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35. The Hopkins: A Revolution in Medicine

ON CHRISTMAS EVE, 1873, the city of Baltimore, Maryland, lost its richest man: Johns Hopkins. The bachelor merchant and financier, aged 78, had willed his substantial fortune.

To found a hospital and a university within which a medical school was to be organized. Each of these institutions, he decreed, was to bear his name. The shrewd and far-sighted Quaker regarded his fortune as a trust, and had spent considerable time planning its use for the good of humanity. As early as 1867, bills had been passed in the Maryland General Assembly authorizing formation of two corporation, The Johns Hopkins Hospital, and The Johns Hopkins University; carefully selected board of trustees had been established to carry out the donor’s wishes; and various plots of real estate, trust funds, and stocks had been earmarked to endow the institutions.

Altruistic as had been Johns Hopkins’ motives and plans, neither he nor his trustees could have envisioned the tremendous impact that the forces thus set in motion would have on the social and cultural life of the nation; or the revolution that would be brought about in methods of medical education and in standards prerequisite to qualification for medical practice. Abraham Flexner, writing in 1940, said of The Johns Hopkins University Medical School: “It Possessed ideals and men who embodied them, and from it emanated the influences that in a half century have lifted American Medical Education from the lowest status it the highest in the civilized world.”

In the North America colonies, medical education in the seventeenth and eighteenth centuries had largely followed the apprenticeship system. First attempt to establish a medical school came at the college of Philadelphia in 1765. Medical students who could afford it finished their training in Germany, France, Holland, Great Britain or Denmark. In the early years of the 1800’s, less than ten per cent of physicians in the United States were graduates of medical schools, and more than eighty per cent had never attended a lecture in a school of medicine.

Early in the nineteenth century, some 460 proprietary schools came into being. The primary aim of many of them was to collect tuition fees from students for the privilege of attending lecture courses running tan to twenty weeks. There were virtually no entrance requirements beyond ability to sign a promissory note or to pay for the course; and, in absence of any state regulation, a diploma from such a school was accepted as a license to practice medicine.

The aim to improve this deplorable state of medical education was one of the pillars upon which The American Medical Association was founded in 1847: but without vested authority, the Association could do little but point the way toward reform. Through Nathan Smith Davis, “father” of AMA, introduced a graded curriculum in the in the Northwestern University School of Medicine in 1859, the Association itself had published the statement: “True University Orientation of Medical Education really began with the Johns Hopkins University Medical School in 1983.”

The Philosophical (arts and science) faculty and the graduate school of The Johns Hopkins University opened their doors three years after the death of the man who made them possible. Significantly, this year, 1876, marked the centennial of the declaration of political independence by the United State of America. Shryock has observed that opening of The Hopkins “in effect announced America independence in scholarship and science.
The trusty selected by John Hopkins took their Responsibility seriously and did their work well. They persuaded Daniel Coit Gilman to leave the presidency of university of California to organize the new university in Baltimore and became its president.

Gilman believed in the value of advanced training and of encouragement of research; as Shryock Stated, “The Hopkins had antiquated neither notions nor obsolescent staff to handicap it the start… The result: Hopkins Products were soon in demand all over the country. Within twenty years (1896) over sixty American colleges or universities had three or more Professors holding Hopkins degrees on their staffs.”

While the university was getting under way, the trustees of The Johns Hopkins Hospital sought to carry out their first assignment: to built the Hospital. Member of this board depended greatly on John Shaw billing, whom they had chosen as their official advisor.Dr Billings was a military physician and librarian attached to the Army Surgeon General’s office, who had acquired wide hospital experience during the civil war. Dr. Billing designed The Johns Hopkins Hospital buildings, and assisted President Gilman in preparing plans both for hospital management and for integration of the hospital with the proposed medical school. Billings included plan for a school of nursing, and for various supporting service, among them pharmacies. It was who recommended small classes, actual clinical teaching, laboratory facilities, and that professors heading departments in the school should also head the appropriate service in the hospital. He also envisaged creation of departments of public hygiene, psychiatry, Pediatric, and medical history. Funds for construction of the hospital came largely from income from real estate, bank stock, and the Johns Hopkins town house. The aggregate from these income sources did not permit rapid Fulfillment of the donor’s plan. Building only as they had accrued income to do so, the hospital trust resisted pressure of person who wished them to operate an incomplete hospital; it was not until May 7, 1889, that the doors of The Johns Hopkins Hospital were formally opened. In absence of a suitable professional administrator, the Hospital trustees asked President Gilman of the university to direct the Hospital. This he did during the first four months following its opening. Then the trustees secured the service of Henry M. Hurd, M.D., to suspend the Hospital, and Dr. Gilman returned to his university duties.

The university trustees had hoped to open the medical school at the same time as the hospital was opened. Several years previously, President Gilman had surveyed British medical opinion regarding educational standards that should be required of applications prior to admitting then to study of medicine. He actually established, as early as 1878, a so- called “preliminary Medical Course`” in the university.

In1883, the trustees of the university created a Faculty of Medicine, which in addition to President Gilman, consisted of Ira Remsen, professor of Chemistry; H.N. Martin, Professor of Physiology; and J.S. Billings, Professor of Hygiene. Through none of these men actively taught in the medical School after it was officially opened, they were influential in establishment of certain general policies of the school notably in recommendation of high admission requirements.

It is significant that all members chosen for the faculty of The Johns Hopkins University Medical School were comparatively young. First to be chosen was Williams H. Welch, M.D. (1850-1934), as Pathologist, in 1884.then 34 years ago, Dr. Welch was to serve the university in various capacities for fifty years, and was the most influential of the faculty members. Dr. Welch was a graduate of Yale and of the college of physicians and surgeons of New York, and had studies for some time Germany. Dr. Welch at once began to organize post-graduate courses in bacteriology and pathology for practicing physicians, using hospital facilities for teaching, since there was as yet no medical school. The greater part of responsibility for selection of his associates on the Medical School faculty fell upon Dr. Welch’s shoulders.

Next to come, in 1888, was Canadian-born William Osler (1849-1919), called from a post oat the University of Pennsylvania to become physician-in-chief at the hospital and professor of the Theory and Practice of Medicine at the university. Dr. Osler’s
Service continued until 1905, when he was called to England to become Reius professor of medicine at Oxford University. Prior to opening of the hospital in 1889, a New York surgeon, Williams S. Halsted (1852-1922), temporarily working in Dr. welch laboratory, was made Acting surgeon to the Hospital; and Howard A. Kelly (1858-1943) was called from the University of Pennsylvania to become Gynecologist and Obstetrician to the Hospital.

The best of plans go awry, however. A substantial proportion of The Johns Hopkins University’s endowment consisted of shares in the Baltimore and Ohio Railroad. These shares, which paid as high as ten per cent dividends when first received by the university trustees, dwindle in values within a decade to provide virtually no income at all. In 1889, President Gilman faced a seemingly insurmountable problem: there were not sufficient funds available to prim it opening of the Medical School. The trustees had agreed that a minimum endowment of $500000 should be accumulated to Guarantee successful operation of the School-and when the Hospital opened, in 1889, the Medical School goal seemed far away, due to shrinkage in revenues from the original University endowment.

Fortunately, a group of young woman in Baltimore, interested in a country- wide movement to provide higher education for women, and particularly desirous of assuring opportunities for women in medical education, formed a committee to raise funds. Among the leaders in this movement were the Misses M.Carry Thomas Mary E. Garrett, Mary Gwinn, and Elizabeth T. King – all daughters of trustees or former trustees of the University. This women’s committee succeeded in raising more than $100,000 in 1890, which was made available to the trustees of the University for the Medical School, on stipulation that women be admitted to the study of Medicine on the same terms as men. Efforts to raise further funds languished during the next two years: but in December, 1892, Miss Garrett offered the trustees the balance required to make up the $500,000 needed to open the Medical School, subject to two conditions: admission of women on the same terms as men, and maintenance of admission qualification for all student of a Bachelor’s degree or equivalent work in chemistry, in physics, in Biology, and in modern language. Through some faculty member had misgivings about this admission standard, the trustees accepted Miss Garrett’s gift and terms.

When The Johns Hopkins University school of Medicine opened, October 2, 1893, its catalogue listed the faculty as follow: Daniel C. Gillman, LL.D., president: Williams H. Welch, M.D., Professor of Pathology and Dean; Ira Remsen, M.D., Ph.D., Professor of Chemistry; Williams Osler, M.D., F.R.C.P., Professor of the Principles and Practice of Medicine; Henry M.Hurd, M.D., Professor of Psychiatry; William S. Halsted, M.D., Professor of Surgery; Howard A. Kelly, M.D Professor of Gynecology and Obstetrics;