Johns Hopkins

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In 1884, after he was offered an appointment to the medical faculty of the newly created Johns Hopkins University, Dr. William Henry Welch wrote to his stepmother: “Such great things are expected of the medical faculty at the Johns Hopkins in the way of achievement and of reform of medical education in this country that I feel oppressed by the weight of responsibility. A reputation there will not be so cheaply earned as at Bellevue, but in so far the stimulus to do good work will be the greater. I shall be surrounded by cultivated, refined and distinguished men, who will estimate a man for his intrinsic worth and not for money or glitter.”

Welch’s concern over the potential responsibility was not exaggerated. The first physician to receive such an appointment to the fledgling university, he was going against the advice of practically all of his friends, relatives, and colleagues. With such great hospitals as Bellevue in New York beckoning, why would any selfrespecting professor of pathology decide to remove himself to the backwater of Baltimore, forsaking the allure and prestige of a ready-made career? As Welch reasoned it: “It is a mistake to believe that a reputation made there [at Hopkins] would not equal one made in New York in my line of work. In practice of medicine of course it would not, but the results of research and discovery redound equally to one’s reputation whether made in Oshkosh or in New York.” And so he accepted.

Although the undergraduate part of the university had opened on a limited basis by October of 1876, nothing was finished by the time Welch received his offer—more than a decade after the death of the school’s benefactor, a wealthy merchant who had died late in 1873. Hopkins, a lifelong bachelor, had genuine philanthropic interests but had trouble deciding what to do with his fortune. As the son of a prosperous Quaker tobacco farmer from Anne Arundel County, Maryland, Hopkins had enjoyed a pampered and leisurely childhood, though he was one of a brood of eleven children. But the hard realities of the working life abruptly dropped onto his young shoulders when, in 1807, his father’s adherence to a new Quaker policy led him to free all his slaves. Suddenly young Johns—it was a family name—was forced to drop out of school at age twelve and go to work in the fields.

Finding the life of a farmer not to his liking, Hopkins waited until he was seventeen and then went to work for his uncle Gérard Hopkins, a wholesale grocer in Baltimore. He soon proved his ability as a shrewd merchant, capably handling the shop whenever his uncle went away on business and making excellent suggestions for improving sales. But when Johns announced a few years later that he wished to marry his first cousin Elizabeth, Gerard Hopkins’ only daughter, the friendly working relationship came to an abrupt end, for his aunt and uncle were appalled at the “incestuous” suggestion. So, having saved sufficient capital to set himself up, and with a little help from his family, he went into business alone as a supplier of whiskey, tobacco, and other staples. He quickly prospered, making $200,000 worth of sales in the first year. But he never courted another woman.

 

Within a few years Hopkins had branched out, selling provisions as far south as North Carolina and as far west as Ohio. By 1847 his now-established wealth and keen business sense had created quite a reputation for him, and he was named, in that year, president of the Merchants’ National Bank of Baltimore and a director of the rapidly expanding Baltimore & Ohio Railroad. The B&O was a further boost to his flourishing fortune; by the time he died, he owned fifteen thousand shares of its stock. During the Civil War he was one of three bankers who loaned the city of Baltimore $500,000; later, during the Panic of 1873, he advanced $900,000 to the railroad to help it meet its interest payments.

With increasing age Hopkins began to ponder more and more the problem of disposing of his considerable fortune “for the good of humanity.” There were plenty of advisers, and someone eventually pointed out that it would be unique for Hopkins to bestow his name on both a university and a hospital. A charter was obtained in 1867 and a board of trustees appointed. Hopkins set down his stipulations for the Johns Hopkins University and Hospital: of his estimated estate of $7,000,000 half was to go toward the university, of which the school of medicine would be a part, and half to the hospital. The capital was to be totally invested in either stocks or real estate, with interest paying the cost of construction. It was a unique arrangement; it would be the first hospital subject to the authority of a university, with the medical school tagging along after both. Eventually the hospital and the university would have separate boards of trustees.

Hopkins had an elaborate conception of what his hospital would be. In March, 1873, he set down his vision in a letter to the twelve trustees: It is my wish that the plan thus chosen shall be one which will permit symmetrical additions to the buildings which will be first constructed, in order that you may ultimately be able to receive four hundred patients; and that it shall provide for a Hospital, which shall, in construction and arrangement, compare favorably with anyother institution of like character in this country or in Europe. … The indigent sick of this city and its environs, without regard to sex, age, or color, who may require surgical or medical treatment, and who can be received into the Hospital without peril to the other inmates, and the poor of this city and State, of all races, who are stricken down by any casualty, shall be received into the Hospital, without charge, for such periods of time and under such regulations as you may prescribe. … It will be your special duty to secure for the service of the Hospital surgeons and physicians of the highest character and greatest skill. … I wish the large grounds surrounding the Hospital buildings … to be so laid out and planted with trees and flowers as to afford solace to the sick and be an ornament to the section of the city in which the grounds are located. … 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 shall ultimately form a part of the Medical School of that University for which I have made ample provision by my will.

He died of pneumonia nine months later at the age of seventy-eight, never to see the ground broken.

It was two years before the trustees sent out invitations to several wellknown authorities on hospital planning, asking them to come up with ideas for the construction of the hospital. The job eventually went to John Shaw Billings, a veteran army doctor and sanitation expert whose concept was the pavilion arrangement: a main building with separate wards branching out from it. Billings was named medical adviser to the hospital, and construction began in 1877 on a thirteen-acre lot that was previously the site of the Maryland Hospital for the Insane. Because the principal of the bequest was not to be invaded, however, and annual interest was only $125,000, it was twelve years before the hospital was completed.

In June of 1883 the trustees told Billings, in his role as medical consultant, to set about the business of selecting the staff of the hospital and future medical school. He had once met William Welch in Germany and been quite impressed with the young pathologist. It was Billings’ recommendation to the president of the new university, Daniel C. Oilman, that he offer the first professorship, that of pathology, to Welch, thus luring him away from Bellevue in New York.

Welch was the son, grandson, and nephew of country doctors in Norfolk, Connecticut. Entering Yale at the age of sixteen, he had been a brilliant student—but in the classics. In fact, he had always had an aversion to things medical as a youth, saying he couldn’t “bear the sight of blood and the sight and sound of pain.” He wanted to teach the classics at Yale, but the coveted position went to a friend. So after a bit of fatherly pressure he entered Columbia University’s College of Physicians and Surgeons in 1872, graduating in 1875. (The standard medical-school curriculum at that time was three years, with no admissions requirements, no grades, and only one final examination.) Wisely assessing the profession and its practitioners in the United States, Welch realized that the best clinical research was going on in Europe, especially Germany and Austria, and knew that he could perfect his craft only by going there to study. He spent the best part of the next two years abroad, working under some of the foremost medical scholars of the age. He returned to New York in 1878 and remained there working in his laboratory at Bellevue and doing part-time teaching until he received the summons from Gilman in 1883. He did manage to squeeze in one more year in Germany before finally delivering himself to Hopkins, and thus was well founded in the latest techniques and theories of bacteriology and pathology. He was especially impressed with John Shaw Billings’ assurance that the laboratories under construction were to be on the German model and that the medical school, when completed, would have high admission standards.

 

“I begin with a salary of $4,000—the others [university professors, not medical faculty] mostly began with $3,000—I am the eighth full professor yet appointed in the history of the university,” he wrote his father. “I am to have all of the paid associates and assistants I need, so that I can be the head and not the hands for everything. I do not have to pay the running expenses of the laboratory. I can develop my field in Baltimore unhampered by traditions. The surroundings are scholarly and academic, and of a much higher order than those of Bellevue College in my opinion.” According to Simon and James Thomas Flexner, Welch’s biographers, “The New York medical profession was aghast; in all the annals of American medicine there had been no instance of so ambitious and able a young man exchanging a brilliant future in practice for an academic professorship in which the rewards were to be like the rewards of a German professor, with the difference of less opportunity for independent work and less remuneration.” Apparently some medical friends gave Welch a going-away party, sending him off with this comforting thought: “You may become a connoisseur of terrapin and madeira, but as a pathologist, good-bye.”

As a promising young doctor and thus highly eligible bachelor, Welch was keenly pursued by Baltimore hostesses. But since he was a short, portly, plain-looking man not given to frivolous conversation, the young ladies were disappointed. Nonetheless, as a genial and well-read companion he continued to be invited to dinner parties. “I accepted five dinner invitations in succession,” he told his sister, “some being very handsome affairs. I attended recently a beautiful reception at the Bonapartes. This is rather more gayety than I care for.” Like his hospital’s benefactor he remained a bachelor for the rest of his life.

It became part of Welch’s responsibility to help Billings recruit more qualified physicians for the new staff, first for the hospital and subsequently as teachers for the medical school. One man who stuck in his mind was William S. Halsted, a superb young surgeon whom he had met in New York in 1878.

Halsted had also graduated from Yale and the College of Physicians and Surgeons, two years behind Welch, and spent two years of intensive postgraduate study abroad. A member of the staffs of several hospitals in New York, including Roosevelt, Bellevue, New York, and Presbyterian, he was a tireless and driven worker who managed somehow, in his spare time, to run a sort of tutoring course for those medical students who wished to pay for it. Dr. Arthur Stout, an associate of Halsted’s during those days, recalled later that a medical student “got his real training from two sources, his preceptor and the private quiz. Every student had to be registered with a preceptor who must be a regular physician or surgeon—this practically amounted to an apprentice system …—and the young graduate’s future might be assured if his preceptor was a person of influence.” The private quiz, Halsted’s favorite teaching device, “took the place of the conferences and quizzes which exist today in the Medical School itself. From three to six doctors would associate themselves under the leadership of the most prominent member and invite the medical students to recite to them by heart the various subjects which they studied [in lecture].” This was a valuable asset to any student who could afford the hundreddollar fee, as he would be taken around to laboratories, dispensaries, and hospitals to witness practical demonstrations. The inexhaustible Halsted was also a popular host at his town house on East Twenty-fifth Street, where with his roommate, a fellow doctor, he gave dinner parties at least once a week, often with musical entertainment. Friends were welcome at a perpetual open house.

As a surgeon Halsted was incomparable. He was constantly searching out new operating techniques and partially incorporated the antiseptic theories of Joseph Lister. He became fascinated with solving the problem of trauma to the tissues during surgery, exercising great care to control bleeding and avoid cutting or tearing tissues wherever possible. Then, in 1884, he got word from Germany of a revolutionary new practice that was to change his life: he learned to inject cocaine, the first local anesthetic of its kind, into the cornea of the eye. Using himself as a guinea pig, he soon discovered that the drug enabled him to go for days on end without sleep and still feel clear-headed and exhilarated. He did not know until it was too late that he had become totally addicted. The exhilaration wore off, and Halsted became so debilitated that he could hardly function at all. Devastated, he entered the Butler Hospital for mental disorders in Providence in 1885, a human wreck.

Welch, saddened at this news of his former colleague, was determined to help him back to his feet. He went to Providence in December of 1886 and asked Halsted to come to live and work with him in Baltimore, offering him a job as a researcher in the pathology laboratory. For the next few years Halsted concentrated on his experiments, finally overcoming his dependence on cocaine. He would not touch a human patient during this time—he operated only on dogs but is said to have treated them as carefully as he would a man or woman. He discovered the benefits of silk as a suture and ligature, far better than the bulkier catgut (and still used); he experimented constantly with all sorts of new and improved clamps, scalpels, needles, and other surgical instruments.

Although eventually he resumed operating on humans, he was no longer William Halsted, the dynamic, self-confident New York surgeon. During his fight against cocaine his personality had undergone such a radical alteration that he bore only a ghostly resemblance to his former self. Once ebullient, lightning-fast, and indefatigable, he was now quiet, deliberate, and introspective. According to Donald Fleming, one of William Welch’s biographers, “a ‘Halsted’ became a synonym for an operation drawn out to interminable length. … ‘Would you mind moving a little?’ he said to one of his assistants after a long operation. ‘You’ve been standing on my foot for the last .half hour.’ ” As Welch himself wrote much later about this dramatic change in Halsted, “While brilliancy, boldness and manual dexterity were attributes which I used to hear applied to Halsted as a surgeon in New York, these were precisely the qualities which in Baltimore he resented and desired to be substituted by conscientiousness, thoroughness and safety.”

Now Welch had his head of surgery. The next step was to find the most capable clinician in the country, if not the world.

William Osler was a Canadianborn physician who had already established an admirable record in his field by the time Welch went after him. Although attracted to theology as a youth, he abandoned this interest and switched to medical school at the age of nineteen, graduating from McGiIl in 1872. He rose swiftly in his new profession: studies in Europe were followed by a professorship at McGiIl Medical School, a fellowship in the Royal College of Physicians in London, and, finally, an appointment as professor of clinical medicine at the University of Pennsylvania. An outgoing, humorous, and extremely popular man, Osler was always playing pranks on his fellows—when he was sixteen, he and a friend answered an advertisement in the local Toronto paper put in by a hapless American looking for a wife; they dressed up in women’s clothes and met him at the station. But Osler was considered the best in his field and much sought after by hospitals all over the country. At a convention of the Association of American Physicians in Washington, B.C., in September, 1888, Billings, the hospital front man, began to court the illustrious Osler diligently, pressing him to take charge of the new medical department at Hopkins. Osler apparently was impressed, for he gave his consent to become the first physician-in-chief shortly thereafter. Welch was delighted; he wrote to his sister, saying: “[Osler] is the best man to be found in the country and it is a great acquisition for us to secure him. I know him well and have the highest opinion of him as a scientist and as a man.”

The fourth and final member of that famous “first faculty” of Hopkins, appointed in 1889, was Howard A. Kelly, an obstetrician-gynecologist from Philadelphia and a protégé of Osler’s. The only one of the four to be both American-born and Americantrained, Kelly was a graduate of the University of Pennsylvania Medical School in 1882 and thereafter its professor of obstetrics. Among his few quirks was a lifelong fascination with snakes. He was adept in the operating room but not possessed of the brilliance of his three new colleagues. Nicknamed the “Kensington colt” because of his dedication to treating the poor of that Philadelphia suburb, he was a staunch conservative who, according to one of Welch’s biographers, “always conducted a prayermeeting for nurses, surgeons, and observers before operating.”

The nucleus of the new hospital and medical school was now complete. There was considerable resentment among the local medical men that none of them had been chosen to head a department, not to mention the threat of all those outsiders taking away their business. But Welch quashed their fears. First, in 1885 he hired as his assistant pathologist a wellknown Baltimorean, Dr. William T. Councilman; then he initiated a policy whereby all professors of preclinical subjects were to be in the full-time employ of the medical school so that they would devote all their time to teaching and research and have none left over for practice. This was considered a revolutionary step in medical education.

The construction of the hospital, as has been noted, took twelve years. Billings’ plan, which aroused much interest both at home and abroad for its progressiveness, called for each ward to have an open area at the southern end, permitting the entry of lots of light and air. There would be twostory wards, each level connected by outside stairways. Billings intentionally omitted elevators in hopes of preventing “contaminated air” from passing between levels. Only the latest in heating and ventilation systems were to be installed. Those buildings to house patients with contagious diseases were to have separate cubicles for each individual, each cubicle to open onto a well-ventilated corridor that would permit breezes to blow through. Typical and impressive are these construction statistics for the year 1887: 8,200 lights, 1,200 kegs of nails, 44 miles of pipe, and more than a half mile of wrought-iron railing. When the hospital officially opened on May 7, 1889, there were seventeen buildings, among them four ward buildings, one isolation building, two private-patient buildings, a pharmacy, a nurses’ dormitory, a kitchen, a bathhouse, and an administration building. There were some two hundred beds, just over half what Johns Hopkins had called for. The public came to gape and stare, to amble through the corridors and examine the wards. Eight days later the first patient was admitted.

The staff organization was also unusual. Each service (i.e., surgical, medical, pathological, obstetrical) was to be supervised by one man, who would have sole responsibility for what happened on that service. He would also, upon the opening of the medical school, be responsible for the teaching of his specialty. Osler’s radical proposal was that each department head have under him a resident assistant, that is, a medical-school graduate who had completed his internship and would have complete authority when his chief was not about. The system proved invaluable, filling the gaping hole between inexperienced intern and busy professor (or, as it is now, practicing physician), and has been in general use ever since.

 

And the hospital was doing business. During that first year there were so many visitors to the dispensary (up to two hundred a day) that a charge of ten cents a patient was instituted—for those who could pay. Unfortunately there were no sinks equipped with running water in the wards, so after an operation the doctor had to scrub in a portable wooden washstand filled by pitchers, and when he couldn’t get an orderly to empty it right away, the dirty water often overflowed onto the floor.

Meanwhile the hospital staff began to get impatient for the medical school to open. After all, the university had been open since 1876, and those undergraduates studying this new course called premed were being turned away to rival medical schools.

The problem, a very common one, was financial. It seemed that Johns Hopkins had left his country retreat and all his Baltimore & Ohio stock to the university, and all his bank stock and the remaining real estate to the hospital. The country retreat had had to be sold to the city as a park; and a terrible situation had arisen with the B&O stock: it had plunged disastrously in value, to the point where no dividend was paid between 1888 and 1891. The trustees could not invade the principal and began to worry lest Harvard and the University of Pennsylvania succeed in wooing Osler and Welch away before the medical school even opened. The situation was complicated by the fact that since the medical school was technically and legally a part of the university and not the hospital, none of the latter’s funds could be used for it.

Into this bleak and unhappy dilemma stepped Martha Carey Thomas, a trustee’s daughter and an English professor at Bryn Mawr College, and her friend Mary Garrett, daughter of the head of the B&O , who saw a way to advance the cause of women in medicine. They offered to form a national Women’s Fund for the Higher Medical Education of Women to raise money for the school—on condition that the admission requirements for women be the same as for men. The trustees, knowing they were in a tight corner, grudgingly agreed, but only if the ladies could raise the seemingly impossible sum of $500,000.

Welch, the newly appointed dean, and President Gilman were against it from the start. Welch indicated much later that his hesitancy sprang from a distaste at having to explain “indelicate things” to ladies. Although Osler, Kelly, and others were anxious to get the agreement settled and sent in a supporting letter, Welch’s signature was conspicuously absent.

By 1892 the faculty of the nonexistent school was growing restive. Osler was sorely tempted to return to McGill, which was dangling a $1,000,000 chair before his nose; and Harvard was still after Welch. The Women’s Fund was nowhere near its goal, having raised less than $200,000. But Miss Garrett, an early feminist and a woman of considerable personal wealth, was not to be thwarted. She would put up the remaining $306,977 but now tacked on even more stringent demands: not only were women to be admitted on an equal footing, but all candidates would have to have an A.B. degree or its equivalent, a reading proficiency in French and German, and knowledge of chemistry and biology as well as Latin, mathematics, and physics. And there was to be a four-, instead of a three-, year curriculum. These were by far the toughest admission standards ever contemplated for any medical school in the country. Osler, on hearing the latest proposal, commented to Welch: “We are lucky to get in as professors, for I am sure that neither you nor I could ever get in as students.”

The administrators of Hopkins had, they said, eventually planned to gradually introduce more rigid standards for admission, but certainly not before the school even got off the ground. In fact, Welch later recalled that he had set down these idealistic terms years before in a letter to Gilman not long after arriving in Baltimore. He surmised that Miss Garrett had gotten hold of the letter through her lawyer, a member of the board of trustees. But, he declared, “It is one thing to build an educational castle in the air at your library table, and another to face its actual appearance under the existing circumstances.”

The trustees knew that they were trapped. First they tentatively agreed but haggled over Miss Garrett’s stipulation that women be admitted “on the same terms” as men. Why not just substitute “equivalent” or “equal” for the word “same”? they asked. Miss Garrett stubbornly refused and in exasperation made it a further condition that all the funds revert back to her or her estate should there be a violation of her wishes. On December 24, 1892, the trustees finally gave in.

To prepare the best possible curriculum President Gilman sent out a questionnaire, describing the proposed courses, to various medical scholars in both the United States and Great Britain. To his delight the response was highly complimentary. But then everyone began to worry about how they would ever get enough qualified applicants to make the whole project worthwhile. They needn’t have. By the time this new branch of the university opened in October, 1893, eighteen students had enrolled —fifteen men and three women—although they were outnumbered by their teachers. Five were graduates of Johns Hopkins University, having been well prepared by the new premedical course. There were even an additional forty-odd physicians doing graduate work. Among the courses studied that first year were osteology, histology, physiological chemistry, and, of course, anatomy. The anatomy professor, Franklin P. Mall, was inclined to let the students learn by trial and error rather than by lecture, so he would give each a knife and then leave the room. This at first was a bit frustrating for the students. He was just as eccentric when examination time came, as he disliked this sort of formality; so he would simply take each student for a walk in the park, and after discussing such totally irrelevant topics as Paris fashions, he would suddenly pull a fragment of bone out of his pocket and demand: “What is this?” Though they all guessed wrong—it was a turtle bone—he passed them.

Mall had a problem at first getting sufficient cadavers, so the dissection part of the anatomy course was postponed until November. When bodies became more plentiful, Mall had a large icebox built, embalmed the bodies with carbolic acid, and stuck them away. But a larger problem awaited him: when classes began, he spied across the dissecting room one day a lovely young woman named Mabel Glover, a Wellesley graduate and one of the three female students in the class. By spring they were engaged, leading Osler to comment wryly when speaking about Hopkins to the Harvard Medical Alumni Association that June: “When I tell you that 331/3% of the lady students admitted to the first year of the Medical Faculty of the Johns Hopkins University are, at the end of one short session, to be married, then you will understand why I saw that co-education is a failure. If we lose 331/3% at the end of the first session where will the class of lady students be at the end of the fourth?” (Some time later he was appalled to learn that another of those first lady students had dropped out after her conversion to Christian Science.)

Meanwhile hospital business went on as usual. While awaiting the arrival of the first medical-school graduates, the house staff positions were filled by graduates of other institutions. Under the supervision of the four chiefs (Halsted had been appointed associate professor of surgery in October, 1889, and then promoted to full professor in 1892) the students were allowed to come directly into the wards to observe those diseases about which they had been lectured. Once again this was an exciting innovation, earning Hopkins its reputation as the first teaching hospital in America. As the Flexners put it in their biography of Welch, at last “laboratories took the place of the lectures traditional in American medical schools—the hospital patient was nature’s laboratory—and experiments the place of precepts. … Almost immediately the young men and women began to taste the joys of self-training, because so much of their time was placed at their own disposal and they were so closely in contact with their professors.”

Welch, Osler, and Halsted, because of their relative youth, were quickly adopted by the staff doctors as friends as well as teachers and dubbed “Popsy,” “the Chief,” and “the Professor,” respectively. The genial Welch, as dean of the medical school, was caught up more in administration than in clinical work but did manage to keep up his lectures in pathology; he was enormously proud of Halsted and wrote to a friend: “The number of patients surpasses all anticipations and Halsted (popularly known in hospital circles as Jack the Ripper) does nothing but operate the whole forenoon and it must be admitted with brilliant results.” Welch himself was making quite a name for Hopkins, for his reputation as an outstanding pathologist had spread to Europe. While attending an international conference in Berlin in 1890 he had been voted an honorary president of the pathological section, and now doctors from all over the East were coming to do research in Welch’s laboratory, among them Major Walter Reed. A further accolade that demonstrated Baltimore’s acceptance of Welch was his election in 1891 to the presidency of the Medical and Chirurgical Faculty of Maryland, the elite society of the state’s physicians.

Welch’s original faith in Halsted was more than justified. Now an aloof, reserved man, the “Professor” discouraged, by his formal, austere presence and caustic wit, most associates from becoming intimate, but as a surgeon he drew enormous attention at home and from abroad to his teaching and operative clinics. His greatest pleasure was training surgeons; and realizing that the best way to teach them was to show them, he would perform operations before their eyes on his old wooden operating table, left over from the Franco-Prussian War, with its deep trough and drainage hole. He was always inventing ways to ease the surgeon’s task; when a nurse complained of a severe rash on her hands and arms after scrubbing in carbolic acid, he asked the Goodyear Rubber Company to make two pairs of rubber gloves for him, as thin as possible. No one had ever thought of such a thing.

 

Perhaps it could be said that Halsted’s greatest contribution to surgery was his pioneer work in the treatment of breast cancer. In the eighteenth century a French surgeon had made the connection between this form of cancer and lymphatic glands, but it was Halsted a century later who performed the first radical mastectomy. He was very successful with his surgery for hernias as well.

The one vestige of the precocaine Halsted was his expensive taste. His suits were made in London, his shoes —of which he ordered six pairs at a time—and shirts in Paris (the shirts were sent back by ship to be laundered at regular intervals), and he could often be spotted walking the hospital corridors in frock coat and tall silk hat. His love of elegance ruled the household after he married his head nurse, Caroline Hampton, in 1890; he selected the antiques and Persian rugs that filled their Baltimore town house and their summer cottage in the mountains of North Carolina, and when they entertained, he would select the china, food, linen, and flowers. Often he and Welch would dine together at the staid Maryland Club on terrapin and Chesapeake oysters.

Osler was probably the best liked of all. A small, slender man of dark complexion, he too dressed in frock coat and top hat. Consistently cheerful and outgoing, possessed of a lively sense of humor, he disliked gossip or criticism and was remarkably modest. He wrote prolifically of his clinical findings and was widely published in medical journals; once in a while he mischievously submitted articles under the unlikely nom de plume “Edgerton Y. Davis of Caughnawauga, P.Q.” He brought his students into the wards and put them to work applying dressings and keeping charts; he called his hand-picked interns “ A.A.I. copper-bottomed young graduates.” He tried to instill in these students his own love of his work, based on untiring thoroughness and the ability to reason things out. His Principles and Practice of Medicine , published in 1891, became the definitive text of internal medicine and was eventually translated into Spanish, French, German, and Chinese.

Osler’s particular bêtes noires were typhoid fever, pneumonia, and tuberculosis, and his researches led him to become an ardent public-health reformer. He cared nothing for the lucrative side of medicine and private practice, being much more concerned with bringing Johns Hopkins’ desire to life: to open the hospital to the poor and the sick, regardless of their sex, age, or race.

By the early 1900’s the hospital and medical school were solvent and universally respected, and some of those who had helped make them so could move on. Osler accepted an invitation to go to Oxford University, where he assumed the formidable title of Regius Professor of Medicine, and later that of baronet. Welch, although he remained in Baltimore the rest of his life, was satisfied that Hopkins was in a condition of relative stability and became involved with the Rockefeller Institute of Medical Research and the Carnegie Foundation as adviser and later a trustee. Intensely interested in medical and health conditions around the world, he travelled to such remote outposts as Peiping, China, and made such an impression there that he was later honored by the doctors of the Peiping Union Medical College on his eightieth birthday in 1930—and by President Hoover as well. The fact that Hopkins was never allowed to become a parochial, nonprogressive hospital is certainly due in large measure to Welch’s unceasing desire to bring international advances in the field back to Baltimore.

Halsted remained at Hopkins the rest of his life, receiving almost as many honorary degrees as Welch and Osler. His contribution is best described by Professor René Leriche, an eminent French surgeon, who said in 1914: “Halsted has created a method in surgery and he has inspired disciples. It is this that gives his clinic such vivid originality, and when one has seen intimately that admirable organization one understands why Baltimore has rapidly become the cradle of contemporary surgery in the United States.”

Construction continued into the 1930’s, often funded by the great financiers of the time: the Rockefeller and Carnegie foundations; “Diamond Jim” Brady, a grateful patient who gave over $300,000; Henry Phipps, who gave money for the psychiatric clinic that still bears his name; James Buchanan’s niece and hostess, Harriet Lane, who founded a pédiatrie clinic. When H. L. Mencken wrote a series of articles for the Baltimore Sun in !937, he discovered that a phenomenal fifteen thousand patients were admitted annually; almost half of these paid nothing whatever, just as Hopkins had ordained. Today those figures have more than doubled, and the hospital can accommodate almost eleven hundred patients at one time. In 1974 there were just under a half million outpatient visits; and the rule, according to the public-relations director, is still “pay what you can.” A new and major redevelopment program has rendered all but a few of the first plain red brick buildings into dust.

All this is a far cry from the days Welch described in a nostalgic letter to Howard Kelly in 1933, on the occasion of the latter’s seventy-fifth birthday: “You will remember some of the mad pranks Osler used to play on your new patients. Osler, arriving early in the morning and learning that you had not seen [them yet], would say that he would prepare the patients for your visit by dropping in and informing [them] that [your] senile tremor disappeared as soon as you began to operate.”

Perhaps Johns Hopkins would have been established as one of the finest hospitals and medical training centers in the world without these men; but it is doubtful. In any case, the name is still synonymous with medical expertise. A fine tribute to the institution made by Halsted’s good friend Henry James when he came to Baltimore to see and admire in 1905 indicates the feeling Hopkins still inspires: “The great Hospital, with its endless chambers of woe … [has] turned … to fine poetry … the high beauty of applied science.”

Kelly and Mencken and God