“At a meeting of the Faculty of the Yale Medical School held on May 7, 1920, the following action was taken for transmission to the Corporation. Voted to nominate Professor Milton Charles Winternitz to the Corporation as Dean of the medical school for a period of five years.” The new dean was a man who evoked strong emotions. He was described by his friends and colleagues as a “vital and vivid man, an intense fountainhead of energy, an inexhaustible generator of ideas and constant stimulator of the imagination.” Others, while acknowledging his accomplishments, portrayed him as a “martinet,” “a terrible little guy who dissipated the financial resources of the school on impractical schemes.”
During his 15 years as dean, Winternitz firmly brought the medical school into the fold of the university by assuring that the medical faculty met the university’s academic standards and by reorganizing medical school departments as university departments. Under his firm hand, the full-time system for clinical teachers was hammered into place. He tirelessly raised funds for buildings and facilities.
Winternitz believed strongly in all he did, but he was particularly adamant that medical students should be treated as graduate students—a view that led to the creation of the Yale System of medical education.
Accomplishments of this magnitude cannot occur without cost, especially when achieved in so short a time. Diplomacy in human relations was not always one of Winternitz’s strengths. Levin Waters, a pathologist trained by and devoted to Winternitz, took the view that “though his methods may continue to evoke controversy, there will always be agreement that Winternitz was the right man in the right place at the right time for the Yale School of Medicine.” John Fulton, physiologist, medical historian and friend of Winternitz, described him as “of Napoleonic temperament and stature and a thoroughgoing autocrat but honest as the day is long and possessed of a broad and sympathetic nature.”
Milton Charles Winternitz was born in 1885 in East Baltimore, the son of an immigrant doctor from Czechoslovakia. He was four when the Johns Hopkins University School of Medicine opened its doors in East Baltimore in 1893, four years after the founding of the Johns Hopkins Hospital. Growing up near the medical school must have been a powerful influence on a neighborhood boy whose father was a doctor. Hopkins’s founding dean, pathologist William Henry Welch, had brought the excitement of German scientific medicine to the young school, which was to become the model for modern medical education in the United States. An outstanding student, Winternitz applied for a house-staff position in surgery under William Halsted, but he was turned down and went to work with Welch in pathology. Welch, a Connecticut native and a staunch Yale alumnus, was a dynamic and stimulating teacher. Winternitz was enthralled with Welch as a role model, followed him into pathology and was awarded a teaching position at Hopkins.
As Welch was in constant demand and traveled frequently, junior members of the faculty were often asked to fill in as lecturers at the last minute, and Winternitz developed a capacity for “extemporaneous elegance.” Like his mentor, he also made a number of trips, including several short visits to Leipzig, Berlin, Freiburg and Vienna. Despite his idolization of Welch, Winternitz developed a very different teaching style. Whereas students described Welch as “a kindly and infinitely wise old gentleman” who went out of his way to be helpful, they saw Winternitz as a martinet who taught by terrorism. John Paul, who had been a second-year medical student at Johns Hopkins, could not understand how “Welch tolerated him as a member of his Department, for even as long as a decade.”
Winternitz was a man of many facets. His granddaughter Susan Cheever described him as a “short man with a tyrannical manner, an intense charm that could make you feel that you were the only person in the world—and a raging temper that could make you wish you weren’t.” He utilized his great charm to attract and marry Helen Watson, whom he pursued with “the sweetness of a kitten and the ferocity of a lion.” A Wellesley graduate and a medical student at Johns Hopkins, she was beautiful, smart, Protestant and the daughter of Thomas Watson, who with his friend Alexander Graham Bell had invented and developed the telephone. Overcoming formidable obstacles, Helen Watson and Milton Winternitz were married in 1913.
Winternitz had hoped to remain at Johns Hopkins and eventually succeed Welch as chair of pathology. But this was not to be. Several authors have attributed Winternitz’s ultimate lack of success at Hopkins to anti-Semitism. Welch told Thomas Watson at a chance meeting that Winternitz was entirely capable of succeeding him but that his scientific contributions, although of high quality, were not yet voluminous enough. Watson relayed Welch’s comments: “Age he intimated was the only objection against your election.” Being Jewish would not have helped his chances, but there were clearly other reasons why Winternitz was not chosen to succeed Welch. Nevertheless he became the first Jewish professor at the Yale School of Medicine.
It was almost certainly on Welch’s recommendation that Winternitz was appointed professor of pathology at Yale in 1917. He was scheduled to start at Yale just as America entered the Great War. Welch attempted unsuccessfully to delay Winternitz’s departure in order to have him work with the Hopkins medical unit. Winternitz arrived at Yale as chair of a pathology department in a medical school that was deeply involved in the war effort. Yandell Henderson, the professor of physiology, who had been a consultant on gases for the Bureau of Mines, enlisted Winternitz’s aid in the war gas project. With a flair for organization that was to serve him well, Winternitz established a center for the biological study of war gases as well as an army training school for laboratory medicine. In 1920 he published a monograph on the results of these studies, Collected Studies on the Pathology of War Gas Poisoning. That same year he published The Pathology of Influenza, which he had co-written in the wake of the postwar pandemic. Although he had been at Yale for only three years and had been heavily involved in the war effort, the faculty elected him the fifth dean of the medical school in 1920.
When Milton Winternitz succeeded George Blumer as dean of the School of Medicine, academic control of the beds in the hospital had been achieved and a full-time clinical program had been organized, although not yet fully implemented. The General Education Board’s criteria had been fulfilled, ensuring solvency of the hospital, at least in the short term. But academic control of the hospital was complicated by the profusion of health care organizations involved in patient care. There was ongoing opposition to the full-time clinical system from both the community and long-term members of the faculty, and the hospital board was making decisions that were not in the interest of medical academia.
Yale University President James Rowland Angell commented that Winternitz became dean at a time when the medical school faced its most disheartening prospects. There was a perception that the “outlook was as unpromising and depressing as could be imagined.” Yet the saga of the School of Medicine had contained many equally bleak periods before. All of the goals which the faculty had fought to achieve in the school and in the hospital had been reached, but Camelot remained elusive. After having worked so hard for so long, the clinical faculty still did not have academic control.
When Winternitz took over the deanship, his first priority was to fill the ranks of the senior faculty. Blumer had resigned as chair of medicine, exchanging the John Slade Ely Professorship for the David Paige Smith Professorship, and had immediately taken sabbatical leave. Morris L. Slemons, founder of the first full-time clinical Department of Obstetrics and Gynecology in the United States, had left to return to California. Joseph Marshall Flint, the professor of surgery, who had experienced persistent pulmonary problems since the war, had retired.
Yandell Henderson, who had been professor of physiology for 10 years, had long been dissatisfied with conditions in the department and had actually announced his resignation in 1917. He did not resign, however, but continued through the years to complain to the president. Finally, President Angell sent him a letter saying that he was impossible—in effect firing him. Henderson tried to explain that it was all a misunderstanding, but he was ultimately transferred to the graduate school and given an appointment in applied physiology. These departures left only seven members of professorial rank to constitute the entire medical school faculty.
In contrast to the somewhat muted George Blumer, Winternitz—whether liked or disliked—was a “steam engine in pants” and incapable of floating in a sea of uncertainty. A number of events occurred within the university that helped Winternitz navigate that sea. In 1921, President Arthur Twining Hadley, a Yale man and a traditionalist, was succeeded by Angell, a psychologist and the first Yale president from “elsewhere” since Abraham Pierson. It was the era of the postwar boom, and funds to build facilities were becoming increasingly available. In addition, the Yale Corporation had yet again examined the future of the medical school and had issued a ringing statement of affirmation. Meanwhile the central university administration had been thrown into a state of turmoil in 1919, fomented by the extraordinary recommendations of an alumni committee, advocating a common course for all undergraduate instruction, consolidation of the college and Sheffield Scientific School and emphasis on teaching rather than research in the undergraduate college.
Most of the committee’s recommendations were accepted. Despite the cataclysmic nature of the reorganization that resulted, it did solve the problem of the college and the Sheffield Scientific School as two separate schools. In addition, professors with similar interests were brought together. The professional schools were given new status, and the graduate school increased in stature. As a result of the reorganization, Yale had been converted into a better-balanced institution with a strengthened administration and a broader university focus.
Winternitz used the university reorganization plan to place all the available resources in the “fundamental” sections of the medical school while eliminating sections that were not crucial. The plan was supposed to unite the various schools with the university, thereby furthering the development of an increasingly unified university with a coordinated scheme of instruction that would eliminate duplication of courses. The members of the faculty were to be Yale University faculty, designated to teach where their talents were most needed, rather than individuals owing primary allegiance to distinct schools within the university. One of the chief duties of the newly created office of provost was to partake in discussions concerned with the educational development of the university, in an attempt to foster this integration.
Using the university plan as a shield, Winternitz avoided the major confrontations that occur when medical school departments are reorganized. He committed the school’s support to anatomy, physiology (including chemical, physical and biological physiology), pharmacology and toxicology, pathology and bacteriology, public health, medicine, surgery, pediatrics and diseases of women (including obstetrics and gynecology). He planned to establish a section of psychiatry and to develop some of the medical and surgical subspecialties, but he felt it unlikely that any of them would develop to the importance of major sections. The issue of what constitutes an academic department continues to be debated. Often the determining factor is not academic principle but a powerful section chief who threatens to leave unless his or her section is made into a department, with no assurance that a replacement can be recruited.
Winternitz immediately began to strengthen his faculty, recruiting Francis G. Blake as chair of medicine, who brought with him John Punnett Peters, a Yale ’08 and Columbia medical graduate. Peters and William T. Stadie constituted the chemical, or metabolic, division of the Department of Medicine. James D. Trask, a pediatrician, and Arthur B. Dayton were appointed to the biological division of the department. Harold M. Marvin was recruited to direct the work in electrocardiography, which resulted in less emphasis on the stethoscope and “heart murmurs,” a trend that has continued to this day. These recruitments marked the beginning of specialization in the medical school.
Joseph Marshall Flint, the professor of surgery, retired in 1921 due to ill health incurred during his military service. Samuel Clark Harvey, who had received both his undergraduate and medical degrees from Yale, succeeded him as chair. Graduating from the medical school in 1911, he spent two years in pathology in New York, followed by four years as a resident with Harvey Cushing in Boston. In 1917 he returned to Yale as an instructor. Harvey was appointed an assistant professor of surgery at Yale in 1920 and was promoted to associate professor and acting chair a year later, a meteoric rise. His rapid promotion to the chair of surgery must have raised some eyebrows, but Winternitz emphasized that he was a good candidate: “For the past two years, Dr. Harvey has been associated as first assistant with Dr. Flint and had been carefully trained to assume responsibility as chief of the clinic.” Winternitz himself retained his position as chair of pathology.
When Morris L. Slemons resigned as chair of obstetrics and gynecology in 1920, Arthur Morse, who had been a Yale faculty member since 1915, was appointed to the post. Morse was said to be one of the very few men in the country capable of conducting a women’s clinic. Indeed, George Blumer had mentioned the Women’s Clinic as one of the high points of his deanship.
A full-time pediatrics section had been one of the conditions for the grant from the General Education Board. Edward Park, a 1900 Yale College graduate, was recruited from Johns Hopkins as professor of pediatrics. Park and his assistant, Grover Powers, had done outstanding work on dietary deficiencies in children. After six years at Yale, Park confided to Angell that he was not pleased with some of the appointments and was not confident about the future of the school. James Gamble from Harvard urged Park to return to Johns Hopkins, where he would “find much better students to teach and proper men to lead into research presenting much more frequently.”
Park did indeed return to Johns Hopkins but during his stay in New Haven had recruited Martha Eliot, a former Johns Hopkins student, to be his chief resident and an instructor in pediatrics. Ethel Dunham, who had arrived a year before Eliot in 1919, was the first female house officer at the New Haven Hospital. When Eliot subsequently left Yale for a full-time post at the Children’s Bureau, Dunham became head of the bureau’s research division in child development. During Yale’s search for a chair of pediatrics, the ever-intrusive [Abraham] Flexner pushed his family physician very hard for the position, disparaging Powers’ abilities in the process. Angell commented to Fred Murphy, an influential physician alumnus of Yale College, that although Powers was good clinically, “nobody has any illusions about Dr. Powers’ qualifications, least of all Powers himself.” As it turned out, both Flexner and Angell were wrong. Powers went on to have a brilliant career as professor of pediatrics at Yale. He was an autocratic, controlling individual who was determined that every child should be well cared for and that all his staff, including the medical students, should consider this a top priority.
In the midst of making appointments to strengthen the school, Winternitz had, as always, to consider ways to attract funds. He sent Flexner a cartoon in 1920 showing submarines from the university, faculty, hospital and community firing torpedoes at one another. The medical school was portrayed as a small boat containing two rowers going in opposite directions, with a life preserver marked “$5,000,000” and “G.E.B.,” a clear message that Flexner and the General Education Board were capable of bringing Winternitz’s dreams to fruition. The cartoon was effective. Flexner replied: “You have certainly devised the most poignant and appealing form of application that was ever presented to our Board.”
In his report to the president of 1921-1922, Winternitz stated that medical education in the United States was in a “state of flux.” Several systems of clinical teaching had evolved, and controversy raged over the relative merits of the various systems, particularly the full-time clinical system, which Yale had adopted in 1915. At Yale, “now more of the major clinical divisions are on a solid and comprehensive full-time basis than in any other school of the world. … Indeed, a small medical school as a part of a great university like Yale is particularly well adapted to pedagogical experiment, and it is to be hoped that such experiments, judiciously carried out, will be one of the means by which this school will aid medical education and give character to itself.”
Winternitz also indicated in his report that “radical changes” in the curriculum had to be made, because of the overloaded course schedules. He wanted to give students more free time, to allow individuals to develop at their own pace, faster or slower. As someone on the Curriculum Committee said, the hope was to “teach the student less but learn him more.” By “judicious pruning” the medical course could be cut by a quarter, and the candidate for the degree of doctor of medicine would still receive a broad, well-grounded training in the fundamentals of medicine. The extra time would give the challenged student more of a chance to review, while the gifted student could elect to do research or special work. With less teaching time available, the instructor would in theory concentrate on basics rather than simply talk faster. With more free time, medical students would develop a particular interest and expertise in a particular area of medicine. Winternitz concluded that the equivalent of one year’s work had been salvaged from the required courses—a major accomplishment, as anyone who has been involved in curriculum reform can attest. The student was expected to use a third of this time for electives, and he could pursue research or other interests during the rest of the time.
In his annual report on the pathology section, Winternitz commented that group teaching along interdepartmental lines would be advantageous. He cited as an example that the physiology, anatomy and histology of the heart and lungs, as well as their pathology and bacteriology, could all be studied together. In his role as chair of pathology, Winternitz was particularly interested in improving the curriculum in pathology by emphasizing the gross pathology and eliminating the “busy work” for students of routine staining and preparation of histological specimens. Emphasis would be placed also on clinical-pathological correlations throughout the clinical years.
Curriculum revision reversed the sequence of the clinical years, so in the third year students concentrated on ward medicine, which entailed acute illness and intensive therapy. On the other hand, fourth-year students, who had more clinical maturity, concentrated their efforts in the dispensary, which allowed the more mature students to acquire knowledge of disease in an outpatient setting, gain an appreciation of epidemiology and develop an interest in preventive medicine. Dispensary patients were to be encouraged to come for consultations even when they did not have a problem, so that the dispensary would be a “health clinic” as well as a “disease clinic.”
It was hoped that the time made available by curriculum revision would also result in research theses of higher quality. The research thesis had been a requirement for the doctorate of medicine at Yale almost continuously since the inception of the school. The first thesis found in the school’s historical library was written by Charles Hooker, later dean of the School of Medicine, in 1823. In spite of this long history, no time had ever been allotted in the curriculum to do the necessary research. Now more advanced research could be undertaken.
Winternitz indicated in his report for 1924-1925 that by allowing time for the student to pursue his particular interests, the opportunity for study in selected fields would be expanded, compatible with a true graduate education. Winternitz’s vision was imaginative and exciting, and although it was not completely realized, it formed the basis of the Yale System of medical education. Winternitz stated that the annual grading system would be abolished and that the student would be allowed to select the sequence of studies from the courses offered in the school. The number of courses and the time taken to complete them would depend on the student, who would require the instructor’s permission. Group examinations and the research thesis would be used to monitor the student’s accomplishments. Closer cooperation with the graduate programs in the biomedical sciences would occur. During the preliminary part of the medical curriculum, students could be enrolled in both the graduate school and the medical school. Winternitz’s plan would have allowed graduate students to switch to the medical school if their interests became more clinical.
The medical faculty adopted many of these components as educational policy at the beginning of the 1926-1927 academic year, including elimination of the traditional annual “class” system, elimination of “final” examinations and greater educational freedom for students, which would place greater responsibility on them. Instead of final examinations, there would be a comprehensive, weeklong examination twice a year, qualifying students to pursue clinical medicine. The third and fourth years of medical school would remain unchanged, with emphasis in the fourth year on the natural treatment and study of disease. Although the “university” aspects of a joint medical school/graduate school venture were not included in his 1924-1925 report, Winternitz had outlined the Yale System of medical education as we know it today. YM