was "to secure voluntary blood donors in a number of the larger cities of the country, to provide the necessary equipment, to transport the drawn blood to a processing center, to arrange for separating the plasma and for storing the resulting product in refrigerated rooms." The National Research Council was requested to assume general supervision of the professional services involved in the collection of the blood and the storage of the plasma, and to provide competent professional personnel, both for a national supervising group and for the centers in which the blood would be procured. The Council was also requested to continue to encourage investigation of various forms of blood substitutes and of other phases of the transfusion problem. The committee of the National Research Council that worked actively throughout the war on these problems, under the chairmanship of Robert F. Loeb, was composed originally of Edwin J. Cohn, Elmer L. De Gowin, Cornelius P. Rhoads, John Scudder, Max M. Strumia, and Owen H. Wangensteen; a few personnel changes occurred later. The members of this committee, in cooperation with representatives of the Army, the Navy, and the Public Health Service, made possible important scientific and technical advances and improved and extended the project during the war. When I assumed office as director in July 1941, the blood donor service was on its way toward meeting its goal of 200,000 units of dried plasma. Blood donor centers had already been organized by the Red Cross chapters in New York, Philadelphia, and Baltimore, all of which had previously had some experience in procuring blood from voluntary donors. The Navy had also begun to procure blood from donors in Washington to provide material for experimental work in the Navy and Army laboratories. The Red Cross chapters in Buffalo and Rochester had organized blood procurement facilities through the direction of Dr. William De Kleine, medical adviser on the staff of the Red Cross national headquarters in Washington, and were about to begin small projects in hospitals. The Army had contracted with seven pharmaceutical companies to process dried plasma from the blood supplied by the Red Cross. However, only the pioneer plant of Sharp and Dohme, in Philadelphia, was then in operation; it 284

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had contracted to process 50,000 units. Six other companies situated in or near Indianapolis, New York, Philadelphia, Cleveland, Berkeley (California), and Chicago had been awarded contracts to process 25,000 units each. It was, therefore, necessary for the Red Cross chapters near these companies to organize blood donor centers as rapidly as possible. The director's office in the Red Cross national headquarters was organized with a technical, a promotional, and an administrative division. The technical division was headed by Earl S. Taylor, a young, well-trained surgeon who had been in charge of blood procurement in the New York chapter. He served at first as a civilian, but was commissioned a major in the Army Medical Corps in April 1943. He was ordered to active duty in Europe a year later, after having rendered energetic and skillful service for three years in developing and directing technical procedures in blood donor centers throughout the country. In August 1944 Taylor was replaced by Henry S. Blake, a lieutenant in the Navy Medical Corps who had been ordered into noncombatant service after participating in the gruelling Guadalcanal campaign with the First Division of the Marine Corps. The promotional division was headed by Charles U. Coggin, Jr., who served as assistant national director in charge of the publicity and promotional activities used to bring the service to the attention of all people and to incite their interest in becoming blood donors. During the first few months, a Red Cross official, P. K. Betts, was in charge of financial operations. After he entered the Army, the director carried responsibility for the entire administration, ably assisted by Camilla S. Quinn, who had years of experience in the American National Red Cross. The initial activities of the director were to coordinate the work that was already under way and to set in motion an extensive educational campaign. By September 1941 the technical procedures prescribed by the National Research Council were published in a manual. This laid down the rules and regulations which were to be followed in all blood donor centers—the physical standards donors had to meet, the procedures to be carried out by doctors and nurses, the techniques of bleeding and of handling the blood, and the professional organization of the centers. In November a second manual, entitled Team Work from Publicity to Plasma, was issued. Its purpose was to stimulate general interest in the service and to inform those involved 285

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in its organization and operation regarding its origin, methods, and objectives. This manual contained material that was especially significant for recruiting donors; it was widely distributed to the Red Cross chapters participating in the service. The initiation of the service required visits to the Red Cross chapters selected to take part in the project for the purpose of meeting with their boards of directors, explaining the requirements of the service, requesting the directors to appoint blood donor committees and to employ full-time center directors. In each city a physician with experience in blood transfusions was appointed by the National Research Council to serve as technical supervisor, to recruit a staff of doctors and nurses, and to supervise professional operations in the center. When the United States was precipitated into war on December 7, 1941, ten blood donor centers were in operation, and four processing laboratories had begun production of dried plasma. After war was declared the service was expanded rapidly. Blood donor centers were established by Red Cross chapters in all the major cities from which blood could be quickly transported to processing laboratories. By the end of 1942 thirty blood donor centers were in operation, and nine laboratories were producing dried plasma. Later, five more centers were opened and three more laboratories were added, so that at the height of the program there were thirty-five blood donor centers and twelve laboratories engaged in collecting and processing blood. The blood procurement program was not limited to the centers. Mobile units went out from them—large trucks carrying complete equipment and personnel to collect blood donations in temporary stations set up by Red Cross chapters within a hundred-mile radius of a center. In all, sixty-three such units were operated, and about 47 percent of the total number of blood donations was obtained by the mobile units, which visited 2,200 Red Cross chapters and branches, 600 industrial plants, and 250 military establishments. Altogether, about 60 percent of the nation's population was within reach of the centers and their mobile units. When the blood donor service began at the end of 1941, 5,000 pints of blood a week were procured; gradually the amount rose to 50,000 pints a week during 1942, and to 100,000 pints a week by the end of 194B. This amount was maintained throughout 1944 and until centers began to close in May 1945. The greatest 286

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number of blood donations in one week was 123,000 in June 1944, when the Normandy invasion took place. In 1941, 48,504 pints of blood were secured; in 1942, 1,321,659; in 1943, 4,282,188; in 1944, 5,371,664; and in 1945, 2,302,227. The service was largely terminated between May and August 1945. A total of 13,326,242 pints of blood were given by the American people to the Armed Forces during World War II. The total Red Cross expenditure for the operation of the blood donor service was approximately $15,870,000. Of this amount $2,600,000 was expended by the local chapters and $13,270,000 by the national headquarters. The average expenditure was $1.19 for each donation of blood. The Armed Forces expended a much greater sum for equipment, processing, and transporting the blood and its derivatives. The costs of research were also considerable. At the peak of its activity the blood donor service involved Red Cross chapters from Portland to San Diego on the Pacific Coast, from Minneapolis to New Orleans along the Mississippi, and from Boston to Atlanta in the East. Both the director and the technical director had to make repeated visits to the various centers and laboratories for conferences and inspections. The Red Cross chapters asked to participate in the service were selected by the national office on the basis of their proximity to processing laboratories, the size of the communities in which they were located, and the probability that they could secure enough blood donors to meet the weekly quotas assigned to them. Each of the processing laboratories had a fixed capacity, and several centers usually combined to supply blood to meet this capacity. Each chapter selected appointed a blood donor committee, which was responsible for organizing the center and appointing a committee leader as chairman. At the same time the National Research Council committee designated the local technical supervisor. These were the people with whom the national office cooperated. On the basis of the projected weekly quota of blood donations assigned to the chapter, a suitable building was secured and equipped; a technical staff consisting of doctors, nurses, and blood custodians was organized, and the volunteer personnel for recruiting, receiving, and serving blood donors was developed. The great enthusiasm with which the Red Cross in every locality, and, in fact, the general public as well, entered into this service was gratifying; it was not sur287

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prising, however, as everyone felt the urge to contribute in every possible way toward saving the lives of our fighting men. The blood donor service was a veritable community-wide undertaking, stimulated constantly by a steady barrage of publicity over the radio and in the press, by virtually every type of promotional campaign, and by enlisting the cooperation of thousands of groups and organizations in the enrollment of donors. There was indeed remarkable "teamwork from publicity to plasma." The development and operation of blood donor centers were carried out with three primary objectives: the safety and comfort of the donor, the proper care and preservation of the blood, the conservation of Red Cross funds donated by the American people. All these factors were borne in mind in selecting the sites of the centers, in adapting a wide variety of buildings as blood donor centers, and in utilizing the services of carefully directed volunteer workers of whom there was never any dearth. A primary reason for the success of the service was the consideration given to the safety and comfort of donors. They were accepted on the basis that each donor could safely give one pint of blood, was between the ages of eighteen and sixty, had a normal temperature and blood pressure, and showed no signs of anemia. No one was permitted to give a pint of blood more frequently than once every eight weeks, and a comprehensive record, including the answers to prescribed questions and the results of the limited physical examination, was kept for each donor. Negroes were never excluded, but the use of their blood for transfusions created a useless emotional controversy which was settled by marking the tag on their bottles A.A. It was the supposition that it would be used for plasma to be administered to Negro troops. As this controversy was not based upon biological facts, the ultimate disposal of the blood so marked was never followed up, although the processing laboratories had instructions regarding its use. The number of persons rejected because of too low a level of hemoglobin in the blood or too high a blood pressure, or for some reason revealed by the history, was 10.5 percent of the total of 14,695,836 blood donor applicants. The problem of whether the withdrawal of a pint of blood caused anemia was carefully studied in a large number of persons who returned several times to donate blood, and sufficient evidence of anemia was found in women donors to justify giving them an iron com288

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pound to be taken for a specified length of time after the withdrawal of blood. Nearly 4 percent of the donors had immediate reactions (usually fainting) to the withdrawal of blood, and donors were always allowed a rest period under a doctor's observation if they felt in need of it. Coffee and light refreshments were always offered after donations, but no alcoholic drinks were allowed. The donors were graciously treated by Red Cross volunteers and were presented with a bronze lapel emblem and a certificate card before they left the center. Three-time donors were awarded a silver emblem; beneath this was attached a bit of red ribbon on the occasion of their eighth donation, which made them members of the "gallon club." This sort of courteous treatment was responsible for the confidence in the service which was generated throughout the population. In the entire service practically no complaints were received from donors concerning their treatment in the centers, and millions returned to give their blood again and again. Preservation

of Blood

A few points regarding the method of preserving the blood may be of interest. The blood was drawn into standard pint bottles that were delivered to the centers from the processing laboratories, where they had been sterilized and equipped with tubing and well-sharpened needles. Each bottle contained 50 cc. of a solution of sodium citrate which prevented the blood from clotting. The needle was introduced into the vein on the inside of the elbow, after the skin had been desensitized by an injection of novocaine. After the bottle was filled it was immediately turned over to a blood custodian who placed it in a refrigerator. At the end of each day the bottles of blood were packed in portable steel refrigerators, each holding eighty bottles. The refrigerators were transported to the laboratories on fixed schedules by Railway Express and were delivered within twenty-four hours. In the laboratories, the bottles were placed in centrifuges, by means of which the blood cells were separated from the plasma. After the plasma from fifty bottles had been pooled and found free from bacterial contamination, the amount from one pint of blood was transferred under sterile conditions to a bottle in which it was frozen and dried to a light brown powder and prepared for shipment to military receiving depots. This preparation consisted of sealing the bottle of plasma in a can con289

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taining a sterile needle and tubing, and packing it in a carton with a similar can containing a bottle of sterile distilled water and the small equipment needed to transfer the water into the plasma bottle. This transfer could be easily performed on the battlefield; the plasma dissolved quickly and was then ready for transfusion into the vein of a wounded soldier. A s experience showed that at least two such transfusions were usually needed, the amount of plasma and water in every other carton was subsequently doubled. Another change made during the war was to have the white labels on the cartons changed to dark green to make them less easily spotted by enemy snipers. This order from the Armed Forces made us at home realize that the plasma was actually reaching the front lines of battle. The complicated handling of the blood from the time of its withdrawal from the vein of a donor to the finished dried plasma was so well planned and so meticulously carried out that only 1.6 percent of the blood was lost through breakage, bacterial contamination, or any other cause. The record of the service in preserving the blood donations in this great mass production effort was considered remarkable. Improvements Resulting from Research Scientific investigation in a number of directions was pursued by many workers throughout the duration of the war, and at least two results of this research were conspicuous—the production of serum albumin and the preservation of whole blood. Through the work of Edwin J. Cohn and his associates at the Harvard Medical School, a method of obtaining serum albumin by the fractionation of blood plasma was developed. Serum albumin had been found to be the substance on which the beneficial properties of plasma depended. It is this fraction of blood plasma, more than any other, that possesses the essential property of maintaining or restoring the blood volume by virtue of its action, when injected into a vein, of drawing water from the tissues into the circulating blood and holding it there. Since the restoration of the normal blood volume is the primary factor in the treatment of shock, serum albumin can be used instead of plasma, and it is particularly advantageous f o r military purposes because it can be preserved and administered in a concentrated liquid form which requires for equivalent therapeutic value a much smaller container and no bottle of water. 290

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Methods were developed for the mass production of serum albumin in containers holding 100 cc. of a 25 percent solution, and about 2,330,000 pints of blood were distributed among the seven laboratories that undertook the complicated process of serum albumin production. The value of serum albumin in the treatment of shock was amply demonstrated during the war, although dried plasma was the mainstay throughout most of the fighting. There were times when serum albumin was available while plasma was not; it was especially valuable in paratroop missions, small vessel naval operations, and other highly mobile situations where space and weight were of primary importance. During the terrific fighting on the beaches of Normandy the value of serum albumin was proved; the medical corps was able to move to off-shore ships seriously wounded men who would have died had serum albumin not been available. The preservation of whole blood to allow its transportation from this country to foreign battlefields presented a problem which was solved in time to be of great value in the treatment of the seriously wounded. At the beginning of the war transportation of whole blood was impractical, for untreated blood deteriorates rapidly and becomes unsuitable for transfusion within a few days. However, it became evident in the treatment of battle casualties, especially those who had lost much blood, that transfusions of whole blood were frequently needed to supplement the administration of plasma. A number of workers studied the problem, and an effective method of preserving blood was developed. Blood treated by this method was safe and efficient for transfusions for at least 21 days after it was withdrawn from the donor. A rapid and simple method of typing the blood was also developed; this procedure allowed the selection, for wholeblood preservation, of type "O" blood, which can be safely given to anyone. Special refrigerators that could be transported by airplanes were also devised, and a system of distributing blood by air was inaugurated. By August 1944 whole blood began to be delivered to the European battlefields, and by November the more complex distribution of whole blood to the Pacific theater of war was begun. This was a great boon in the treatment of battle casualties. Over 200,000 units of whole blood were sent to Europe, and a nearly equal amount went across the Pacific Ocean; a total of 387,462 units was distributed to the Armed Forces overseas. This service was greatly appreciated by the 291

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medical corps. One medical officer reported giving blood transfusions to casualties of the battle of Leyte seven days after the blood had been withdrawn in this country, and with excellent results. The procurement of blood by the Red Cross was terminated by closing the blood donor centers as fighting in Europe, and later in the Pacific, ceased. By September 15, 1945, the service was completed, and I resigned as its director at the end of the year. The Value of the Service

The Red Cross Blood Donor Service was a war effort which was carried out with good will, energy, and thoughtful cooperation by a great many people. The response of the American people to the call to donate their blood was a stirring example of their desire not only to contribute to winning the war, but to make every effort to alleviate the inevitable suffering of war. The work of the Blood Substitutes Committee of the National Research Council and of those associated with it was of great importance from the time the service was inaugurated until its task was finished. Many scientific and technical problems were solved by the members of the committee and by those who cooperated with it, and to them belongs the credit for making the service possible. The value of plasma and whole blood transfusions in saving the lives of great numbers of our fighting men was attested to by those who directed the war on the battlefield, on the sea, and in the air. The great advantage of dried plasma was that it could be administered to the badly wounded on the field of battle in a matter of minutes, sometimes on the spot where the soldier fell. It was of much value both in preventing the occurrence of traumatic shock and in arresting its frequently fatal course; it thus made possible the transportation to dressing stations and hospitals of many wounded who would have died on the field of battle. The knowledge that plasma was available at the front was an appreciable factor in maintaining the morale of the fighting men. When it became possible to fly whole blood to the theaters of war, the medical services had the ideal combination for saving the lives of the wounded by transfusions. Plasma had its unique usefulness right at the front in tiding men over the critical 292

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period directly after severe wounds had been inflicted; whole blood was essential for those who had had severe hemorrhage or who needed immediate surgical operations. The combination brought through to recovery hundreds of wounded men who would otherwise have perished. The records of military hospitals show that the mortality of those admitted to hospitals was reduced from 8 percent in World War I to 4 percent in World War II. The use of blood and blood derivatives was given much credit for this remarkable saving of life, although improvements of military medical organization, the use of new drugs, and the general advance of medical knowledge share the credit. General Norman T. Kirk, Surgeon General of the Army, stated that "plasma and whole blood rank among the truly great life savers in the war"; Vice Admiral Ross T. Mclntire, Surgeon General of the Navy, said that "our low mortality rate among the wounded, less than half of that of the last war, is due in large part to the use of whole blood and plasma from volunteer donors back home. Thousands of men are alive today because someone, somewhere, took the time to donate a pint of blood." During the battle of Okinawa 40,607 blood transfusions were administered, and General Joseph W. Stillwell, commanding the Tenth Army, stated that many of the wounded would have died except for the availability of blood transfusions. Dwight D. Eisenhower, then general of the Army, said: "If I could reach all America, there is one thing I would like to do—thank them for blood plasma and whole blood. It has been a tremendous thing." It is naturally a great satisfaction to have participated in the Red Cross Blood Donor Service during World War II. This great humanitarian service was possible because our medical schools had trained members of the profession to carry out skillfully and efficiently complicated technical procedures, and because the American universities had developed scientists capable of solving through medical research many of the problems related to the use of blood transfusions under conditions of modern warfare. TUBERCULOSIS

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While on leave of absence from Johns Hopkins, serving in the American National Red Cross, I reached the age of retirement from the university, effective on July 1, 1946. As only a 293

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few months remained after the blood donor service was terminated at the end of 1945,1 accepted the appointment of executive secretary of the Maryland Tuberculosis Association, which was at that time in need of a guiding hand. In November William B. Matthews, the executive secretary for over twenty years, had died. During the period of the war many activities had been suspended, and the association needed a thorough overhauling. Beginning January 1, 1946, I resigned from its board of directors, of which I had been a member for a number of years, and undertook the reorganization of the association. There was no thought at that time that I would remain in office until April 1, 1955, a period of over nine years. The Maryland Tuberculosis Association is a component of the National Tuberculosis Association and serves as the local association in Baltimore City as well as the state organization with affiliated associations in all the counties of Maryland. It is almost entirely supported by the well-known Christmas Seal sale through which over $20,000,000 a year are raised nationally (as much as $500,000 being raised in Maryland in 1955). While World War II was in progress, the tuberculosis program in Maryland had to mark time, and at the close of the war there were many needs to be met—not only in the association but also in the state and city health departments and in the public tuberculosis hospitals—in order to raise their standards to those advocated by the U.S. Public Health Service and by the National Tuberculosis Association. The Maryland association was in a favorable position to work toward many of the needed improvements, as it was coordinated with the official tax-supported health departments through the membership of their leaders on its board of directors. The first task before the association was to put its own house in order, and the first step in that direction was to invite the National Tuberculosis Association to study the situation in Maryland and to recommend a program of improvement. On the basis of these recommendations, the board of directors was reorganized under a new constitution and by-laws, the antiquated building owned by the association was remodelled, and the staif was enlarged. In 1945 the U.S. Public Health Service undertook to help the states to improve their programs of tuberculosis control by granting federal funds to state health departments. These funds 294

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would enable the states to develop a fourfold program: to discover cases of tuberculosis, to isolate and treat tuberculous patients, to rehabilitate patients for safe living and self-support after recovery, and to protect patients and their families against social and economic hardships. To assist in the development of this program in Maryland the Public Health Service not only began to make annual grants to the state department of health, but also assigned two of its medical officers who had special training in tuberculosis to the state and to the Baltimore city health departments. Through these funds and under the direction of these medical officers, a case-finding service was widely developed in Baltimore and throughout the state. This service provided transportable equipment for the x-ray examination of the lungs of large numbers of healthy people assembled for the purpose. Through these facilities, small x-ray photographs of the lungs could be taken, by which early tuberculosis could be detected. The association cooperated both financially and technically in these services. The Maryland State Tuberculosis Survey

In order to obtain expert advice on the needs in Maryland for a state-wide program of tuberculosis control, in 1947 the medical care committee of the Maryland State Planning Commission appointed a survey committee, under the chairmanship of the executive secretary of the association, and arranged to have the association finance its work. First, an extensive study of the Maryland situation was made by Dr. Henry D. Chadwick of Massachusetts, to determine the facilities needed for an effective and comprehensive program of tuberculosis control. Some months later, Dr. Edward X. Mikol of the New York State Department of Health reviewed the situation and submitted a full report with specific recommendations. On the strength of this report, a Division of Tuberculosis of the Maryland State Department of Health was organized to operate the state-sponsored tuberculosis hospitals and clinics and to improve generally the program of tuberculosis control. In 1949 the Maryland state legislature appropriated nearly $6,000,000 for a new 300-bed tuberculosis hospital and for additions and improvements in two other state hospitals. At the 1948 election in Baltimore, the city was authorized to borrow $8,000,000, through a bond issue, for improved health facilities. 295

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Part of these funds was expended for a new 300-bed tuberculosis hospital to replace a disgraceful old building used to house Negro tuberculous patients. Another splendid tuberculosis hospital of equal size was built in Baltimore by the Veterans' Administration. This latter hospital was opened on October 22, 1952; the new state hospital on February 26, 1953; and the new Baltimore city tuberculosis hospital on May 1, 1953. With these new hospitals Maryland had, for the first time, adequate facilities for all the tuberculous patients needing hospital care and was able to provide for their isolation, so that they would no longer be an uncontrolled source of infection to others. These three hospitals represented an investment of about $12,000,000—one of the largest developments ever carried out at one time in this country for the treatment and isolation of tuberculosis patients. Beyond efforts to educate the public and the legislators regarding the urgent need and value of these hospitals, the tuberculosis association took no direct part in their construction and operation. However, it constantly carried on a program υι' health education aimed at adult groups and school children, conducted an x-ray case-finding service, served as the link between the national and local associations, and assisted the official state and city health and welfare services in their tuberculosis programs. Social Service in Tuberculosis

The control of tuberculosis requires a combination of medical and social services, and I was particularly interested in the social problems of patients suffering from this protracted disease. We therefore took a leading part in initiating medical social service in the tuberculosis hospitals and in the "chest clinics" of the city health department. Miss Amy W. Greene was secured for a year to organize the social work in the state hospitals. She had directed the medical social service in the Johns Hopkins Hospital for a number of years and had recently worked in the tuberculosis field; she was, therefore, especially well qualified to initiate this service in Maryland. After her year was over, she was succeeded by Miss Frances Clay, who ably maintained the high standards Miss Greene had set and developed social case work in tuberculosis into a well-organized service in the state hospitals. With the cooperation of Robert C. Thompson, director of 296

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the Vocational Rehabilitation Service of the Maryland State Department of Education, the association inaugurated workshops for convalescent patients in the hospitals. This service, conducted under the direction of Miss Myrtle E. Chell, was of much value in preparing patients for living safely and supporting themselves after they were discharged from the hospital. This type of rehabilitation was supplemented by occupational therapy for bedridden patients and for those in early convalescence. With the cooperation of the Library Extension Division of the Maryland State Department of Education, libraries were developed in each hospital. They were directed by qualified librarians, who, by means of a book-cart service in the wards, stimulated and guided the reading and other mental activities of the patients. Academic studies supervised by qualified teachers were also furnished, for which patients could receive public school credits; a few patients were awarded high school diplomas partly on the basis of their studies in the hospitals. A fine spirit of teamwork developed among all those engaged in conducting the social services in the hospitals. Their efforts were appreciated by the doctors and nurses of the medical staff who, in turn, gave to the social aspects of medical care their enthusiastic support and leadership. The combined endeavors of the medical and social service staffs were effective in reducing the number of patients who left the hospitals against medical advice; thus a solution was afforded to one of the most serious problems in adequate treatment and control of tuberculosis. Through the close contact of social workers and patients, it was found that about one third of the hospital cases were destitute and had no family resources. As patients in public hospitals are legally ineligible for public relief, these people had no money for clothing, incidental expenses, or other needs, such as false teeth, for which no state funds were available. After a detailed study of the needs of these patients, the association established a fund on which the social workers could draw to provide the aid these patients required. A clothing service was organized, and a small monthly cash allowance was provided, so that these patients would not be entirely without such things as newspapers, cigarettes, and cosmetics. This service was considered another reason why a smaller number of patients left these hospitals against medical advice than left most tuberculosis 297

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hospitals. Another useful service was conducted by a staff member of the association designated the supervisor of volunteer services. The supervisor organized the social and recreational activities carried on by volunteers and coordinated volunteer services with the administrative and professional operations of the hospitals. This service proved particularly useful at Christmas, when literally hundreds of organizations and individuals almost swamped the hospitals with their efforts to brighten the Yuletide of the patients. Teaching, Research, and Health Education

I was especially interested in working out a project for the improvement of the study and teaching of tuberculosis in the Johns Hopkins Medical School. When this project was formulated the association made an annual grant to support a faculty position, a social worker, and a secretary who would devote their full time to organizing the care and public health aspects of tuberculous patients in the wards and outpatient department of the Johns Hopkins Hospital, and to teaching in this field. Dr. Miriam E. Brailey, in charge of this work, had had long experience in tuberculosis, and she stimulated much interest in the disease among the students and staff. Research in tuberculosis was for the most part assisted and directed by the National Tuberculosis Association with funds contributed by the state associations specifically for this purpose. However, the Maryland Tuberculosis Association, with the approval of the national director of research, participated in the support of valuable research projects conducted by the tuberculosis bureau of the Baltimore City Health Department and by the Veterans' Administration. Such projects added an academic interest to the work of the association. While improvements of facilities were going on in Maryland, other factors were also affecting favorably the tuberculosis situation. A natural decline in tuberculosis was taking place which seemed to stem from the higher standards of living and of hygiene and from the marked improvements in the treatment of the disease that were being rapidly developed. The death rate from tuberculosis fell steadily after World War II, partly because a much larger number of those contracting the disease recovered, and partly because fewer people were being infected. The latter situation was the result of the long and seemingly successful 298

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battle against the disease by the means which scientific research had placed in the hands of a well-trained and well-organized medical profession. The year 1946 was a favorable time to have become identified with the fight against tuberculosis, and my adventure in this field was especially timely because the opportunity was at hand to contribute toward the control of the disease through the development of social services that could alleviate some of its oldest and most pressing problems. By April 1, 1955, I was convinced that the time had come to retire to village life and to devote myself to writing a book. Although the experiences in the Red Cross Blood Donor Service and in the Maryland Tuberculosis Association were outside of the field of medical education, they provided opportunities to observe the results of the great movement in medicine, begun at the turn of the century, which had raised medical education to new levels and had brought it into our universities. The outcome of this revolution was the training of many scientists capable of conducting research that increased medical knowledge; this knowledge was applied very effectively by a superior medical profession to supply blood for transfusions to those wounded in battle and to carry forward successfully the fight against tuberculosis. It is interesting to speculate on the value of the blood donor service and the case-finding program of the Maryland Tuberculosis Association as agents of mass health education, and on their effect on the general health of the population. The millions of people who donated blood made contacts with the medical profession and either found they were physically fit to give a pint of blood or that they were in need of further medical attention. All those found unfit, about 10 percent of the total number, were advised by doctors in the blood donor centers regarding their need for medical care by their private physicians. The tuberculosis case-finding program in Maryland, which provided over 200,000 chest x-ray examinations a year, was part of a similar service that was carried out in every state and that reached millions of people annually. Here again, great numbers of people were brought in contact with medical procedures, and opportunities were presented for extensive mass health education, as well as for detecting early signs of an insidious and serious disease. 299

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It is natural that these far-reaching contacts of the American population with the medical profession created an awareness of the value of good health and increased the public's reliance on medicine based upon a scientific foundation. These services were surely of value, not only because they achieved their immediate objectives, but also because they provided an opportunity for mass health education which should have an effect on the future health of the nation.

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HALF A CENTURY OF PROGRESS IN MEDICINE URING the past fifty years great changes have taken place in medicine, and medical education has undergone a veritable revolution. I have had the good fortune to have my medical career coincide with what Simon Flexner has called "The Heroic Age of American Medicine," and as I have reviewed my experiences in this age, in writing this book, a flow of events that mark the course of progress of medical education has become discernible. Now I wish to review briefly the most significant of these events to show how they are related and how important concepts have been developed.

D

The Evolution of Medical Education Modern concepts of university education began to be applied to medicine in the latter part of the nineteenth century, under the influence of a few forward-thinking educational leaders like Charles W. Eliot of Harvard and William Pepper of Pennsylvania. At about the same time, in 1875, Daniel C. Gilman was appointed president of the new Johns Hopkins University and organized the first American graduate school devoted to scholarship and research. It is important that Gilman believed this form of education should be extended to medicine and that he had John Shaw Billings as his associate. Billings, as has been related, not only designed a teaching hospital then far in advance of any other like American institution, but formulated a plan for the development of a medical school in the setting of the hospital and the new university that ultimately exerted great influence on the advancement of medical education. The story has been told of how the Johns Hopkins Medical School was established in 1893 301

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under the leadership of William H. Welch and William Osier, and how it developed as a strong research-centered institution and adopted university standards to a degree that no other medical school had previously done in this country. The conspicuous progress in medical education that began under the leadership of Johns Hopkins and a few other university schools, created much dissatisfaction with existing medical education, as it became evident that unendowed proprietary schools, dependent solely on students' fees for their support, were becoming quite incapable of coping with the expansion of medical knowledge and technique that had to be incorporated into medical teaching. This situation led the Carnegie Foundation for the Advancement of Teaching to undertake a study of American medical schools. This was initiated in 1908 by Abraham Flexner. Untrained in medicine but expert in the field of education, Flexner was convinced of the advantages of the university system. He accepted Johns Hopkins as his ideal for a medical school and Dr. Welch as the ideal medical teacher. It was indeed fortunate that high academic standards had been established at the Hopkins and that Flexner was such a tireless, intelligent, and persuasive advocate of these standards. The famous Report Number Four, published in 1910, exerted great influence on the future of American medical schools. Flexner succeeded in separating "the sheep from the goats," and while he offered encouragement to the good schools to develop new university standards of education and to seek increased financial support, the discouragement he gave the poor schools caused many of them to retire from the scene. By advocating the standards of medical education which he had absorbed at the Hopkins, Flexner was largely responsible not only for the obliteration of hopelessly inadequate medical schools, but for the initiation of a great wave of philanthropy in support of medical education. It was at this time, during the first twenty-five years of the present century, that the great revolution occurred. The most tangible evidence of this upheaval was the transfer of the teaching of medicine from proprietary schools to universities. The privately endowed universities obtained large amounts of money for the support of medical education, for teaching hospitals, and for other facilities; state-supported universities received funds derived from taxes for these purposes. The American people had become aware that well-trained physicians, advance302

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ment of medical knowledge through research, and organized medical services are necessary to maintain and advance the health standards of the nation and of the individual, and that a high quality of medical education is the fundamental requirement for these purposes. Another result of the accomplishments at Johns Hopkins was the interest they aroused in medical research. It was this interest that directed the great Rockefeller fortune toward medicine as its principal field of philanthropy. The founding of the Rockefeller Institute for Medical Research and the extensive support of medical education through the contributions of the General Education Board constituted pioneer activities that were influential in focusing the attention of other philanthropists on medicine as the best medium through which to contribute to the advancement of human welfare. These events were linked with the Flexner report by the fact that not long after the completion of his study of medical education, which demonstrated the great need for financial support, Flexner became secretary of the General Education Board and took an important part in directing the expenditure of large sums of Rockefeller money. Both in the organization of the Rockefeller Institute and in the support of medical education and research, William H. Welch continued throughout his life to serve as the wise, statesman-like adviser to the Rockefeller interests. During the rapid evolution of medical education, the American foundations created by men or families of wealth have taken an important part in advancing medicine and health through their support of medical schools. The early contributions of the Carnegie Corporation and especially of the General Education Board and the Rockefeller Foundation were of outstanding value in providing the resources that enabled some of the medical schools to adopt the educational standards required for the new university relationships. This situation is exemplified by the reorganization of the Vanderbilt University School of Medicine. At the same time, largely through Abraham Flexner's influence, this type of expansion was being supported by individuals such as Robert Brookings and his associates in St. Louis, Payne Whitney and the Harkness family in New York, George Eastman in Rochester, the Duke family in Durham, North Carolina, and a group of wealthy sponsors of the University of Chicago—to name a few of the benefactors. The twenty-five years beginning 303

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in 1910 have been called the "Golden Age of Medicine." During this period $500,000,000 were contributed to medical education, including the endowment of schools and teaching hospitals and the building of plants for teaching and research. This represents the most extensive educational development ever undertaken in so short a time. The great philanthropic foundations have always been staffed by highly intelligent, well-educated men, who have advised the trustees as to where funds were especially needed and would be wisely and effectively spent. These staff members, following the lead of Abraham Flexner, form a group of medical statesmen who have greatly influenced the progress of medical education and at the same time have refrained to a remarkable degree from directing the policies of the schools they have aided. The reports of the various foundations contain much valuable information regarding the progress of medicine and the new steps being supported in the advancement of research and education. The leading foundations particularly concerned with medical support have chosen somewhat different fields for their beneficence. The Rockefeller Foundation, through its division of medical sciences, has been especially concerned with the cultivation of research and with the development of psychiatry. The Commonwealth Fund has, in recent years, shown a special interest in medical education, particularly the pregraduate course, and has not only sponsored educational experiments, but has assisted a number of schools in maintaining and elevating their academic standards. The John and Mary R. Markle Foundation has strengthened teaching personnel by providing long-term, wellpaying fellowships for the training of promising young teachers. The Josiah Macy, Jr. Foundation appears to have much interest in cultivating the social aspects of medicine, and the Milbank Memorial Fund seems to be particularly concerned with public health developments and problems of population. The present serious financial plight of most medical schools constitutes an appeal to which the Ford Foundation is responding by distributing $90,000,000 from its very large resources among all the non-tax-supported medical schools. These grants are intended to help the schools meet the basic costs of education, rather than to support research. The course of events had changed by 1932; medical education in this country seemed to have become mature. The great medical 304

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development of Columbia University and the Presbyterian Hospital in New York, opened in 1928, was the outstanding medical center of the new type; the New York Hospital-Cornell Medical Center began its operations in 1932. In the meantime, new schools had been created at the University of Rochester and at Duke University. The medical schools of Vanderbilt and of the University of Chicago had been reorganized along the new university lines, and the development of clinical departments with full-time teachers was well under way. In 1932 the report of the Commission on Medical Education was published, and the final report of the Committee on the Costs of Medical Care appeared. Both were influential and somewhat controversial documents. The Commission on Medical Education was organized by the Association of American Medical Colleges in 1925 "to make a study of the educational principles involved in medical education and licensure, and to make suggestions which would bring them into more satisfactory relationships with the newer concepts and methods of university education, on the one hand, and with needs of present-day society, on the other. It was believed that such a study would assist the efforts to develop a program adapted particularly to the educational, economic, and social conditions of this country." This statement recognizes two important principles that were then emerging as basic for medical education: one, that medical science should be taught in conformity with the best university standards, and the other that physicians should be educated in the art of effectively rendering to society certain essential services. The commission was composed of seventeen members, all of whom were eminent in education or medicine. President Lowell of Harvard was chairman, and Willard C. Rappleye was director of studies. Its report was influential in liberating medical education from worn-out traditions and in strengthening its position in the universities. Although the Committee on the Costs of Medical Care was concerned primarily with the economic problems of medicine, it included among its recommendations that the training of physicians give increasing emphasis to the teaching of health and the prevention of disease, that more effective efforts be made to provide trained health officers, and that the social aspects of medical practice be given greater attention. These recommendations indicate a growing interest in expanding medicine to meet 305

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its responsibilities to society as a whole as well as to individuals —a principle which has engendered a major movement in recent years. Prior to 1932 medical schools had concentrated their efforts on achieving distinctive scholarship, research, and teaching in the departments of the medical sciences, and by 1932 these departments had attained true university standards. The clinical departments—medicine, surgery, obstetrics, pediatrics, and psychiatry—were slower in achieving this goal. During this earlier period the clinical departments were generally headed by professors eminent in their fields of practice as leading consultants and brilliant surgeons, men who had won their high academic posts through preeminence in medical practice and through their positions as highly regarded leaders of the profession. These skillful clinicians were often excellent teachers, but their lives were divided between their obligations to their private patients and their academic duties, and they seldom had an absorbing interest in advancing medical knowledge through intensive studies and research. As a rule, they did not have the same university spirit as did the teachers of the medical sciences, and in most schools a fairly sharp intellectual and academic division existed between the scientific preclinical departments and the less scientific clinical departments. This division in medical education could not be removed from the school system until the development of clinical research demonstrated the need for study of disease in patients —a project to which clinical teachers could devote themselves— and until trained workers, facilities, and methods were organized in clinical departments. This evolution went forward at the Hopkins under the influence of a few men such as Barker and Halsted and, in a more thoroughgoing way, at the Hospital of the Rockefeller Institute, as has been previously recounted. The development of clinical research made a striking change in the American medical schools as it opened the way for establishing the clinical departments on the same university level as the laboratory departments. An essential requirement, however, for this transition was that the clinical departments be headed and partially staffed by a new type of physician and surgeon for whom the academic interests of teaching and research would not only take first place, but would literally fill their lives. With the growth of medical science and the broadening of medical 306

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practice and clinical responsibility, medical schools aspiring to obtain true university standards found it necessary to have professors and assistants in the clinical departments who were not engaged in private medical practice. This was the reason the full-time plan of clinical teaching was inaugurated and why it has been widely adopted by the American schools. The transformation of clinical departments in which the teaching of medical practice was the primary object to departments dominated by scholarship and research has created serious problems which still exist forty years after the full-time plan was initiated. These problems have concerned the higher salaries paid to fulltime clinical teachers than to other faculty members, the relation of full-time teachers to private practice and the disposition of fees collected from private patients, and the attitude of the medical profession toward full-time teachers. The relation of full-time teachers to the medical profession continues under discussion, and Joseph C. Hinsey, director of the New York Hospital-Cornell Medical Center, presented an interpretation of full-time clinical teaching as it concerns medical school administration at the 1956 Annual Congress on Medical Education and Licensure. This address contains a statement of policy on meeting the challenge of medical education which was recently approved by the executive council of the Association of American Medical Colleges and which expresses the social significance of medical education as viewed by its present leaders. The main points of this statement are as follows: "The maintenance and improvement of the physical and mental health of the population are among the primary responsibilities of any nation. Health ranks in importance with other major features of the national economy, such as food supply, housing, employment, education, and industrial and agricultural production. The level of any health service depends upon the competence of those who participate in it." As the future health of the nation rests largely on the continuing supply of competent physicians, their education is of common concern to universities, medical schools, teaching hospitals, and the medical profession; in order to maintain high standards of medical education, it is essential that they all appreciate the problems created by the changing pattern of medical and hospital services, the growing emphasis on medical research, 307

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and the complexity of the operation of a modern teaching medical center. The production of competent physicians depends upon adequate facilities, financial support, the recruitment of a sufficient number of well-prepared students, and particularly the maintenance of a staff of qualified scientists and clinicians dedicated to the education of physicians. The great change in the economic aspects of medicine, the marked increase in the cost of medical care, the trend toward specialization, the inauguration of prepayment plans for hospital and medical services, and various other developments have considerably disrupted the older methods of practice and have necessitated fundamental adjustments in the teaching of clinical medicine. The required adaptation of medical and hospital services to changing economic, social, and professional conditions has caused much concern to those obliged to meet the new situations. These changes inevitably have an impact on professional education. Under the present conditions, many medical schools have found it essential to establish some of the appointments in the clinical departments on a full-time basis in order to insure proper instruction, the conduct of research, and adequate supervision of patient care. This development has increased the effectiveness of instruction, the productiveness of research, and the quality of patient care. The closing paragraph of Dr. Hinsey's address indicates that medical educators continue to feel that a lack of understanding and of whole-hearted cooperation exists within the medical profession, as exemplified by medical associations, and that a plea for the support of the profession as a whole seems necessary: "The teaching institutions which have the function of preparing the future generations of physicians should be encouraged to secure the services of full-time teachers and investigators under any reasonable plan satisfactory to the staff members and the school that will strengthen and improve the quality of medical education. They should have the support of the profession, the universities, and the hospitals in their endeavors to maintain the quality of teaching which, in turn, will insure a high level of health services for the future. The teaching centers associated with medical centers should be concerned with providing patient care of the highest standard, and, in doing so in an ethical manner, they should be free from hampering regulation and censure by the medical profession. The profession and the teaching insti308

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tution should work together to encourage legislation which will not restrict the teaching centers in performing their essential functions in a modern society." There is no longer in this country the complacency of which William Pepper bitterly complained in 1877, when he said that for fifty years medical schools had never been disturbed by a new idea or by suggestions for improvement. Today, not only are medical schools under constant review by the American Medical Association, but the active Association of American Medical Colleges is dominated by the deans of the schools, who constantly stimulate one another with new plans, improved teaching methods, studies, and criticisms. The Basic Problems of Medical

Education

The basic problem which medical educators now face is how the medical curriculum should be formulated. This problem was well stated by George Packer Berry, dean of the Harvard Medical School, in his 1952 address as president of the Association of American Medical Colleges: ". . . it is the phenomenal growth of the natural sciences that stands out clearly as the driving force responsible for the extraordinary advances that have been made in medicine. It has led to an enormous increase in man's understanding of his physical constitution and to effective measures for treating a host of diseases that beset it. This is common knowledge. We tend to see less clearly, at least we tend to forget, how the phenomenal growth of science has complicated the teaching of medicine." This has made it necessary for medical educators to grapple with a massive curriculum, which has grown more by accretion than by design and which now demands a critical reexamination. The crucial questions are how can the medical school best use the four years available for the preparation of the student before he is liberated by graduation to go his own way? and how can it best meet its obligation toward the student and his future patients, toward the profession and the public, of making each student into an efficient and happy physician, worthy of public confidence? These are the questions with which serious medical educators have been concerned ever since the escape from complacency over fifty years ago. The medical student of the present day is entering a career the core of which should be the lifelong study of man and medi309

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cine. A fundamental requirement is to teach him how to keep abreast of the rapid developments of medicine by cultivating in him studious habits and an enthusiasm for new knowledge. The educational process consists of equipping the student with a knowledge of contemporary science and technique, and of molding him into the right sort of person to apply this knowledge as medical service to individuals and communities. These are the two purposes of medical education, one academic and the other social. One teaches the facts of medicine, the other creates the physician. This concept has long been recognized in the distinction between the science and the art of medicine: science concerned with knowing and art concerned with doing. At the beginning of this century, the German teacher Marchand wrote a definition of medicine which I have cherished as a medical ideal: "Seek truth; discover causes. Learn how they disturb life and how order is reestablished. By science and persuasion preserve men. By science, gentleness, and firmness combat death and reduce suffering. Guide, encourage, and console in a brotherly and tolerant spirit. This is medicine." In these few words the science and the art of medicine are given their proper relationship. To seek truth, discover causes, and learn how the order of the human body is disturbed and may be reestablished, involves the major scientific aspects of medicine. These objectives are based on knowledge of the human body derived from the study of anatomy, physiology, and biochemistry, and on an understanding of pathogenic microorganisms, pathological processes, derangement of bodily functions, and the action of drugs. These subjects have been taught in separate departments of our medical schools, to which students have been assigned for periods of instruction according to a rational order of sequence and for a length of time relative to the "size" of the subject. The great expansion of knowledge in each subject has created the serious problems now being faced and has aroused much interest in the study of teaching methods. The Association of American Medical Colleges now holds an annual institute for the study of the medical curriculum and maintains continuing interest in adapting medical teaching to the ever-changing conditions of medical science and of American society. Efforts are being made to correlate the various medical sciences in order to prevent overlapping and to integrate medical teaching that introduces the student 310

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to the basic principles and facts of man's structure, function, growth, behavior, and relation to his surroundings. In one school, that of Western Reserve University, all the laboratory work in the basic sciences is performed by the students in "home rooms" to which instructors from the various departments come; and the teaching is done by interdepartmental groups. The purpose of this plan is to unify the student's experience and to make him realize that he is studying medicine as a whole, rather than piece by piece. The training of teachers to carry out this integrated instruction has been instituted at Harvard. Similar problems have arisen in clinical teaching, as the expansion of knowledge and technique in the various fields of medical practice—all with legitimate claims for teaching time in the curriculum—has led more and more to the development of specialties. Not only has the knowledge of disease become divided into many specialties, but the scope of medicine as related to a single patient has greatly broadened. This may be illustrated by the possible consequences of a patient's consulting a doctor for the first time for symptoms that seem beyond relief by self-medication. The simplest response is for the doctor to obtain a description of the symptoms from the patient and to examine the part of the body where they seem to originate. This may be sufficient to convince the doctor that he knows the nature of the illness and also the prescription that will alleviate or cure the symptoms. This first-aid type of medical care may satisfy the patient, and a considerable portion of medical practice does not go beyond this stage. The assurance gained by the visit to the doctor may relieve the patient's mind, and the natural powers of the body, helped by the prescribed remedy, may soon succeed in reestablishing order. Then the symptoms disappear, and the doctor gets the credit for a cure. Although the patient may be satisfied, what about the doctor? One of the primary objectives of medical education today is to create an everlasting dissatisfaction with medical service that goes no farther than this shortcut to a prescription. The responsibility of the physician cannot be limited to concern only with the present; his thoughts must go back into the patient's past and forward into his future. He must seek to discover causes (the etiology) and to decide what the eventual outcome of the illness may be (the prognosis). It is only by consideration of the past that causes can be discovered; the 311

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question "what made the patient ill?" has led medicine into broad avenues of scientific study. The enormous forward step initiated by the discovery that many diseases were caused by specific microorganisms that could be isolated, recognized, and controlled resulted from efforts to answer this question. It was one of the most important answers scientists have ever given to the human race. Once the nature of a disease has been revealed by finding the agent or mechanism by which it is engendered, the next questions asked of medical science are "how can the disease be controlled?" and "how can it be resisted and removed?" It is the effort to answer these questions that has initiated the development of preventive medicine and public health, dealing especially with the harmful elements of man's physical environment. Recognition that emotional strain and unsuitable social conditions may cause illness led to the study of the mind and of the social environment of patients. This has required that increased emphasis be given to past experiences as well as to the present mental state of the patient and the environment in which he has been living. The scope of medicine has indeed been broadened by the responsibility of the physician to answer the question "what made the patient ill?" The other question of paramount importance which the physician has the responsibility of answering is "how will the illness affect the patient's future—how serious or dangerous may it be, how long will it last, and is it contagious?" It is not enough to relieve the patient's symptoms. He and his family want to know the significance of the illness, and it is a primary obligation of the physician to give the answers as accurately, fully, and helpfully as he can to those with whom he has established a professional doctor-patient relationship. Prognosis is a conclusion or prediction relating to the future course and final outcome of any case of illness. Sometimes the prognosis may have serious national or even international significance, as for example when President Eisenhower suffered a coronary artery occlusion in September 1955. The diagnosis was clear, but the whole nation awaited, almost with bated breath, the medical opinion as to the significance of his illness. The outcome of disease may be a decisive matter to an employer or to an organization, when the patient holds a prominent place in the business world, and it is always of sufficient meaning to the patient's associates, his clients, and his dependents to demand 312

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serious consideration on the part of the physician. He must give a prediction based on all obtainable facts, based primarily on evaluation of the diagnosis that has been reached. The formulation of a prognosis in every case with serious implications should be carefully considered and thoughtfully expressed by the doctor. The problem is to collect all the data required to make as accurate a prognosis as possible and then to use judgment in conveying the conclusions drawn from the facts to the patient, either directly or through the proper representative of his family. The patient has an inalienable right to know what the doctor believes to be the truth, although medical ethics and custom allow the physician to withhold certain facts when he thinks it better for the patient not to be informed. To formulate a prognosis skillfully and thoroughly requires a wide range of study, and this important function of the physician should have a more conspicuous place in the educational program of our medical schools. An accurate and comprehensive prognosis indicating the relative state of usefulness and happiness the patient may expect to attain when the benefits of medical science and skill are available to him may be considered the ultimate objective of medical care. The various conditions and circumstances that have to be taken into account in forecasting the future of a patient in relation to his illness, indicate how much the scope of medicine is broadened by this process. The Problems of Clinical Teaching

The medical student must learn to gather many facts, both by the use of his unaided senses and by performing numerous technical procedures, and to understand their significance in the application of medical science to the need of the individual patient, whom he must understand as a person. All this means that the two years available for the introduction of the student into the field of clinical medicine, with its many divisions, is causing much the same problems as has the overloading of the curriculum in the basic sciences. The satisfactory solution of these problems requires the selection and coordination of subjects and the application of an academic philosophy. The objective is to decide how, in a short period of four years, the student can best be started on the lifelong continuing education that must be carried on under the initiative and stimulus he receives in medical school. What may be called the basic course in clinical 313

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medicine must be formulated by representatives of the various departments, who together must carefully determine the essential disciplines the student should study and the ways that the various departments can best participate in an integrated plan. This requires educational teamwork in which all the clinical departments should take part. The successful development of "comprehensive medicine" at Cornell University Medical College is a good example of cooperative teaching. Here, a joint project involving all clinical departments and the public health department has been instituted in the outpatient service of the hospital. The fourth-year student devotes a large part of his time to this Comprehensive Care and Teaching Program. It is a synthesis of the many disciplines to which he has been exposed and may be considered a laboratory course in patient care. The comprehensive approach includes the traditional study of the diagnosis and treatment of illness, and it stresses the importance of the emotional aspects of illness. Social problems are also studied through visits to homes of patients whom the student and his adviser serve as family physician. To meet educational standards at the university level, medical schools require three groups of clinical teachers. The first group comprises the full-time teachers for whom academic life is a career. Upon these men the main reliance is placed and to them leadership is assigned. They must be university professors and teachers as wholeheartedly as are professors of mathematics, history, or the languages. They should be selected carefully, and early in their careers they should be given an opportunity to conduct research, to gain clinical experience, and to participate in teaching. A trial period to determine their fitness should be provided. Such a training program is being made possible for a small number of prospective medical teachers through the provision of well-paying fellowships, and it should be greatly expanded. Full-time teachers with such training must not be disturbed by the income some of their friends may derive from medical practice. Teachers find their compensation in a career that assures great social usefulness, that surrounds them with well-educated young people whom they can greatly benefit, and that offers them opportunities to do creative work through scientific research and to lead intellectually stimulating lives with congenial associates. They should have very happy lives and they 314

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should reap great satisfaction; even though the monetary rewards may seem meagre, there ought to be strong competition to attain these teaching positions among the best quality of medical graduates. The part-time clinical teachers, who form the second group, do not have a sharply defined and uniform status in the various medical schools. They carry on much of the medical care of patients in the various specialty and outpatient services of the teaching hospitals, and they form an essential link between medical practice, through which they support themselves, and the academic aspects of medicine. Although medical education is no longer an appendage of medical practice as it was in our medical "dark ages," an important part is still carried by doctors primarily interested in their private practices, conducted either in the teaching hospitals where they may be designated as "geographical full-time teachers," or in offices entirely separated from the medical school. The part-time teachers not only instruct students in the practice of medicine, but they may also exert a valuable educational influence among their professional associates outside the school and enjoy superior opportunities for their own continuing education. For these reasons, positions on the part-time staff in the clinical departments of medical schools are highly prized and are filled by practitioners of the best quality who receive small salaries or even no salaries at all. The third group of teachers comprises the educational leaders who are concerned with the direction and administration of the schools as a whole and with the national significance of medical education. Although medical schools continue to have deans of their faculties, a number of universities have recently appointed vice presidents or directors to supervise their medical affairs and to bring the medical schools into closer academic and administrative relations with other parts of the universities. The administrative and educational leaders of the medical schools now form a strong and influential group, united in the Association of American Medical Colleges and making their opinions known through the Association's Journal of Medical Education. A great advance was made in the teaching of medicine in this country when the student was permitted in hospitals to study individual patients and to take part in their medical care. This had a far-reaching effect on medical education, as it created conditions for acquiring the art of medicine and for learning the 315

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principles of the doctor-patient relationship that is the basis of medical practice. The quality of this relationship largely determines the success with which the art of medicine is practiced, the extent to which the physician can use "science, gentleness and firmness" to combat death and reduce suffering, and the skill with which he is able "to guide, encourage and console in a brotherly and tolerant spirit." William Osier, my illustrious teacher who left in my memory "an habitual vision of greatness," knew that all the components that go to make up the art of medicine can only be taught by example, and he nobly accepted the challenge. He took great satisfaction in having been the first to demonstrate in this country how medical students should be instructed in the art of medicine. In his farewell address to the Johns Hopkins University in 1905 he said: "I desire no other epitaph than the statement that I taught medical students in the wards, as I regard this as by far the most useful and important work I have been called upon to do." Osier understood that participation in the activities of a group is the oldest and most effective form of education, one that begins in the family circle. It is the means by which the whole person may be educated in body, mind, and spirit—the rounded training the physician needs. By participation in group activities, learning by living rather than by formal instruction, a stimulus is felt that goes below the level of ideas to the deeper feelings that motivate the will. Ideas received from lectures or books have little motive power unless they are reinforced through activity. "If the bridge between thought and action is crossed often enough," to quote Howard Brinton, a Quaker philosopher, "thought and action become integrated, and the result is training in its most profound and enduring form." The development of clinical training through the participation of students in the study and care of individual patients necessitated the provision of hospital ward and outpatient services under the professional control of the medical faculty, and it required much time and the effort of many schools to obtain adequate clinical teaching facilities. In recent years, however, the direct study of patients has been well established in all American medical schools. The development of university clinical departments also involved the provision of laboratories and other facilities for the investigation of disease in patients, and clinical research became an essential function of the full-time staff of 316

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the departments. Two movements went forward simultaneously, one aimed at the cultivation of the art of medicine through a close contact of student and patient, and the other concerned with expanding the science of medicine. There is a subtle antagonism between the art and the science of medicine: the art is centered on the patient as a person, while the science is centered on the phenomena of disease. They represent two opposing influences in medical thought: one the impulse to help the sick, and the other the compulsion to explain life and its phenomena. As the German surgeon Sauerbruch pointed out: "The humanitarian motive does not occasion an interest in nature such as develops from a more detached and impersonal curiosity." The conditions most favorable for the study of disease tend to relegate the patient as a person to the background or to leave him almost entirely out of consideration; as specialism develops, thought becomes concentrated on localized medical problems and interest in the patient as a whole lessens. These two conditions, scientific study and specialism, affecting the doctor-patient relationship in the university hospitals, produced a definite defect in the medical care of patients and created a weakness in the American plan of medical education. The Social Aspects of

Medicine

After a number of years in teaching hospitals, I became convinced that medical care and instruction would be definitely improved by giving greater consideration to the patient as an individual and to the social problems related to illness. The hospital patient, I reasoned, was no longer being seen in his home surroundings, and no serious thought was being given to the personal problems that might be contributing to his illness. His disease was being studied with great care, often by a number of specialists, but the patient as a person was being neglected; and his medical care was therefore definitely restricted. The devotion to scientific aspects of medicine left little time and energy for consideration of the patient as an organism subjected to many strains and stresses from his social environment; training in the art of medicine had deteriorated. It was with these conceptions that I undertook the study of the social aspects of medicine in the medical clinic of the Johns Hopkins Hospital in 1936. I wanted to find out the relative significance of social problems as components of illness and their 317

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bearing on diagnosis and treatment, and I hoped to stimulate the interest of students in the social aspects of medicine. When I became at that time a member of the Johns Hopkins department of medicine, I believe I was the first internist in this country to devote his full time to this field. An account of this "adventure" in social medicine has been given in a previous chapter. This experience was significant because it represented one of the pioneer efforts which brought about a definite change in the philosophy of medical education. A movement was initiated at that time to revive interest in the social aspects of medicine which had become submerged since the family doctor no longer held a dominant place in medical care. This revival manifested itself by an increased interest in the teaching of preventive medicine and public health, by the participation of medical social workers in medical teaching, and by the expansion of psychiatry into the fields of social work and of general medicine. This movement in academic medicine, which started before the Second World War, has made much progress since then. It represents a new phase of medical organization and teaching in which the social aspects have a much more widely recognized significance. It has become almost general practice in American medical schools to have the student make contacts with patients in their homes and to study their social situations and problems as related to their illnesses. The student may be assigned to serve as medical adviser to certain families, or to return for a short period to the old preceptorial plan, he may serve as assistant to a general practitioner, sometimes in rural districts. Home visits by the student are arranged for in a variety of ways and may be part of "comprehensive medicine" as organized at Cornell. Social medicine has become a well-defined discipline, especially in Great Britain. My friend John Ryle resigned as regius professor of medicine to become the first professor and the director of the department of social medicine at Oxford University in 1943. Since then many British medical schools have established departments of social and preventive medicine and are conducting research in this field. A corresponding club has been organized by British and American teachers to stimulate a world-wide interest in this field by an exchange of ideas and by international visiting. As social medicine is based on the study of the patient as a person in his relations with other people and as a member of 318

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his community, it emphasizes certain aspects of medicine which are fundamental in the education of the doctor. It influences the student to give consideration to the patient as a whole and to medical care before it has been divided up among a number of specialists. The teaching of social medicine stresses the intimate, confidential relationship of doctor to patient that is essential for good medical practice. It makes the student realize the importance of learning to listen as well as to talk to patients; it teaches him the art of medicine, and cultivates his humanitarian interest. Hippocrates is credited with saying, in the fifth century B.c.: "Where there is love of humanity there is also love for the art of medicine," and "to care for the human body it is necessary to have a knowledge of the whole of things." A similar idea was recently expressed by a modern leader in academic medicine, Francis W. Peabody of Harvard, who wrote: "One of the essential qualities of the clinician is interest in humanity, for the secret of the care of a patient is in caring for the patient." These are the principles on which the art of medicine is based, and they should permeate the spirit of medical schools. The leaders of American medical education now generally agree that there is a need for cultivating the humanitarian spirit without weakening scientific interest and activity. While medical knowledge is constantly progressing at an accelerated rate, the qualities that go to make the best sort of physician are changeless. Teaching the facts of medicine in a university medical school requires a corps of teachers who are themselves at the scientific frontier of medicine and who are taking part in advancing that frontier. The process of molding the student into the best sort of physician depends more on the influence of the school as a whole and on the spirit that pervades it and its teaching hospitals. As the influence of the alma mater on its graduates is an important factor in setting the future standards of medicine, I shall close with a brief discussion of those things that appeal to me as the desirable attributes a medical school should strive to cultivate in its students. Cultivating

the Attributes

of the

Physician

A primary objective of medical education is the creation of conditions that stimulate students to develop their own capabilities and interests. They must be encouraged to acquire a sound scientific attitude and a genuine spirit of curiosity as a way of 319

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life, to carry the principles of the basic sciences into clinical medicine, and to apply free and clear reasoning in the study and practice of medicine. Among the traits of character the physician should possess integrity must be given first place, and by integrity is meant an attitude that holds truth sacred, not only in relation with other people, but also with himself. Dissatisfaction with the acceptance of anything less than what seems to be the truth and a valiant effort to determine at all times what is true, constitute integrity. Fair-mindedness and fair play in his relations with members of the medical profession and with everyone else, and a saving sense of humor, should be cultivated as essential qualities of the physician. It is of great value to develop sentiments and attitudes in a student that will submerge self-interest. Selfish motives must be superseded by motives of service, by pride in excellence in medicine, by an abiding interest in people and in applying medical knowledge for their benefit. A well-fertilized soil and a properly adjusted atmosphere are the conditions for growth that medical teachers must do their best to provide for the young people whom they have the responsibility of forming into efficient and happy physicians. I recently heard a minister in our town preach a sermon concerning building a house upon rock. The spiritual rock on which our lives should be built is composed, he said, of the love of God, the love of man, and the love of truth. It seemed to me that these should also be the foundation on which medicine is built. When we contemplate the newborn baby we know the love of God, which may be interpreted as the reverence, wonder, and humility we feel before the great creative force that surpasses human understanding. The child has developed in nine months' time the miraculous central nervous system endowed with myriad potential complexities of function; it has developed the everbeating heart that sends oxygen to every living cell of the human body. The doctor should give everlasting thanks that the human body is endowed with a wonderful force that not only provides it with the power to heal its wounds, but which restores it from disorder to its individual form and function. The wonders of the human body should be contemplated with a sense of thankfulness, faith, and worship, which is an expression of the love of God. Love of man is surely the basic source of inspiration and 320

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stimulus that underlies interest in medicine and propels its progress. Love of truth is the foundation of science and scientific progress as well as the keystone of human relations on which medicine is built. Medical education should cultivate the love of God, the love of man, and the love of truth because these form the foundation on which medicine should be firmly based in order that it may attain its highest place for the service of man.

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INDEX

Abbott, Alexander C., 49 Abel, John J., 39, 45, 46,143 Administrators of medical schools, 315 Albany Medical College, 185,214 Allbutt, Clifford, 170 American Medical Association Council on Medical Education and Hospitals, 61 Plexner report backed by, 61 founding, 21 presidents from Nashville, 154 from St. Louis, 104-105 mentioned, 155, 309 American Red Cross Blood Donor Service, 281-289 amount of blood procured, 286 cost, 287 director (Dr. Robinson), 281282, 284-286 Negro donors, 288 operation, 287-289 organization, 283-286 plasma preservation, 289-290 research,290-292 serum albumin, 290 value of service, 292 whole blood preservation, 291 nursing service, 124 rehabilitation service, 139 St. Louis chapter, 139 mentioned, 200 Amsden, George S., 214 Anatomy obtaining dissection material, 10-11

study at Johns Hopkins, 40-42 teaching at Cornell, 65

Anderson, Lydia, 215 Architectural League of New York, 206 Arizona, University of, 212 Army Nursing Corps, 124 Association of American Medical Colleges, 186, 305, 307, 309,310, 315 Association of American Physicians, 266 Atchley, Dana W., 163 Auer, John, 98,100 Austrian, Charles R., 163 Avery, Oswold, 93,173, 211, 245 Avery, Roy C., 179 Avon Old Farms School, 230 Ayer Clinical Laboratory. See under Pennsylvania Hospital Bacteriology, study at Johns Hopkins, 43-44 Baer, William S., 53 Baetjer, Frederick H., 53 Baker, George F., Jr., 190 Baker, George F., Sr., 190 Baltimore, Maryland City Health Department, 260,298 Dr. Robinson's home, vii, 161,260 Eastern Health District, 260 Barbour, Josephine C., 259, 267 Barcroft, Joseph, 170 Bard, Samuel, 7,190,191 Bardeen, Charles R., 41 Barker, Lewellys F., 36,162,163, 306 teaching compared with Osier's, 84-85 Barnard, Chester I., 277 Barnard College, 199

323

INDEX Barnes Hospital, St. Louis affiliation with Washington University, 113 history, 116-118 occupational therapy workshop, 140 reorganization, 125,126-127 Bauer, Charles E., 124 Bayne-Jones, Stanhope, 226 Beard, Mary, 215 Beaumont, William, 104,109 Behrens, F r a u Major, 75 Belgian professors, tour with, 160161 Bellevue Hospital, 194, 208 Benedict, Stanley R., 195,208-209 Bennington College, 320 Berkley, Henry J., 51 Berlin (Germany), study of medical education, 167 Bern (Switzerland), visit, 75 Berry, George Packer, 309 Betts, P. K., 285 Bien, Charles, 245 Bigelow, George, 197 Bigger, Isaac Α., 180,185 Biggs, Hermann M., 83 Billings, John Shaw and Johns Hopkins Medical School, 30-38, 49, 301 career, 31-32 Suggestions on Medical Education, 33-34 Billroth, Theodor, 37 Biochemistry. See Physiological chemistry Bishop, E. L., 179 Bixby, William K., 116 Black, Arthur P., 245 Blair, Jacob J., 277 Blair, Vilray P., 138 Blake, Henry S., 285 Blalock, Alfred, 176,180 Blood Donor Service. See under American Red Cross "Blood for Britain," 283 Blood Transfusion Association of New York, 283

Blood transfusion problems in warfare, 282 Bloodgood, Joseph C., 49 Bloomfield, Arthur L., 163 Bloomingdale Hospital, 213, 214 Bloor, Walter R., 120 Bodleian Library, 169 Body Snatcher, The (Robert Louis Stevenson), 10-11 Boerhaave, Hermann, 25,168 Boggs, Thomas R., 163 Boise, Margaret G., viii Bond, Thomas, 7, 67 Booker, William D., 51 Bordet, Jules, 160 Boston City Hospital, 94, 259 Dispensary, 259 medical education in 18th century, 7 medical social service, 259 Bowdoin College, Medical School of Maine, 9 Bowen, Trevor, 237 Bowling, W. K., 154 Bowman Gray School of Medicine, 182 Brady, James Buchanan, Foundation, 211 Brailey, Miriam E., 298 Bredeck, Joseph F., 127 Briggs, W. Τ., 154 Brodel, Max, 45,183 Brodie, Edith P., 177,183 Brookings, Robert S. and Abraham Flexner, 110-112 and St. Louis Children's Hospital, 117-118 and Washington University, 102, 107,109-118,128,132-134 career, 107-110,133-134 mentioned, 99,124,144, 201, 303 Brooks, Barney, 137,175,180 Brotherhood, J. S., 125 Brown, George, 202 Brown, Thomas R., 48 Brown University, 276 Burch, John C., 181

324

INDEX Burch, Lucius E., 155,156,176,181 Burwell, C. Sidney, viii, 165,173, 174,181,185,187,238 Busch, Adolphus, 116 Buttrick, Wallace, 145,152,155,156, 158, 234, 235,240,241 Byerly, Martha G., 70 Cabot, Eichard C., 259 Cairo (Egypt), visit, 231 California, University of, 160,182 Cambridge University, visit, 169-170 Cannon, Ida M., 259 Cannon, Walter B., 243, 246,283 Carlson, Anton J., Jr., 243 Carnegie, Andrew, 112,122,151 Carnegie Corporation, 158-159, 303 Carnegie Foundation for the Advancement of Teaching, 61,184, 302 Carrel, Alexis, 100 Carson, Norman B., 122 Carter, William Spencer, 110 Cason, Charles, 158 Casparis, Horton R., 173,174,183 Chadwick, Henry D., 295 Chang, H. C., 245 Chell, Myrtle E., 297 Chen, C. C., 248 Chesney, Alan M., viii, 33,137,164, 255,256 Chicago Medical College, 24 University of, 39,160, 209, 216, 234, 241, 242, 303, 305 China political conditions (1935), 243 public health movement, 247-249 voyages to and from, 230-233, 249-250 West China Union University, 250 Υale-in-China, 240 See also China Medical Board; Peiping Union Medical College; Rockefeller Foundation China Medical Board, viii, 230, 232, 234-235,236-238, 240,250-251 Christian, Henry Α., 94

Cincinnati, Ohio early medical schools, 15,16 Medical College, 16-17,103 University of, 16-17,142,185, 212

Civil War, and founding of Johns Hopkins University, 27 Clark, Paul F., 97 Clark University, 39 Clark-Kennedy, A. E., 169 Clausen, Samuel W., 137 Clay, Frances, 296 Clifton Springs Sanitarium, 64-65 Clinical clerk system, 49-50 Clinical research, development, 86, 92-99,306-307,316-317 Clinical teachers, 314-317 Clinical teaching, full-time at Washington University, 126 opinions regarding, 85-86 principles, 130-137, 307-309 Clinical teaching, problems, 313-317 Coggin, Charles U., Jr., 285 Cohn, Alfred E., 90,96, 97,100,243 Cohn, Edwin J., 284, 290 Cohnheim, Julius, 36 Cole, Rufus and Rockefeller Institute Hospital, 81, 86-89, 92-93 medical training, 83-84 tribute to, 100 mentioned, viii, 48, 80,82, 99,241 Cole, Whitefoord R., 155 College of Philadelphia, 4, 6 Colleges, relations with early medical schools, 11 Colonial period, medical education, 2-3 Columbia University, 162,166, 248, 283 College of Physicians and Surgeons, 7, 36,164, 200,202, 244, 305 Law School, 199 Teachers College, 216 See also King's College Commercial Hospital (Cincinnati), 16 325

INDEX Commission on Medical Education, report, 305 Committee on the Costs of Medical Care, 305 Commonwealth Fund, viii, 267, 304 "Comprehensive medicine," at Cornell, 314 Congress on Medical Education and Licensure (1956),307 Connell, Clarence P., 176 Conner, Lewis Α., 194,196, 208 Cook, Jean V., 137 Cook County Hospital (Chicago), 241 Coolidge, Charles Α., 155, 235 Coolidge and Shattuck, 155, 236 Coolidge, Shepley, Bulfinch, and Abbott, 187, 202 Copenhagen, university hospital, 167 Cornell Pay Clinic, 196-197 Cornell University Medical College association with New York Hospital, 186, 192,195-196,197-198 faculty letter from Dr. Robinson, 222224 reorganization, 207-215 grant from General Education Board, 190 history, 192-197 instructor in anatomy (Dr. Robinson), 65-66 mentioned, 185,219, 222, 314 See also New York HospitalCornell Medical College Association Cornell University-New York Hospital School of Nursing, 215-217, 226 Council on Medical Education and Hospitals, A.M.A., 61 Cowan, Sam, 176,181 Crampton, George, 68, 71 Crowe, Samuel J., 53 Cullen, Glenn E., 173,174,178,185 Cullen, Thomas S., 36, 51,152 Cullen, William, 4 Culver, Mary, 133 Cunningham, Eileen R., 183

Cunningham, R. Sydney, 173,178, 185 Cupples, Samuel, 109,110 Cupples and Marston, 108 Cushing, Harvey, 50, 52, 53, 56,115116,119

Dandy, Walter E., 53 Dartmouth College Medical Department, 8 Davis, Nathan Smith, 21,22 Davison, Wilburt C., 52 Dawson, Percy M., 43 De Gowin, Elmer L., 284 De Kleine, William, 284 Delafield, Francis, 90 Denmark, visit, 167 Dieuaide, Francis R., 163, 230,232, 243,244, 245, 246 Dill, D. B„ 277 Discourse on Medical Education (John Morgan), 4-6 Dochez, Alphonse Raymond, 89, 9293, 98,163,164,245 Dock, George, 86, 96, 99,101,119, 120,123,127,133 Dock, Mrs. George, 101 Doctor-patient relationship, 261, 316 Dodd, Katharine, 183 Douglas, Beverly, 180 Downey, W. W., 218 Drake, Daniel at medical convention of Ohio (1838),21 career, 15-17 Practical Essays on Medical Education and the Medical Profession of the United States, 17-21 writings, 17 mentioned, 31, 33,103 Draper, George, 78, 79, 89, 90, 95, 97, 98 Dryer, George P., 43 DuBois, Eugene F., 164, 208, 209 Dudley, William L., 149 Duke University Medical School, 98, 303, 305 du Vigneaud, Vincent, 227 326

INDEX Eastern Health District, Baltimore, 260 Eastman, George, 303 Eastman, Nicholson J., 243 Eddy, Thomas, 192 Edens, Ernst, 78 Edgar, J. Clifton, 193 Edinburgh, University of, 3, 9, 25, 48,168, 213 Edsall, David L., 114-116,119,122123,161, 243 Education, medical. See Medical education Ehrlich, Paul, 94, 97 Eidlitz, Marc and Son, 202 Einthoven, Willem, 96,167 Eisenhower, Dwight D., 293, 312 Electrocardiograph, 96 Eliot, Charles W., 22,24, 234, 301 Ellicott, Nancy P., 89, 92 Ellis, Arthur W. M., 90,94,95 Elser, William J., 195, 210 Emerson, Charles P., 48,49,65 Emmel, Victor E., 120 England, study of medical education, 168-170 Erlanger, Joseph, viii, 43, 71,119, 120,176, 211 Europe, visits (Dr. Robinson), 75-79, 166-170, 213-214,231 Eve, Paul P., 154 Ε wing, James, 193, 209 Farrand, Livingston, 186,189,199, 200, 222 Federal Board for Vocational Education, 138-139 Financial problems medical education, 106 New York Hospital-Cornell Medical Center, 219-220 Vanderbilt University Medical School, 184-185 Washington University, 110,115, 132-133 Finney, John Μ. T., 46, 48 Fischel, Washington E., 122 Fitz, Reginald, 160 Fletcher, Robert, 49

Flexner, Abraham and General Education Board, 6162,151, 303 and Johns Hopkins Medical School, 57 and Vanderbilt University Medical School, 145,149,152,156 and Washington University Medical School, 110-112,119 and William Welch, 57, 62 leadership in medical education, 56 report on medical education in Europe, 61 report on medical education in the U.S., 10, 57-62,111-113,149151, 302, 303 mentioned, 6,19,106,155,158, 304 Flexner, James Thomas, 36 Flexner, Simon, 36, 66, 83, 86, 97, 100,114,177,201,210, 235, 240, 241, 301 Flint, Austin, 193 Ford Foundation, 304 Forkner, Claude E., 245,250 Fosdick, Raymond B., 82, 238-239 Fothergill, John, 6, 69, 71-72 Fox, Marjorie E., 103,110,116,121, 122,128 Francis, William W., vii, 169 F r a n k f u r t (Germany), visit to medical school, 167 Franklin, Benjamin, 67 Fraser, Francis R., 98,168 Frazier, Chester N., 243, 245 French, John C., 29 Fuller, Deacon Samuel, 2 Full-time clinical teaching. See Clinical teaching, full-time Futcher, Thomas B., 48

Galloway Memorial Hospital (Nashville), 146 Garrett, Mary E., 38 Garrey, Walter E., 120,175-176,178 Garrison, Fielding H., 17,18, 32, 48 Gasser, Herbert S., 211 Gates, Frederick L., 235 Gates, Frederick T., 82,83, 233-234

327

INDEX General Education Board Abraham Flexner as secretary, 61-62,151, 303 grant to Cornell University, 190 grants to Vanderbilt University, 145,153,157-159,172,174,181, 194 grants to Washington University to support full-time clinical teaching, 132-133 to support pharmacology, 142143 influence on medical education, 303 mentioned, 112,130,146,152,172, 234 German universities, influence on American medical schools, 24-25, 35 Germany, visit, 75-79,167, 213-214 Gesellschaft f ü r Naturwissenschaft, meeting in Leipzig, 167 Gibbon, John H., 73 Gibson, Charles L., 196, 208 Gillam, S. Margaret, 218 Gilman, Alice S., 215 Gilman, Daniel C. and Johns Hopkins Medical School and University, 29-34, 37, 301 mentioned, 111 Glasgow, University of, 213, 245 Goforth, William, 15 Goodpasture, Ernest W., 173,174, 179,185 Goodrich, Annie W., 215 Graham, Evarts Α., 142 Grant, John B., 243 Graz, University of, 241 Greene, Amy W., 296 Greene, Roger S., 230, 232, 234, 236, 243 Gregg, Alan, 222, 238, 246, 255,257 Gregory, Ε. H., 104 Groningen (Holland), visit, 79 Gross, Samuel D., 15,17 Guthrie, Clyde S., 164 Hagedorn, Herman, 107,109

Haggard, William D., 154 Haidane, J. S., 169 Hall, Frederick Alden, 124 Halsted, William S., 36, 37, 48, 50, 53,173,180,212, 306 Hamberger, Louis P., 48,163 Hamman, Louis, 163 Hanes, Frederic M., 98 Hanover (Germany), visit, 75-76 Harris, Norman Mac L., 43 Harrison, Ross G., 41 Harrison, Tinsley R., 176,181,185 Harrop, George Α., Jr., 245 Harte, Richard H., 73 Harvard Medical School, 8, 39,122, 173,185, 208, 209, 214,234, 244, 259, 290,309 Harvard School of Business Administration, 276 Harvard University, 24, 212, 248, 276, 283, 311 Hatcher, Robert Α., 195, 210 Hedges, Pearle C., 183 Helmholz, Henry, 142 Henderson, D. K., 213 Henderson, Lawrence J., 276 Herrick, Alfred B., 43 Herrmann, George R., 127 Herter, Christian Α., 83 Heuer, George J., viii, 212 Hinsey, Joseph C., viii, 226, 227, 251, 307 Hippocrates, 1, 319 His, Wilhelm, 39 Hodgen, John T., 105 Hodges, Fred J., 127 Holland, visits, 167-168, 213 Holt, L. Emmett, 83, 243 Homans, George C., 276 Hoover, Herbert, 56 Hopkins, Frederick Gowland, 170 Hopkins, Johns, 12, 27-29 Hospital for Ruptured and Crippled (New York), 227 Hospital for Special Surgery (New York), 227 Hospital of the Rockefeller Institute. See Rockefeller Institute Hospital Houghton, Henry S., 232, 237 328

INDEX Houston, David Franklin, 110,114, 124 Howard, Campbell P., 48 Howard, John R., Jr., 218, 221 Howell, William, 218 Howell, William Η., 39, 42-43,151 Howland, John, 119,120,122,124, 133,161,173 Hunter, John, 4 Hunter, William, 4 Hunter, W. S., 276 Hurd, Henry M., 37, 51 Hutchinson, James P., 73

Illinois, University of, 185 Industrial conditions, study of, 276277 Influenza epidemic (1918), 141 International Health Board, 174,184 Internship (Dr. Robinson), 63-64 Iowa, University of, 160

Jackson, Dennis E., 120,142 Jacobs, Henry Barton, 46 James, Walter B., 96 Janeway, Edward G., 162 Janeway, Theodore C., 162,166 Japan, visit, 249 Jeans, Philip C., 137 Jefferson Medical College, 16, 65,103 Johlin, J. H., 178 Johns, Ethel, 215 Johns Hopkins Hospital history and organization, 30-31, 37-38 internship system, 63 physician-in-chief (Dr. Robinson), 164 resident staff system, 55 social aspects of medicine studied, 256, 317-318 tuberculosis teaching program, 298 mentioned, 165,173, 244, 254, 260, 270, 296 Johns Hopkins Medical School, 27-62 history, 24, 30, 38-40, 301-302 influence, 55-57, 303-306

Johns Hopkins Medical School (coni.) medical department professor of medicine (Dr. Robinson) , 161-166 reorganization, 162-165 organization, 35-36, 52-55 student days (Dr. Robinson), vii, 40-55 mentioned, 6, 22,58, 62,112,173, 175, 180,185, 209, 210, 211, 212, 226, 244, 247, 255 Johns Hopkins School of Hygiene and Public Health, 177, 256 Johns Hopkins School of Nursing, 216 Johns Hopkins University history, 27-30 mentioned, 316 Joint Administrative Board. See New York Hospital-Cornell Medical College Association Jones, Mrs. Robert McKittrick, 117118 Jones, Walter, 43 Jordan, Minnie H., 215 Journal Club, Rockefeller Institute Hospital, 97 Journal of Clinical Investigation, 161 Journal of Medical Education, 315 Judson, Harry P., 234 Kelly, Howard Α., 37, 39, 51, 54-55 Kemper College, medical department, 103 Kendrick, Douglas B., 283 Kerr, Abram T., 41, 65, 66 King, Charles C., 178 King's College, 7,190 Kirby, George H., 196 Kirk, Norman T., 293 Kirkland, James H. and Vanderbilt University, 145, 146,151-153,156-158 career, 147-149 mentioned, 155,166,177,183,184, 201 Kirkland, Mrs. James H., 149,153 Klebs, Arnold, 48

329

INDEX Knower, Henry McE., 41 Kocher, Theodor, 75 Krause, Allen K., 163 Krogh, August, 167 Krumbhaar, Edward B., vii, 72 Kuhn, Adam, 6 Kuttner, Ann G., 245 Ladd, William S., 163, 214, 225 Lakeside Hospital (Cleveland), 160 Lamson, Paul D., 175,178-179 Lawrence, John S., 182 Leathers, Waller S., 173,174,179180,185,187 Le Conte, Robert G., 73 Lee, C. U., 239, 245, 250 Lee, Roger, 165 Lehman, Edwin P., 137 Leipzig (Germany), visit, 167 Lester Institute (Shanghai), visit, 232 Levene, Ρ. Α., 83,100 Lewis, Dean, 142 Lewis, Morris J., 73 Lewis, Thomas, 96 Lexington (Kentucky), medical school, 14 Leyden (Holland), visit, 167 Life Insurance Medical Research Fund, 244 Lim, Robert K. S., 243 Lind University Medical School, 22 Linnaeus, Carolus, 6 Liu, J. Heng, 243 Liu, S. H., 245 Lobenstine, Edwin C., 250 Loeb, Jacques, 100 Loeb, Robert F., 163, 283, 284 Loevenhart, Arthur S., 43 London Hospital Medical School, 95,168 University of, 98 visit, 168 Long, Perrin H., 265 Longcope, Warfleid T. career, 64, 66,166 mentioned, 79, 97, 98,160,173, 256 Loomis, H. P., 193

Loomis Laboratory, 193 Loucks, Harold H., 238, 243, 251 Louis, Pierre-Charles-Alexandre, 25 Louisiana Purchase Exposition, 110 Louisville, University of, 17 Louisville Medical Institute, 17 Low, Seth, 195 Lowell, A. Lawrence, 305 Lowsley, Oswald S., 211 Ludwig, Karl, 36, 39 Lund, Wallace, 218 Lusk, Graham, 164,195, 208,209 Luten, Drew, 127 Lying-In Hospital (New York), 190, 201, 212-213, 214,218 Lyman, Richard S., 245, 255 Lyons (France), University of, 180 Macaulay, Patrick, 12-14, 33 MacCallum, William G., 44, 45, 243 Mackenzie, James, 168-169 Macy, Josiah, Jr., Foundation, 265, 304 Magnus, Rudolph, 168 Maine, Medical School of, 9 Mall, Franklin P., 36, 39, 41 Mallinckrodt, Edward, 116,133,143 Edward Mallinckrodt Department of Pharmacology, 143 Manhattan Maternity and Dispensary, 190 Marburg (Germany), visit, 167 Marchand, Felix, 310 Markle, John and Mary R., Foundation, 265, 304 Marks, Henry, 89, 92, 93-94 Marriott, William McKim, 120,133 Marshall, E. Kennerly, 143 Marshall, Harry T., 44, 45 Martin, Henry Newell, 35, 39 Maryland Medical and Chirurgical Faculty, 12 State Department of Education Library Extension Division, 297 Vocational Rehabilitation Service, 296-297 330

INDEX Maryland (cont.) State Department of Health, Division of Tuberculosis, 295 State Planning Commission, tuberculosis survey, 295-296 Tuberculosis Association, 294-298 executive secretary (Dr. Robinson), 294-295 See also Baltimore, Maryland Mason, Karl E., 178 Mason, Verne R., 164 Massachusetts Agricultural College, 211 Massachusetts Bay Colony, medical practice, 2 Massachusetts General Hospital, 8, 94,122,165, 244, 259 Mathieu, Augusta K., 176 Matthews, William B., 294 Mayo, Elton, 276 Mayo Clinic, visit, 160 McCann, William S., 164 McCracken, Joseph, 231 McCrae, Thomas, 48 McCrudden, Francis H., 89-90 McCulloch, Hugh, 127 McDowell, Ephraim, 103 McDowell, Joseph Nash, 17,103-104 McFarland, Ross Α., 277 McGill University, 37 Osier Library, vii Mclntire, Ross T., 293 McKim, Mead and White, 193 McLean, Franklin C., viii, 236, 241242 McTyeire, Bishop Η. N., 146 Meakins, J . C., 168 Medical College of Alabama, 182 Medical College of Ohio, 16,17, 31 Medical College of Virginia, 185 Medical curriculum Billings' discussion, 34 Macaulay's plan, 13 Medical education Billings' theory, 33-34 financial support, 303-304 Flexner report, 57-62,111-113, 149-151

Medical education (cont.) in Colonial period, 2-3 in 18th century, 3-9 in 19th century, 9-26,103-107, 301 in 20th century, 107-108, 302-313 influence of environment, 223-224, 254-255 philosophy (Dr. Robinson's), 318321 preceptorial system, 3,11 problems, 309-313 See also Clinical teachers; Clinical teaching, full-time; Clinical teaching, problems of; and under names of medical schools Medical Education, Discourse on (John Morgan), 4-6 Medical Fund Society, St. Louis, 105 Medical Improvement, Discourse on (Patrick Macaulay), 12-14 Medical practice (Dr. Robinson), 79-80 Medical school administrators, 315 Medical social service at New York Hospital, 217-218 at Washington University, 123-124 for tuberculosis patients, 296-298 ideas regarding, 254 Medicine, philosophical foundations, 320-321 Medigreceanu, Florentin, 98 Meigs, Arthur V., 73 Meleney, Henry E., 179 Meitzer, Samuel J., 83,100 Memorial Hospital (New York), 209, 227, 283 Meyer, Adolf, 213, 256 Michael, Rachel Stix, 140 Michigan, University of, 21-22, 24, 39,128,160,187, 218, 245 Mikol, Edward X., 295 Milbank Memorial Fund, 248, 304 Milliken, John T., 133 Mims, Edwin, 148,156-157,158 Minot, George R., 259, 266 Mississippi State Department of Health, 179 University of, 173,179 331

INDEX Missouri Medical Association, 139 Medical College, 104 Occupational Therapy Association, 140 Mitchell, Charles P., 79 Moorhead, John, 16 Morgagni, Giovanni Battista, 4 Morgan, Hugh J., 163,173,174,181, 187 Morgan, John, 3-7,13, 23, 33, 40, 72 Morgan, J. Pierpont, Jr., 190,199, 201 Morris, Harold, 231 Morris, Roger, 120,124,151 Mosenthal, Herman 0., 162 Mudd, Henry J., 105 Müller, Friedrich, 71, 76-78,167 Munich, study, 75-79 Murphy, Fred T., 122,123,124,133, 137,141-142 Mustard, H a r r y S., 260, 265 Myers, Minot, and Company, 219

Naples (Italy), visit, 231 Nashville, Tennessee City Hospital, 146 early medical education, 147 medical profession, 154 University of, 146,147,149,151 Vanderbilt University, 145-188 visit, 145-146 Nassau Smelting Company, 276 National Academy of Sciences, Committee on Work in Industry, 276 National Research Council, 276, 281, 283-284, 286, 287, 292 National Tuberculosis Association, 294,298 See also Maryland Tuberculosis Association Neill, James M., 173,174,179,185, 211 New Haven Hospital, 212 Newhouser, Lloyd R., 283 New Jersey Bell Telephone Company, 277

New York Hospital association with Cornell Medical College, 186,192,195-196,197198 bed capacity, 204 history, 7,190-192 intern examinations (Dr. Robinson), 63 library, 191 Nurses' Alumnae Association, 215 opening, 219 Payne Whitney Psychiatric Clinic, 203, 212 Pediatric Department, 203 School of Nursing, 215-217, 226 social service department, 217-218 Women's Clinic, 203, 212 See also New York HospitalCornell Medical College Association New York Hospital-Cornell Medical College Association, 189-228 administrative problems, 225-226 administrative staff, 218-219 director (Dr. Robinson), 186-187, 201, 222-225, 229 finances, 189-190, 219-220 formation, 189 organization, 197-201 director's functions, 199 Joint Administrative Board, 199-201,216, 221, 225, 226 plant, development, 201-207 professional staff, 207-215 visit (1956),226-228 New York Nursery and Child's Hospital, 208, 218 New York Post Graduate Medical School, 214 New York University and Bellevue Hospital Medical College, 193 Niles, Walter L., 186,196,199, 200, 201, 226 Nobel prize in medicine, 160,211, 227, 266 Noguchi, Hideyo, 83,100 Northwestern University, medical department, 22

332

INDEX Norwood, William Frederick, 9,10 Occupational therapy in St. Louis, 140 Ohio Valley, early medical education, 15 Olin Hall, Cornell Medical College, 227 Opie, Eugene L. address at dedication of Washington University Medical School, 128-129 career, 83,119,123, 210 mentioned, 44,120,123,124,142, 151, 243 Oregon, University of, 183, 241 Osier, William as teacher, 47-50, 52, 82-86, 316 career, 37, 38, 52-53 Principles and Practice of Medicine, influence, 52, 82 teaching compared with Barker's, 84-85 visit to Oxford home, 169 mentioned, 1, 46, 95, 215,256 Osier Library, McGill University, vii Oxford University Ellis at, 95 Osier at, 52-53 visit, 169 Packard, Francis R., 67, 72, 75 Palmer, Walter W., 161,163-164 Paris, University of, 248 Parker, Willard, 15,17 Parkhurst, Irving B., 177 Part-time clinical teachers. See Clinical teachers Pathology, study at Johns Hopkins, 44-45 Patient as a Person (Dr. Robinson), 267 Paul, John R., 68 Paulson, Moses, 277, 278 Payne, Oliver Hazard, 189,193 Payne Whitney Psychiatric Clinic. See under New York Hospital

Peabody, Francis W., 90, 94, 98, 234, 319 Peabody College for Teachers, 151, 184 Pearce, Agnes M., 251 Peconic (Long Island), 229 Peiping Union Medical College, 229251 and Rockfeller Foundation, 233239,251 department of medicine, 244-246 department of neuropsychiatry, 255 history, 233-239, 250 organization, 239-244 teaching (Dr. Robinson), 244-247 mentioned, viii, 94, 216 Pennock, G. Α., 276 Pennsylvania, University of, 4,16, 23, 24, 37, 80,173, 210 Pennsylvania Hospital, 66-75 assistant pathologist (Dr. Robinson), 66 Ayer Clinical Laboratory, 69-72 Bulletin, 70-71 museum, 71-72 staff, 70 history, 5, 6, 66-70 residency (Dr. Robinson), 72-75 staff, 72-75 mentioned, viii, 3,13, 64, 65, 97 Pepper, William, 23-24, 301, 309 Peter Bent Brigham Hospital (Boston) , 94 Peters, John P., 161 Pharmacology department of, Washington University, 142-143 study at Johns Hopkins, 45 Phipps Institute for Study of Tuberculosis, 210 Phipps Psychiatric Clinic, Johns Hopkins, 213 Physical diagnosis, study at Johns Hopkins, 46 Physician attributes and character, 319-321 responsibility, 311-313 333

INDEX Physick, Philip Syng, 16, 68 Physiological chemistry, study at Johns Hopkins, 43 Physiology, study at Johns Hopkins, 42-43 Pinel, Philippe, 192 Pittsburgh, University of, 277 Pneumonia, study in Rockefeller Hospital, 93 Poliomyelitis, study in Rockfeller Hospital, 97-98 Polk, Frank L., 199, 200 Polk, William M., 193,194,195 Pope, Charles Alexander, 104-105 Powell, Wilson M., 221, 222, 225 Practical Essays on Medical Education and the Medical Profession of the United States (Daniel Drake), 17-18 Pratt, Joseph H., 259 Preceptorial system of medical education, 3 , 1 1 Presbyterian Hospital (New York), 162, 202, 305 Presbyterian Hospital of Philadelphia (Dr. Robinson as clinical pathologist) , 80 Pritchett, Henry S., 57, 58-59, 111, 112,115,151 Prognosis physicians' responsibility, 312 significance, 313 Prudden, T. Mitchell, 83 Quinn, Camilla S., 285 Rappleye, Willard C., 305 Red Cross. See American Red Cross Rehabilitation of physically handicapped, 138-140 Remsen, Ira, 35 Renard, Blanche, 254 Research, clinical. See Clinical research Research (Dr. Robinson's) cardiac, 78,127-128 circulation, 95-96 early assignments, 45 Reutinger, Anna, 215

Reynolds, Henry, 108 Rheumatic fever, study in Rockefeller Hospital, 95 Rhoads, Cornelius P., 283, 284 Robinson, G. Canby first patient, 65 marriage, 98 Robinson, Margaret Boise, 230 Robinson, Mrs. G. Canby, 166-167, 230 Robinson, Otis Boise, 230 Rochester, University of, 164,182, 226, 305 Rockefeller, John D., 82,112,184, 193, 233, 303 Rockefeller, John D., 3rd, 250 Rockefeller, Laura Spelman, Foundation, 190 Rockefeller Foundation activities in China, 233-239, 251 grant to Cornell University, 222 International Health Board, 174 support of study of social aspects of medicine, 257, 259, 265 mentioned, 94,160, 215, 255, 277, 303, 304 Rockefeller Institute for Medical Research history, 81, 82-83 influence on medical schools, 303, 304 mentioned, 186, 210,211, 227 Rockefeller Institute Hospital, 81100 history, 81, 83-89 influence, 85-86, 89, 99-100, 306 objectives, 91-92 organization, 89-92 plant, 90 research, 92-99 resident physician (Dr. Robinson) , 81-82 mentioned, viii, 161,164,173, 241 Rogers, Coleman, 16 Roosevelt, Theodore, 195 Rous, Peyton, viii, 100 Rush, Benjamin, 6 - 7 , 1 6 Rush Medical College, 241 Russell, Walter, 2 334

INDEX Russell, William L., 208, 213-214 Russell, William W., 51 Russell Sage Institute of Pathology, 208 Ruttenberg, Harold J., 276,277 Ryle, John, 318 Sabin, Florence R., 173 Sachs, Ernest, 120,126,138 Sage, Mrs. Russell, 122 St. Andrews (Scotland), visit, 168169 St. Bartholomew's Hospital (London), 98, 168 St. John's University (Shanghai), 231 St. Louis, Missouri City of, 102-103 Children's Hospital, 43,117-118, 123,124 Junior League, 140 Medical College, 104-105 Placement Bureau for Handicapped Men, 139 University, medical department, 104 St. Luke's Hospital (New York), 63 St. Luke's Hospital (Shanghai), 231 St. Luke's Hospital (Tokyo), 249 Saito, Kiyoshi, 249 Sand, Rene, 160 Sargent, Murray, 221, 226 Sauerbruch, Ernst Ferdinand, 317 Schloss, Oscar M., 196, 208 Schurman, Jacob Gould, 195 Schwab, Mrs. Sidney I., 139 Schwarz, Henry, 121,123 Scott, J. Alison, 73 Scudder, John, 284 Shaffer, Philip Α., viii, 119,120,137, 138 Shanghai (China), visit, 230, 231232 Shapleigh, John B., 122 Sharp and Dohme, 283, 284 Sheldon, Edward W., 186,189,191, 199-200, 202 Shepley, Henry R., viii, 155,159,172, 187,202, 205, 219

Shippen, William, 6,23, 72 Shoulders, Harrison H., 154 Sia, Richard, 245 Sigerist, Henry E., 206-207, 256 Singer Memorial Laboratory (Pittsburgh) , 173 Slack, Elijah, 16 Sloan-Kettering Division of Cornell Medical College, 227 Smith, Alan P., 66 Smith, Augustine J., 219 Smith, Captain John, 2 Smith, Charles Forster, 147 Smith, DeWitt, 281 Smith, George M., 120 Smith, Nathan, 8-9, 66 Smith, Nathan Ryno, 15, 66 Smith, Theobald, 83 Smith, Winford H., 155,156,202, 219 Social aspects of medicine, 253-280 Eastern Health District, Baltimore, study in, 264, 265 interest in (Dr. Robinson), 253255, 317-319 other studies, 279-280 Patient as a Person (Dr. Robinson), 267 study in Johns Hopkins experimental, 257-260 patients with digestive symptoms, 277-279 planning, 255-257 program, 260-266 reports, 266-275 study of industrial conditions, 266267 teaching, 280 Social medicine, significance in medical education, 317-319 Social service. See Medical social service Southern Association of Colleges and Secondary Schools, 153 Southern Medical Association, 254 Southern Methodist Church, 146,151 Southwestern Medical School, 182, 185 Spaulding, Lyman, 9 Spiller, William, 218 335

INDEX Thorndike Memorial Laboratory, Boston City Hospital, 94 Thro, William C., 210 Tinghsien (China), 247-249 Tinker, Martin B., 64-65 Torrey, John C., 210 Toxicology. See Pharmacology Transylvania University Medical School, 14,16,103 Truelson, George, 202 Tuberculosis medical education and, 298 research, 298 social service, 296-298 value of case-finding in health education, 299-300 Tucker, Frances T., 92 Tucker, Katherine, 215 Tuke, William and Samuel, 192 Tulane University, 176 Tung, C. L., 245 Tyson, James, 73

Stander, Henricus J., 212 Stanford University Medical School, 160 Steel Workers Organizing Committee, 276 Stengel, Alfred, 73 Stevenson, Robert Louis, 10 Stiles, Percy G., 43 Stillwell, Joseph W., 293 Stimson, Candace C., 194 Stimson, Henry L., 194 Stimson, Julia C., 123,126,137, 254 Stimson, Lewis Α., 193,194,195 Stockard, Charles R., 195, 208-209 Strumia, Max M., 284 Sudler, Mervin T., 41 Surgery, study at Johns Hopkins, 46-47, 50 Swarthmore College, 221 Sweet, J. E., 83 Swett, Prank H., 178 Swift, Homer F., 89, 94-95 Switzerland, visits, 75, 213 Syphilis, study in Rockefeller Hospital, 94 Syracuse University, 24 Taylor, Earl S., 285 Teaching, clinical. See Clinical teaching Teaching facilities, hospital, 13-14, 315-316 Tennessee Flexner's discussion of medical education, 150 State Department of Health, 179 University of, 151 Terry, Robert J., viii, 111, 115,119, 120,138 Thayer, William S., 36, 46, 48, 96, 163 Therapeutic Use of Digitalis (Robinson) , 161 Thomas, Henry M., 36, 48 Thomas, Henry M., Jr., 164,265 Thomas, M. Carey, 38 Thompson, Mary B., 89, 92 Thompson, Robert C., 296 Thompson, W. Gilman, 193

United States Public Health Service, 283,294 University Hospital (Philadelphia), 23 Universities. See under appropriate city or state Utrecht (Holland), visit, 168 Van Allen, Chester M., 243 Vanderbilt, Cornelius, 146 Vanderbilt, William K., 151 Vanderbilt University Chancellor Kirkland, 146-149 history, 146-147 semicentennial celebration, 177178 Vanderbilt University Dental School, 146 Vanderbilt University Hospital financial support, 184-185 organization, 176-177 Vanderbilt University Medical School dean (Dr. Robinson), 143,145, 155-156,187 finances, 183-185

336

INDEX Vanderbilt University Medical School (cont.) grants from General Education Board, 145,152-153,158-159, 172,174,181,194 history, 149-153 opening, 177-178 professional staff, 172-177 reorganization, 156-160,170-183, 187-188 mentioned, viii, 11, 211, 303, 305 Van Dyke, Harry B., 232, .243 Van Leeuwen, W. Storm, 167 Van Slyke, Donald D., 98,100,161, 173, 243, 245 Veeder, Borden S., 120,124 Veldee, Milton V., 283 Vienna (Austria) University of, 241 visit, 25 Vincent, George E., 160 Virginia, University of, 180,182 von Recklinghausen, Friedrich Daniel, 36 Wangensteen, Owen H., 284 Warburton Anatomy Act, 10 Ward, George Gray, 196 Warren, John, 8 Warren, Joseph, 7-8 Washington University and Robert Brookings, 109-110 medical department, 105,110 mentioned, 161,175,177 Washington University Medical School, 101-144 and Barnes Hospital, 113 and Robert Brookings, 102,107, 110-118,128,132-134 and St. Louis Children's Hospital, 117-118 associate professor of medicine (Dr. Robinson), 99 clinical teaching, full-time, 131132, 134^137 dean (Dr. Robinson), 138 Flexner report, 110-112 grants from General Education Board, 132-133,142-143

Washington University Medical School (cont.) history, 105-106,110 opening, 126-131 organization, 112-114 professional staff, 119-124 teaching (Dr. Robinson), 124-126 visit (1955), 102-103 World War I activities, 137-141 mentioned, viii, 164,185, 210, 211, 254 Waterhouse, Benjamin, 8 Weed, Lewis H., 281 Welch, William Henry and Abraham Flexner, 62 and Chinese medical education, 235, 240 and John Shaw Billings, 57 and Johns Hopkins Medical School, 36, 44, 302 and New York Hospital, 191-192 and Rockefeller Institute, 83, 303 and Washington University Medical School, 130-131 leadership in medical education, 56-57 mentioned, 86,112,114,128,152, 173,177, 201, 210,241, 256 Wenkebach, Karl Friedrich, 79 Wesson, Lawrence G., 178 West, Olin, 154 West China Union University, 237238, 250 Western Electric Company, 276 Western Journal of the Medical and Physical Sciences, 17 Western Reserve University, 160, 245, 311 White, J. DuPratt, 199, 200 White, Paul D., 165 White, Stanford, 194 Whitney, Payne, 186,189,202, 213, 303 Wilbur, Ray Lyman, 160 Wilkes, Susan H., 183 Willard, F. W., 276 Williams, Horatio B., 96 Williams, J. Whitridge, 36, 52, 55, 212 337

INDEX Willis, Henry S., 164 Willson, J. Thorn, 219 Wilson, Charles P., 182 Wilson, Frank N., 127,137, 245 Wilson, James C., 73 Wisconsin, University of, 248 Wistar, Caspar, 16 Witherspoon, John Α., 154 Witthaus, R. Α., 193 Wofford College, 147 Wolf, Anna D., 216, 219 Women's Clinic (New York Hospital), 212 Women's Fund Committee (Johns Hopkins), 38-39 Woodhouse, James, 16 Woodward, William, 199, 200-201 Woodyatt, Rollin T., 142 Woolsey, George, 193 World War I effects, 124,137-141 role of Dr. Robinson, 138-141

World War II Blood Donor Service, 281-293 effect on Peiping Union Medical College, 237-238 Wotton, Thomas E., 2 Wright, Arthur W., 179 Wright, Η. Α., 277 Wu, C. J., 245 Wu, Hsien, 244 Yale College Medical Institute, 9 Yale-in-China, 240 Yale Medical School, 161,180, 209, 226 Yale School of Nursing, 215 Yale University, 247 Yang, Marion, 247 Yen, F. C., 232 Yen, James, 247 Youmans, John B., 181,185,187 Young, Hugh H., 50, 53 Zinsser, Hans, 174, 245

338