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Colony of Maryland, 1633

Baron Baltimore, a Catholic, received a charter for the Colony of Maryland in 1632 from Charles I, and settlement began in 1633. Although the colony was named for the Virgin Mary, and was intended as a refuge for English and Irish Roman Catholics, Maryland was never predominantly Catholic.

Gerard Hopkins, of English background and member of the Church of England, was among the early colonists. Between imprisonments in England George Fox, founder of the Society of Friends and great preacher, came to America in 1671 on a mission to spread the Quaker doctrine. While in the Colonies he visited Maryland where he converted many to his belief including Gerard Hopkins. In due course Gerard married Margaret Johns, also of the Quaker persuasion, and they became the great grandparents of the wealthy Baltimore merchant and banker, Johns Hopkins (1795-1873), who endowed the Johns Hopkins University, Hospital and Medical School.

Johns was one of eleven children. There were six sons, of whom he was the second, and five daughters. The family lived comfortably on a tobacco plantation operated by slave labor until the local Quaker Meeting declared that slavery was unacceptable to their creed. Whereupon in 1807, when Johns was 12 years of age, his father freed all their slaves while continuing to provide for those who were young or old and still dependent. Life changed drastically for the Hopkins family, parents and children alike, all of whom now took up the considerable manual labor and other homely tasks required to tend the farm and make themselves completely self sufficient. This change brought to Johns and the other children the blessings of a disciplined life of hard work, frugality and sharing, with parents who imparted an uplifting faith and a love of learning. We may be sure that Johns's attitudes and ideals were influenced by the experiences of his youth. "Just as the twig is bent, the tree's inclined."

When Johns Hopkins' uncle would not give his daughter permission to marry Johns because of Quaker disapproval of consanguineous marriage, they both remained single. Later in life the childless Johns Hopkins, who was highly successful in business in Baltimore, looked upon his wealth as a trust and began to consider how he could best dispose of it for the benefit of humanity. After much thought and consultation he "was given to see", as the Quakers say, the course that he should follow: found a University, a Hospital and a Medical School in Baltimore. The Johns Hopkins University was opened in September 1876; the Johns Hopkins Hospital on 7 May 1889; and the Johns Hopkins University School of Medicine in October 1893. When Hopkins named the twelve-member Board of Trustees of the Hospital in 1867, he appointed his personal friend and fellow Quaker, Francis T. King, as President of the Board. Quite a few other members were also of the Society of Friends so that Quaker influence permeated the Board. [49]

In his Address at the opening ceremonies of the Hospital in 1889, Francis King had this to say about Johns Hopkins: [50]

What were the motives that led him to found his two great trusts (for the University and the Hospital), each with an endowment of nearly three million and a half dollars? Was it the act of a man of great wealth without children, who near the close of life wished to build a monument to his memory? No, not at all; it was done conscientiously, with all the deliberation, judgment and grasp of subjects which characterized him through life, first as a successful merchant, then as a banker.

l remember, many years ago, while spending an evening at Clifton (the country home of Johns Hopkins), I heard (him) say, in reply to a question put to him by an intimate friend of his own age, why he had never made a will, that he looked upon his wealth as a gift, for which he was accountable; that it grew and piled up from a small beginning, he hardly knew how; but he was sure it was given to him for a purpose, and he did not believe he would die before he was given to see how he should dispose of his estate. "This wealth," he repeated, "is my stewardship."

During the same period another prominent financier, Leland Stanford, and his wife were led by a personal tragedy, the death of their only child, also to devote their fortune and the remainder of their lives to the founding of a university on the other side of the continent from Maryland. Leland Stanford, Jr., died in Florence, Italy, from typhoid fever on 13 March 1884, a few weeks before his sixteenth birthday. "In the shadow of a great sorrow" Mr. Stanford, one of the builders of the first transcontinental railroad and former Governor of California, and Mrs. Stanford were guided by deep religious and humanitarian sentiments in their resolve that, in memory of their son, "the children of California shall be our children." The cornerstone of Leland Stanford Junior University was laid on the outskirts of Palo Alto, California, on 14 May 1887, the nineteenth anniversary of Leland Junior's birth. Opening exercises of the new University took place on 1 October 1891. Seventeen years later, in 1908, the University acquired the medical college founded by Elias Cooper. [51] [52] [53]


Johns Hopkins Medical School

The Medical School of Johns Hopkins University was the harbinger of change in many important respects. It was the first American medical school to require a bachelor's degree for admission and the first to be of the "university type" on the German model, as opposed to the clinically oriented schools and the large number of inferior proprietary establishments that characterized nineteenth century medical education in the United States. As late as 1871 Henry J. Bigelow, the influential Professor of Surgery at Harvard, referring to the commercialization of medical schools in order to maximize income from student fees, wrote: "It is safe to say that no successful school has thought proper to risk large existing classes and large receipts in attempting a thorough education". The Hopkins school was prepared to take the risk. [54]

Johns Hopkins was a medical school, albeit on a small scale, with something approaching an adequate endowment; it had well equipped laboratories conducted by modern teachers committed equally to medical investigation and instruction; and it had its own hospital where clinical research and teaching were combined with patient care. It is true that Harvard, Pennsylvania and a few other schools were evolving along similar lines but Hopkins made the first definitive move and became the national paradigm. It was held up as an example for emulation by Abraham Flexner whose critiques of medical education in 1910 and 1925 are the most influential writings on the subject ever published in the United States, and are justly credited with spurring much needed reforms. [55] [56]

The fact is that the innovations at Johns Hopkins Medical School, which were the original manifestation of the so-called Flexnerian reforms, placed it in the forefront of medical education at the time. Similar developments were also in progress at Harvard and some other institutions, but to a lesser extent. Far from deterring students, Hopkins' high admission and other standards brought them flocking. The School's program was initiated under the guidance of Johns Hopkins University's first President, Daniel Coit Gilman (who resigned as President of University of California, Berkeley, to take the post), and William Welch, first Dean and Professor of Pathology. In addition to Dr. Welch, 34 years of age at the time of his appointment, the original Hopkins faculty included a stellar group of relatively young professors whose names are inscribed in the annals of American Medicine: Anatomy (Franklin Mall, aged 31); Pharmacology (John Abel, 36); Physiology (William Howell, 33); Gynecology (Howard Kelly, 31); Medicine (William Osler, 40); and Surgery (William Halsted, 37). [57]

The issue of full-time appointment of faculty in Clinical Departments arose early in the life of the new medical school. Here, as in numerous other aspects of medical education, Hopkins set an important precedent. Full-time appointment meant that the faculty member was employed full-time by the University and was not permitted to hold any outside paid position or, in the case of a physician, to engage in private medical practice for personal gain. The purpose of the full-time system is, of course, to encourage the faculty member to devote full effort to teaching, research and related activities, and to prevent diversion from these pursuits by outside commitments and the prospect of additional income from private practice.

Full-time appointment of basic science faculty was the policy at Johns Hopkins Medical School from its inception because basic science departments were analogous in function to the academic departments of the University at large where full-time appointments were already the norm.

However, full-time appointments did not exist in the Clinical Departments at Hopkins or, on an organized basis, in any of the other American medical schools at the time. The professors in Clinical Departments in these schools and at Hopkins were free to engage in private practice and keep the income, thereby earning some or all of their salaries and relieving the School of a major expense. In fact, few if any American medical schools in the late nineteenth century could have existed without freedom of the professors in the Clinical Departments to support themselves by private practice.

Nevertheless, the Hopkins faculty concluded, with the urging of Flexner, that earnings from medical practice by members of Clinical Departments, as well as the demands of patient care, represented a potential distraction from their responsibilities in teaching and research.

As a result, Hopkins furthered the revolution in medical education by becoming the first American medical school to effectively introduce a full-time system in the Clinical Departments. That is, the professors and their staffs in these departments received a regular salary in full payment for their services. They held their posts on the condition that, while employed by the university and hospital, they would be free to engage in any medical practice required by humanity or science; but that the fees for these services would not be collected by the faculty member but by the medical school which would use them as it saw fit in support of the school's program. [58]

Installation of the full-time system for appointments in Clinical Departments was the most controversial feature of the Hopkins program. In 1911 Welch wrote: "I am sorry to say that Dr. Osler is strongly opposed to the plan, going so far in a letter received today as to say that it will wreck the hospital if we attempt it, at least on the basis of $7500 salaries for the chief physicians and surgeons. I am myself equally strong on the other side of the question....". [59] (Some years later Sir William Osler changed his view of the full-time system and supported the concept in principle.) Many voices within the medical profession, including the American Medical Association, were also critical. They predicted that the very physicians, surgeons and specialists best qualified by motivation and experience to teach clinical subjects in a medical school could not be adequately supported by the school on a full-time basis; that these practitioners would be reluctant to forego the income associated with private practice; and that full-time faculty would tend to give insufficient priority to patient care and clinical problems. These same caveats regarding the full-time system are not without substance and they are still heard today. As we shall see, the full-time question was warmly debated and proved to be a divisive issue when the Clinical Departments of Stanford Medical School were moved from San Francisco to the Campus and the full-time system was adopted in 1959.

Indeed, Hopkins had considerable difficulty in recruiting for the first full-time professorship in the Department of Medicine. The circumstances were these. Dr. Lewellys F. Barker, in a notable address in 1902, was the first American physician to make the case for full-time appointments in the Clinical Departments of medical schools. [60] In 1905, when William Osler departed for Oxford to become the Regius Professor of Medicine, he was replaced as Professor of Medicine at Hopkins by none other than Dr. Barker, an early exponent of the full-time system. However, in 1913, when Barker was invited to become the first full-time Professor of Medicine, he declined the offer and stepped aside to become a Professor of Clinical Medicine (which allowed him to continue in private practice and retain the fees) because he believed that he could not make adequate provisions for his family on the income from the full-time appointment. The next in line at Hopkins, William Thayer, then a clinical professor of medicine, also refused the full-time professorship and it became necessary to seek an outside candidate for the post. An intensive recruiting effort finally culminated in the appointment in on 1 July 1914 of Theodore Janeway from the Columbia University College of Physicians and Surgeons in New York as the first full-time Professor of Medicine at Hopkins. [61] [62]

Implementation of the full-time system at Hopkins was made possible (1) by a grant on 23 October 1913 of $1.5 million from the General Education Board (established in 1903 by John D. Rockefeller, Sr.) from which funds were obtained to support full-time salaried "University" appointments in Clinical Departments; and (2) by the decision to augment the full-time staff by offering unpaid "clinical" appointments (e.g., Professor of Clinical Medicine, etc.) to professors who chose to remain in private practice and donate their services as teachers. The full-time system was thus finally installed in 1914 with the following as the first group of full-time faculty in Clinical Departments: Professor of Medicine Theodore Janeway; Professor of Pediatrics John Howland; and Professor of Surgery William Halsted. The importance of some full-time appointments in Clinical Departments is now well recognized, and such appointments are a normal component of American medical faculties. However, many medical schools (Stanford included) find it necessary to continue experimenting with various titles and financial and procedural arrangements in an effort to maintain, in the face of changing conditions, an appropriate balance of "University" and "clinical" appointments. We shall return to this subject when discussing Stanford's faculty policy. [63]

We are also indebted to the Hopkins faculty for other innovations that have since become standard components of undergraduate and graduate medical education. These now-familiar features are the clinical clerkship for medical students and residency training for graduate physicians.

The father of the clinical clerkship is William Osler, world-renowned physician and medical educator, author of The Principles and Practice of Medicine (first edition, 1892), the most respected medical textbook of his day. It was in the autumn of 1896 that he brought fourth year medical students into the wards, outpatient department and clinical laboratory of the Johns Hopkins Hospital to take histories, examine the patients, and participate in their diagnosis and treatment. He did so with many misgivings at the time for he feared that there would be a hostile reaction. On the contrary, under his auspices the experiment was a resounding success, and the clinical clerkship is now an essential ingredient of medical education. Indeed, introduction of medical students into the wards and outpatient clinics as an integral part of a hospital's machinery for the care of patients is considered by some to be Osler's most lasting contribution to medicine. The overall reform in clinical teaching for medical students introduced at Hopkins consisted mainly in the reduction or abandonment of didactic lectures as the principle mode of instruction in clinical subjects, and the substitution of practical, supervised training experiences such as the clinical clerkship. Involvement of students in research was an additional invigorating aspect of the Hopkins teaching program. By 1896 senior medical students all had a research project of one kind or another which overlapped or supplemented their work in the clinic and laboratory. The students presented their findings in papers read at Hopkins' meetings, and many notable contributions by medical students were published in the Johns Hopkins Hospital Bulletin. [64] [65] [66]

For a personal reminiscence of Sir William Osler (who was created a Baronet in 1911), and a nostalgic commentary on the inauguration of the clinical clerkship at Hopkins, we are indebted to a distinguished Stanford alumnus, Dr. Emile Holman (1890-1977), Stanford A. B.. 1911, who was Professor and Executive Head of the Department of Surgery at Stanford from 1926 to 1955. As a young man, Holman entered Oxford University on a Rhodes Scholarship in 1911 where for three years he studied medicine and came to greatly admire Dr. Osler, the Regius Professor. After returning to America Holman received an MD in 1918 from Hopkins. He continued there for five more years as a surgical resident under Dr. Halsted before completing his surgical training with a year at Harvard in the Peter Bent Brigham Hospital under Dr. Harvey Cushing (who had himself spent fourteen years at Hopkins). It is not surprising that the Hopkins educational ideals accompanied Dr. Holman when he finally returned to his alma mater in 1925 as a member of the Stanford medical faculty. In 1964 Dr. Holman wrote as follows of Dr. Osler and the clinical clerkship: [67] [68] [69]

The claim of Sir William Osler to enduring fame may well rest on one simple fact: Said he, "I hope my gravestone will bear only the statement: 'He brought medical students into the wards for bedside teaching' ". As early as 1896, students at Johns Hopkins Hospital were assigned the duties of recording the patient's past medical history and present illness, of making a complete physical examination, and of doing the simpler laboratory examinations. To us, now, all this seems quite commonplace, but at that time it took vision, courage, and faith to assign such important tasks to "mere" students. As Iris Noble reports, Osler himself was beset by the haunting fear that these radical innovations would be fought by the public and spurned by the medical profession. To his genuine relief, their acceptance was immediate and general, and they survive today as important keystones in medical education.

Residency training, in a modern sense, was introduced at Hopkins. Simply stated, this type of training is a supervised program of study and experience, usually in a hospital, for a physician who has already graduated from medical school. It should be pointed out that hospital training for doctors wishing further experience after graduation has a diverse history extending back over many centuries in Europe, and since colonial times in America. Various arrangements evolved whereby the doctor seeking additional training before entering practice or other medical work served in a hospital under such titles as dresser, walker, intern, resident, house pupil, house physician, Assistant to the Professor (in Germany), etc. On the American scene in the 1800s, hospital-based training during the first year or two after graduation from medical school was usually known as an "internship", and generally amounted to an inpatient apprenticeship. The growing need in American medicine for advanced training beyond the internship, leading to maturity and clinical specialization grounded in medical science, was first met in a systematic fashion by the Hopkins residency training program.

In its original form the Hopkins program began after the internship and consisted of an indefinite number of years (reduced in modern times to an average of three or four) of hospital-based clinical and scientific work in a specific field, such as medicine or surgery, during which an optimum balance of supervision, responsibility, service and education was achieved. The Johns Hopkins Hospital was completed in 1889 and a resident staff in medicine and surgery could begin their work in the next year because John Shaw Billings who planned the hospital had, with keen foresight, included a unique facility: ample living quarters for a resident staff in a dignified setting in the front building of the hospital. These accommodations made it possible for a relatively large number of carefully selected medical graduates to live in the hospital and obtain long periods of training under professorial guidance, bringing them to levels of competence rarely attainable under other conditions. Osler in Medicine and Halsted in Surgery, influenced by their knowledge of the German Assistantships, designed and in 1890 installed training programs that presaged present-day residencies, and prepared an unparalleled number of academic and scientific leaders in their respective fields. The joint statement of residency training objectives by Osler and Halsted was brief and to the point: "Clinical training, to be truly graduate training, should discipline the resident in scientific attitudes toward health and disease, and should enable the graduate to begin the practice of a clinical specialty in a scientific manner without supervision." Dr. Welch was later to say that the residency training system introduced into American Medicine by the Johns Hopkins Hospital was "the most important contribution which Johns Hopkins made to medical education". [70] [71] [72]

Graduates from Johns Hopkins Medical School and physicians who had served in the Hopkins residency training program went forth in unprecedented numbers to become influential faculty members in medical schools across the country.

The following Hopkins graduates held full professorships at Stanford Medical School:

  • Arthur Meyer, MD (JHMS 1905) Professor of Anatomy
  • Wilfred Manwaring, MD (JHMS 1904) Professor of Bacteriology
  • Edward Schultz, MD (JHMS 1917) Professor of Bacteriology
  • Albion W. Hewlett, MD (JHMS 1900) Professor of Medicine
  • Arthur Bloomfield, MD (JHMS 1911) Professor of Medicine
  • John Luetscher, Jr. MD (JHMS 1937) Professor of Medicine
  • Ernest Martin, PhD (JHU 1904) Professor of Physiology
  • Emile Holman, MD (JHMS 1918) Professor of Surgery
  • Frederick Reichert, MD (JHMS 1920) Professor of Surgery

Other Stanford professors who had Hopkins experience include Dr. Emmet Rixford, Professor of Surgery from 1898 to 1930, who worked in Welch's laboratory during the summer of 1892, a year before admission of the first class of students to the Hopkins medical school. There was Dr. Ernest Dickson who served as an Assistant Resident Physician at Johns Hopkins Hospital from 1907 until 1908 when he became a Fellow in Pathology with Dr. Welch. Soon after beginning his fellowship Dr. Welch called him into his office to tell him that Dr. William Ophüls, Professor of Pathology at Cooper Medical College and a brilliant young German-trained pathologist whom Dr. Welch held in high regard, needed an assistant. With Dr. Welch's blessing, Dickson was accepted by Dr. Ophüls and in 1908 moved to San Francisco to take up his new post. Dr. Dickson continued on the faculty when Stanford took over Cooper Medical College, and from 1926 until his death in 1939 he was Professor and Chairman of the Stanford Department of Public health and Preventive Medicine. For his outstanding research on botulism he earned worldwide recognition. Dr. Windsor Cutting (Stanford AB,'28; MD, '32), after two years as a Fellow in Pharmacology and Medicine at Hopkins from 1936 to 1938, joined the Stanford faculty in 1938 where he rose to the rank of Professor of Pharmacology in 1950, and was Dean of the School of Medicine from 1953 to 1957. [73] [74]

We have seen how the program of the nation's oldest medical school, founded in Philadelphia in 1765, was based on the Edinburgh model. Similarly, the evolution of medical education at Stanford strongly reflects the influence of Johns Hopkins. And in the early history of all three of these important American schools, we can discern a relationship to the Society of Friends.

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