Medicine – The Fixed Period Part 2

Such an occasion as the present affords an opportunity to say a few words on the work which the Johns Hopkins foundations have done and may do for medicine. The hospital was organized at a most favourable period, when the profession had at last awakened to its responsibilities, the leading universities had begun to take medical education seriously, and to the public at large had come a glimmering sense of the importance of the scientific investigation of disease and of the advantages of well trained doctors in a community. It would have been an easy matter to have made colossal mistakes with these great organizations. There are instances in which larger bequests have been sterile from the start; but in the history of educational institutions it is hard to name one more prolific than the Johns Hopkins University. Not simply a seed farm, it has been a veritable nursery from which the whole country has been furnished with cuttings, grafts, slips, seedlings, etc. It would be superfluous in this audience to refer to the great work which the Trustees and Mr. Gilman did in twenty-five years—their praise is in all the colleges. But I must pay a tribute to the wise men who planned the hospital, who refused to establish an institution on the old lines—a great city charity for the sick poor, but gave it vital organic connexion with a University. I do not know who was directly reponsible for the provision in Mr. Hopkins’ will that the hospital should form part of the Medical School, and that it should be an institution for the study as well as for the cure of disease. Perhaps the founder him-self may be credited with the idea, but I have always felt that Francis T. King was largely responsible, as he had strong and sensible convictions on the subject, and devoted the last years of his useful life putting them into execution. As first President of the Hospital Board he naturally did much to shape the policy of the institution, and it is a pleasure to recall the zeal and sympathy with which he was always ready to cooperate. It is sad that in so few years all of the members of the original Board have passed away, the last, Mr. Corner—faithful and interested to the end—only a few weeks ago. They did a great work for this city, and their names should be held in everlasting remembrance. Judge Dobbin and James Carey Thomas, in particular, the members of the staff in the early days remember with gratitude for their untiring devotion to the medical school side of the problems which confronted us. To John S. Billings, so long the skilled adviser of the Board, we all turned for advice and counsel, and his influence was deeper and stronger than was always apparent. For the admirable plan of preliminary medical study, and for the shaping of the scientific work before the hospital was opened for patients, we are indebted to Newell Martin, Ira Remsen and W. H. Welch. The present excellent plan of study leading to medicine, in which the classics, science and literature are fully represented, is the outcome of their labours.

About this time sixteen years ago Mr. King, Dr. Billings, Dr. Welch and myself had many conferences with reference to the opening of the hospital. I had been appointed January 1st, but had not yet left Philadelphia. As so often happens the last steps in a great organization are the most troublesome, and after some delay the whole matter was intrusted to Mr. Gilman, who became acting director, and in a few months everything was ready, and on May 7 the hospital was opened. I look back with peculiar pleasure to my association with Mr. Gilman. It was both an education and a revelation. I had never before been brought into close contact with a man who loved difficulties just for the pleasure of making them disappear. But I am not going to speak of those happy days lest it should forestall the story I have written of the inner history of the first period of the hospital.

At the date of the organization of the hospital the two great problems before the profession of this country were, how to give to students a proper education, in other words how to give them the culture, the science and the art commensurate with the dignity of a learned profession; and secondly, how to make this great and rich country a contributor to the science of medicine.

The conditions under which the medical school opened in 1893 were unique in the history of American medicine. It would have been an easy matter, following the lead of the better schools, to have an entrance examination which guaranteed that a man had an ordinary education, but Miss Garett’s splendid gift enabled us to say, no! we do not want a large number of half-educated students; we prefer a select group trained in the sciences preliminary to medicine, and in the languages which will be most useful for a modern physician. It was an experiment, and we did not expect more than twenty five or thirty students each year for eight or ten years at least. As is so often the case, the country was better prepared than we thought to meet our conditions, and the number of admissions to the school has risen until we have about reached our capacity. Our example in demanding the preliminary arts or science course for admission to the school has been followed by Harvard, and is to be adopted at Columbia. It is not a necessary measure in all the schools, but there has been everywhere a very salutary increase in the stringency of the entrance examinations. Before we took up the work great reforms in the scientific teaching in medicine had already begun in this country. Everywhere laboratory work had replaced to some extent the lecture, and practical courses in physiology, pathology and pharmacology had been organized. We must not forget however that to Newell Martin, the first professor of physiology in this university, is due the introduction of practical classes in biology and physiology. The rapid growth of the school necessitated the erection of a separate building for physiology, pharmacology and physiological chemistry, and in these departments and in anatomy the equipment is as complete as is required. Of the needs in pathology, hygiene and experimental pathology this is not the occasion to speak. It is sufficient to say that for instruction in the sciences, upon which the practice of the art is based, the school is in first class condition.

Indeed the rapidity with which the scientific instruction in our medical schools has been brought to a high level is one of the most remarkable educational features of the past twenty years. Even in small unendowed colleges admirable courses are given in bacteriology and pathology, and sometimes in the more difficult subject of practical physiology. But the demand and the necessity for these special courses has taxed to the utmost the resources of the private schools. The expense of the new method of teaching is so great that the entire class fees are absorbed by the laboratories. The consequence is that the old proprietary colleges are no longer profitable ventures, certainly not in the north, and fortunately they are being forced into closer affiliation with the universities, as it is not an easy matter to get proper endowments for private corporations.

The great difficulty is in the third part of the education of the student: viz., his art. In the old days when a lad was apprenticed to a general practitioner, he had good opportunities to pick up the essentials of a rough and ready art, and the system produced many self-reliant, resourceful men. Then with the multiplication of the medical schools and increasing rivalry between them came the two year course, which for half a century lay like a blight on the medical profession, retarding its progress, filling its ranks with half-educated men, and pandering directly to all sorts of quackery, humbuggery and fraud among the public. The awakening came about thirty years ago, and now there is scarcely a school in the country which has not a four years course, and all are trying to get clear of the old shackles and teach rational medicine in a rational way. But there are extraordinary difficulties in teaching the medical student his Art. It is not hard, for example, to teach him all about the disease pneumonia, how it prevails in the winter and spring, how fatal it always has been, all about the germ. all about the change which the disease causes in the lungs and in the heart—he may become learned, deeply learned, on the subject—but put him beside a case, and he may not know which lung is involved, and he does not know how to find out, and if he did find out, he might be in doubt whether to put an ice-bag or a poultice on the affected side, whether to bleed or to give opium, whether to give a dose of medicine every hour or none at all, and he may not have the faintest notion whether the signs look ominous or favourable. So also with other aspects of the art of the general practitioner. A student may know all about the bones of the wrist, in fact he may carry a set in his pocket and know every facet and knob and nodule on them, he may have dissected a score of arms, and yet when he is called to see Mrs. Jones who has fallen on the ice and broken her wrist, he may not know a Colles’ from a Pott’s fracture, and as for setting it secundum artem, he may not have the faintest notion, never having seen a case. Or he may be called to preside at one of those awful domestic tragedies—the sudden emergency, some terrible accident of birth or of childhood, that requires skill, technical skill, courage—the courage of full knowledge, and if he has not been in the obstetrical wards, if he has not been trained practically, if he has not had the opportunities that are the rights of every medical student, he may fail at the critical moment, a life, two lives, may be lost, sacrificed to ignorance, often to helpless, involuntary ignorance. By far the greatest work of the Johns Hopkins Hospital has been the demonstration to the profession of the United States and to the public of this country of how medical students should be instructed in their art. I place it first because it was the most needed lesson, I place it first because it has done the most good as a stimulating example, and I place it first because never before in the history of this country have medical students lived and worked in a hospital as part of its machinery, as an essential part of the work of the wards. In saying this, Heaven forbid that I should obliquely disparage the good and faithful work of my colleagues elsewhere. But the amphitheatre clinic, the ward and dispensary classes, are but bastard substitutes for a system which makes the medical student himself help in the work of the hospital as part of its human machinery. He does not see the pneumonia case in the amphitheatre from the benches, but he follows it day by day, hour by hour; he has his time so arranged that he can follow it; he sees and studies similar cases and the disease itself becomes his chief teacher, and he knows its phases and variations as depicted in the living; he learns under skilled direction when to act and when to refrain, he learns insensibly principles of practice and he possibly escapes a “nickel-in-the-slot” attitude of mind which has been the curse of the physician in the treatment of disease. And the same with the other branches of his art; he gets a first hand knowledge which, if he has any sense, may make him wise unto the salvation of his fellows. And all this has come about through the wise provision that the hospital was to be part of the medical school, and it has become for the senior students, as it should be, their college. Moreover they are not in it upon sufferance and admitted through side-doors, but they are welcomed as important aids without which the work could not be done efficiently. The whole question of the practical education of the medical student is one in which the public is vitally interested. Sane, intelligent physicians and surgeons with culture, science, and art, are worth much in a community, and they are worth paying for in rich endowments of our medical schools and hospitals. Personally, there is nothing in life in which I take greater pride than in my connexion with the organization of the medical clinic of the Johns Hopkins Hospital and with the introduction of the old-fashioned methods of practical instruction. I desire no other epitaph—no hurry about it, I may say—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.

The second great problem is a much more difficult one, surrounded as it is with obstacles inextricably connected with the growth and expansion of a comparatively new country. For years the United States had been the largest borrower in the scientific market of the world, and more particularly in the sciences relating to medicine. To get the best that the world offered, our young men had to go abroad; only here and there was a laboratory of physiology or pathology, and then equipped as a rule for teaching. The change in twenty years has been remarkable. There is scarcely to-day a department of scientific medicine which is not represented in our larger cities by men who are working as investigators, and American scientific medicine is taking its rightful place in the world’s work. Nothing shows this more plainly than the establishment within a few years of journals devoted to scientific subjects; and the active participation of this school as a leader is well illustrated by the important publications which have been started by its members. The Hospital Trustees early appreciated the value of these scientific publications, and the Bulletin and the Reports have done much to spread the reputation of the Hospital as a medical centre throughout the world. But let us understand clearly that only a beginning has been made. For one worker in pathology—a man, I mean, who is devoting his life to the study of the causes of diseases—there are twenty-five at least in Germany, and for one in this country there are a dozen laboratories of the first class in any one of the more important sciences cognate to medicine. It is not alone that the money is lacking; the men are not always at hand. When the right man is available he quickly puts American science into the forefront. Let me give you an illustration. Anatomy is a fundamental branch in medicine. There is no school, even amid sylvan glades, without its dissecting room; but it has been a great difficulty to get the higher anatomy represented in American universities. Plenty of men have always been available to teach the subject to medical students, but when it came to questions of morphology and embryology and the really scientific study of the innumerable problems connected with them, it was only here and there and not in a thorough manner that the subjects were approached. And the young men had to go abroad to see a completely equipped, modern working anatomical institute. There is to-day connected with this university a school of anatomy of which any land might be proud, and the work of Dr. Mall demonstrates what can be done when the man fits his environment.

It is a hopeful sign to see special schools established for the study of disease such as the Rockefeller Institute in New York, the McCormick Institute in Chicago and the Phipps Institute in Philadelphia. They will give a great impetus in the higher lines of work in which the country has heretofore been so weak. But it makes one green with envy to see how much our German brethren are able to do. Take, for example, the saddest chapter in the history of disease—insanity, the greatest curse of civilized life. Much has been done in the United States for the care of the insane, much in places for the study of the disease, and I may say that the good work which has been inaugurated in this line at the Sheppard Hospital is attracting attention every-where; but what a bagatelle it seems in comparison with the modern development of the subject in Germany, with its great psychopathic clinics connected with each university, where early and doubtful cases are skilfully studied and skilfully treated. The new department for insanity connected with the University of Munich has cost nearly half a million of dollars! Of the four new departments for which one side of the hospital grounds lies vacant, and which will be built within the next twenty-five years, one should be a model psychopathic clinic to which the acute and curable cases may be sent. The second, a clinic for the diseases of children. Much has been done with our out-patient department under Dr. Booker, who has helped to clarify one of the dark problems in infant mortality, but we need a building with fine wards and laboratories in which may be done work of a character as notable and worldwide as that done in Dr. Kelly’s division for the diseases of women.’ The third great department for which a separate building must be provided is that of Syphilis and Dermatology. Already no small share of the reputation of this hospital has come from the good work in these specialities by the late Dr. Brown, by Dr. Gilchrist, and by Dr. Hugh Young; and lastly, for diseases of the eye, ear, and throat, a large separate clinic is needed, which will give to these all-important subjects the equipment they deserve.

For how much to be thankful have we who have shared in the initiation of the work of these two great institutions. We have been blessed with two remarkable Presidents, whose active sympathies have been a stimulus in every department, and whose good sense has minimized the loss of energy through friction between the various parts of the machine —a loss from which colleges are very prone to suffer. A noteworthy feature is that in so motley a collection from all parts of the country the men should have fitted into each other’s lives so smoothly and peacefully, so that the good fellowship and harmony in the faculties has been delightful. And we have been singularly blessed in our relationship with the citizens, who have not only learned to appreciate the enormous benefits which these great trusts confer upon the city and the state, but they have come forward in a noble way to make possible a new era in the life of the university. And we of the medical faculty have to feel very grateful to the profession, to whose influence and support much of the success of the hospital and the medical school is due; and not only to the physicians of the city and of the state, who have dealt so truly with us, but to the profession of the entire country, and more particularly to that of the Southern States, whose confidence we have enjoyed in such a practical way. Upon a maintenance of this confidence the future rests. The character of the work of the past sixteen years is the best guarantee of its permanence.

What has been accomplished is only an earnest of what shall be done in the future. Upon our heels a fresh perfection must tread, born of us, fated to excel us. We have but served and have but seen a beginning. Personally I feel deeply grateful to have been permitted to join in this noble work and to have been united in it with men of such high and human ideals.