"Father of Modern Medicine": The Johns Hopkins School of Medicine, 1889-1905

" . . . I have been in Baltimore seeing Johns Hopkins, & [am] more than delighted. It is the university of the future & when the Med School is organized all others will be distanced in the country."

– Sir William Osler writing to his friend John Mullen, November 8, 1886

When Baltimore merchant banker Johns Hopkins died in 1873, he left $7,000,000 to establish a new university and hospital, with a medical school to unite them. He had envisioned a university on a German model, where the students would be highly qualified, and the faculty would not only teach but carry on research and train graduate students in their fields. The Johns Hopkins University opened in 1876, but construction of the hospital and medical school was repeatedly delayed because their endowments were tied to poorly performing investments. When the hospital opened in 1889, some of the medical school faculty had been recruited, but there was no way to pay them. Osler was appointed Physician in Chief of the hospital (with a salary) and Professor of the Theory and Practice of Medicine (without a salary). For the first year, Osler worked with the Hopkins leadership, among them John Shaw Billings, director of the Surgeon General's Library, and pathologist William Welch, to fill other hospital and medical school positions. Their choices included William Halsted as head of surgery, and Howard Kelly as head of the gynecological services. Meanwhile, the hospital recruited many young medical residents, and the first faculty members were doing post-graduate teaching and mentoring for several years before the medical school opened. These first "Hopkins men" enjoyed much camaraderie, and, led by Osler, founded a journal club, a medical society, and a historical club, plus the Johns Hopkins Hospital Bulletin and the Johns Hopkins Hospital Reports.

In 1890, with the medical school opening delayed and private practice slow, Osler began writing a medical textbook, The Principles and Practice of Medicine. Published in 1892, it was a huge success and eventually ran through sixteen editions (Osler did the first seven, and the book royalties were a major part of his income for the rest of his life). Writing in a clear, literary style, Osler discussed symptoms, diagnosis, prognosis, treatment, etiology, and morbid anatomy for thirty infectious diseases and a wide range of other disorders. His descriptions incorporated the latest scientific research--especially germ theory--but also drew heavily on his own large collection of case studies and, often, his historical knowledge. Although rapid advances in medical knowledge and therapeutics during the next century would radically change most aspects of clinical practice, Osler's astute "natural histories" of many diseases retained their value and even became "classics." With its straightforward style and emphasis on medical science, The Principles and Practice of Medicine also inspired Rockefeller advisor Frederick T. Gates to recommend the establishment of the Rockefeller Institute for Medical Research, which opened in 1901.

Soon after the textbook was published, Osler married Grace Revere Gross, an old friend from his Philadelphia days. She was a great-granddaughter of Paul Revere, and widow of Dr. Samuel W. Gross. The couple had two children: the first son, born in 1893, died soon after birth. The second, Edward Revere, born December 28, 1895 survived, but would be killed in World War I at the age of twenty-two. The Oslers moved into a large house on West Franklin Street where, with Grace's competent management, they frequently hosted Hopkins colleagues and students, as well as visiting relatives, friends, and physicians.

Teaching at the Bedside

The Johns Hopkins Medical School finally opened in 1893. It was a model of modern medical education: entering students had to have an undergraduate degree and a working knowledge of French and German; the medical program was four years long, with the first two years spent largely in pre-clinical laboratory science courses; the faculty was recruited from the best and brightest in the United States and abroad, rather than from the local medical community. And, remarkably, it was the first American medical school that admitted women on the same basis as men. A committee of wealthy women, notably Mary Elizabeth Garrett, had raised the funds needed to open the school, and the admission of women was one of the conditions of their bequest.

The outstanding innovation at "the Hopkins," however, was the clinical teaching system developed by Osler. Beginning in their third year, medical students began learning at the bedside, and participated continuously in the care of real patients in the medical, surgical, obstetrical, and gynecological departments of the hospital. Supervised by the medical and surgical resident physicians, third year students began working with patients in the dispensary (outpatient clinic), taking histories of new patients and following assigned cases. They received ongoing instruction in examination, diagnosis, and clinical microscopy, and attended weekly case discussions. In the fourth year clerkships, students worked in the hospital wards, again under the supervision of senior residents. Each clerk was assigned five or six patients to attend during their rotation through each hospital department. They took histories, did initial examinations, kept the daily records, took and examined blood and urine samples, and learned to dress wounds. In surgical clerkships, they assisted with operations. The clerks followed their patients until discharge; if a patient died, students often helped with the autopsy. Throughout this apprenticeship, clerks met several times each week with an attending faculty physician, to discuss cases, and attended weekly general clinics where all the cases could be discussed and compared. At Johns Hopkins, the hospital essentially became the medical school and the patients became the students' texts. Nowhere else in America was such experience available to medical students.

Osler's ward rounds with his students, conducted three days each week, became legendary. He would examine each patient, quiz the clerks and residents intently about diseases and treatments, and often send them to the library to learn more. Yet he had an informal style that put both patients and students at ease. And as Henry Christian (later dean of medicine at Harvard) recalled, "His criticisms of students and their work were incisive and unforgettable, but never harsh or unkindly; they inspired respect and affection, never fear." Osler often surprised--and impressed--students by using his own clinical mistakes as teaching examples.

Osler had never forgotten the kind and generous mentoring he received in his student years; as a teacher he likewise combined high expectations with a genial support of his students. On Saturday evenings a few students were always invited to dinner, and more came later for coffee and hours of discussion of medicine and medical history. Osler also allowed senior students and residents free use of his personal library. While he was well-known for his diagnostic acumen, his broad knowledge, and his prodigious publishing output, Osler was perhaps loved most and remembered best for this cheerful and consistent generosity.

During his Hopkins years, Osler continued to investigate clinical problems such as angina, aneurysm, typhoid fever, thyroid deficiency (myxedema), and malaria. He was especially interested in typhoid, a disease that flourished in areas with poor sanitation and killed hundreds of Baltimoreans each year. In 1898, he also led one of the first efforts to survey the incidence of tuberculosis in Baltimore by following up on patients seen at the Hopkins hospital and outpatient dispensary, and to suggest measures to control its spread. The surveys were initially done by several women medical students; later a staff of public health nurses took on these duties. Osler was a founding member of the National Association for the Study and Prevention of Tuberculosis and helped organize the first international tuberculosis conference.

As Osler became known as America's best diagnostician, he was in great demand for consultations and received requests from all over the country. These were often lucrative, but the frequent traveling, added to his other duties and projects, left him exhausted. In modern terms, he was suffering from "burnout." He began to think about scaling back his activities or even retiring. When Oxford University offered him the Regius Professorship of Medicine in 1904, it seemed a perfect solution. His American colleagues, especially those at Johns Hopkins, were surprised and even depressed by his decision to leave. Osler spent much of his last six months in America attending dinners in his honor and speaking at various graduation ceremonies. At one of these (Johns Hopkins, February 1905) he gave an address in which he stated his belief that a man's best work was done before he was forty years old, and that by age sixty, he should retire. He jokingly referred to Anthony Trollope's story "The Fixed Period" with its idea that men should be put to sleep at the age of sixty. Osler was trying to explain why he himself was retiring at what seemed the peak of his importance. Journalists, however, took his remarks completely out of context, announcing that the eminent Dr. Osler suggested euthanizing old people. For the next several months, Osler received a barrage of angry letters from those offended by reports of his speech. "The Fixed Period" speech prompted many jokes and cartoons, and the coining of the term "Oslerize" to mean euthanasia.