Memories of Milton C. Winternitz

Howard Spiro, M.D.
howard.spiro@yale.edu

The following piece and its companion were given in the Beaumont Room of Yale Medical School as the opening lecture of the 2001-2002 Program for Humanities in Medicine on September 20, 2001. They deal with Milton C. Winternitz, Dean of the School in the 1920's, and speak for themselves. We have not edited them but present them as they were given.

  Milton Winternitz , dean of the medical school from 1920-1935, was the agent of New York foundations that wanted to turn the school into a first-class institution . He saved it from being split in two by those in New Haven who wanted to send students off to New York for their clinical years, giving only scientific training at Yale. When its faculty was disheartened, he brought energy and ambition to rebuild a school whose teachers despised and despaired of their students. He created the "Yale System" of teaching to free students from rote learning and too many classes, he hired a first-class full-time faculty, established the Nursing School and the Department of Psychiatry, and did much more. Unfortunately, at Yale he is remembered today, if at all, for presiding over a school which, like most others of its time, greatly limited the admission of Jews and turned away all blacks.. That makes him look like a bigot, but minorities in his time had to make their peace with the chauvinistic society of the 1920s . The Jewish students of that time whom we have interviewed did not regard him as anti-Jewish as much as "going along" with what was. Even Yale's failure to hire many of the Jewish professors escaping Germany in the 1930s did not arouse him, but that is another story.

  As Dean, Winter had four goals , the first two for scientists and the last two for practitioners: 1) to base medicine on biology by encouraging research at the bedside as well as in the laboratory, 2) to integrate the Medical School into Yale University, to make medical training a truly postgraduate experience. 3)to get doctors to consider the whole person, not just sick patients, 4) to promote health as a positive ideal by attention to preventive medicine. 

  Now that medical practitioners talk of "wellness" rather than sickness and focus on the patient, they should recognize how much three trends in the 1920's have contributed to these renascent concepts. Social , constitutional , and psychosomatic medicine all tried to get physicians to look at the patient as a whole rather than as the collection of cells and organs that scientific medicine isolated. This afternoon, I focus on Winternitz's contributions to social medicine because he was right on track about that unpraised fore-runner to alternative medicine. 

  I like to think of Western medical practice from its beginnings in ancient Greece as veering between its Hippocratic heritage and its Aesculapian background. Hippocratics learned that they were rational professionals who knew more than their patients; their knowledge , not their relationships, would help healing. The priests of Aesculapius took a different tack; relying on rhetoric and suggestion; after they had plied their suppliants with wine, they went around assuring them that they were better . Today we call the first group "mainstream" and the latter "alternative" practitioners, even if their methods are more subtle. The mainstream relies on science, on measuring and on technology , while the alternative turns to intuition and perception, to persuasion and rhetoric, or what in another place has been called placebos. Currently " modern" mainstream treats disease while what can be labeled "postmodern" medicine cares for the patient. 

  Milton Winternitz , came to New Haven from Johns Hopkins in 1917 in the guise of a scientist as chairman of Pathology. But shortly after he had become Dean in 1920, he asked his colleagues to establish a department of psychiatry ; he was not bashful about relating that the General Education Board was prepared to give substantial funds to that endeavor. Psychiatry in the 1920s was as popular as neurobiology today, thanks to those same New York foundations whose leaders were funding new vistas of the mind as enthusiastically as today they hail the brain.

 In this, Winter was much influenced by the famed William Welch, the dean of academic medicine, who had become a proponent of psychiatry in part, one suspects, because his private life was so very different from the genial public persona he had fashioned. Winter had his reasons too. He was already convinced that medical practice required a view far wider than one simply cellular: he wanted medical students to observe the evolution of sickness in the outpatient clinics rather than just seeing on the wards a snapshot of the end stage of disease. Moreover, the transformation of his young wife Helen from the energetic even rebellious woman physician of their Baltimore days into the languid sick mother of the New Haven years must have had something to do with his enthusiasm for psychiatry even before a daughter was diagnosed as schizophrenic. Then too, Winter himself was so moody that Nick Spinelli has labeled him a "manic depressive" from his observations as a Yale medical student. Pertinent too, his closest ally at Yale, President James Angell , was a psychologist who wanted to see the department of psychology become big-time. 


  With that background, it is not surprising that Winter was attracted to the promise of social medicine. That was the 19th-century response to the social problems created by industrialization so vividly described in the novels of Charles Dickens. George Rosen, a cherished medical historian at Yale, summarized the point: "Social medicine rests equally upon the social and the medical sciences. Anthropology, social psychology, sociology and economics are as important for this field as the various branches of medicine. Social medicine had begun with "sanitary reforms", but gradually split into a mixture of public health and personal medicine . In putting emphasis on diseases in groups, social medicine moved away from concern for the single patient to a preoccupation with the community. That has led to its rebirth as "outcome," or "evidence- based" medicine today, and even to managed care.

  The other major concern of social medicine was what we would now call "the patient as a person," but proponents did not readily perceive the conflicts between serving the particular or aiming at the universal, between concerns for the psychiatric and attention to the sociological. That was to make little difference, however, as the triumphs of scientific medicine out-distanced any contributions that social medicine could make. Social medicine could not stand up to victories of scientific advances, even though Rudolf Virchow cautioned that no matter how important bacteria were, crowded unsanitary conditions tipped the balance to lead to typhus epidemics in Silesia as they were to do again in the death camps of Germany half a century later. Tuberculosis had yielded to improved sanitation before the final victory of streptomycin , but that antibiotic highlighted the role of scientist as knight, far more dramatic than myrmidons digging sanitary ditches. Another former,if ephemeral , Yale Medical School Dean, Lewis Thomas, the articulate champion of science, is enshrined as a saint of molecular medicine for stressing how the scientific approach makes superfluous what he derided as the "halfway measures" of clinicians and public health workers.

  Other prominent physicians became proponents of social medicine, many in Great Britain. In the early 1940s, John Ryle, a quondam gastroenterologist, resigned as Regius Professor of Physic at Cambridge to head an Institute of Social Medicine at Oxford. Ryle had grown weary of studying and teaching clinical medicine "on the whole more and more mechanically". He complained that physicians were becoming less attuned "to the deeper personal needs of the individual," and to the "broader social needs of the group or the community." Ryle, who had earlier designed a tube to suck gastric juice from the stomach, proudly pronounced that "We no longer believe that medical truths are only or chiefly to be discovered under the microscope... by means of the tube and the animal experiment or by clinical examination and increasingly elaborate pathological studies at the bedside. Psychological and sociological studies have as important a part to play."

  Ryle and Winternitz, and Richard Cabot in Boston , were urging a different way of regarding patients, one in which a duodenal ulcer would be regarded as not merely a hole in the gut, but a problem arising from stress and economics, anxiety and fear . Later, it became so much easier, cheaper, and better to treat an ulcer with PPI's and antibiotics that no one any longer look the time to pay attention to the person who had the ulcer. 

  Constitutional Medicine , side-by-side with social medicine, also had a big run before the rise of psychosomatic medicine . It focused on the body, on endocrine function and on the "diathesis" or inborn predisposition and relied heavily on physical measurements.Intent on correlating personality with its three body types, ectomorph , mesomorph and endomorph, it left its influence in the linkage that Franz Alexander made between specific personality characteristics and his "seven psychosomatic disorders."

  The Institute of Human Relations was a creation of this time and it provided a a refuge for Angell and Winternitz as the apotheosis of social medicine. The IHR was to serve as the great unifying agent for law , divinity, and medicine along with psychology , anthropology, psychoanalysis and "mental hygiene". Characteristically impulsive, Winternitz made diagrams with the IHR in the center, with the Law and Divinity schools "equal" to the medical school but on the side. Winter always relied on proximity ; he suggested moving the divinity school and the law school down to Cedar Street to the consternation of their deans whose faculties quickly voted against any such a removal. Worse , Abraham Flexner , who had financed Winternitz's earlier plans, campaigned against the whole idea sneering that the IHR was just another term for Yale University, one for Winternitz to run. . When the Yale Corporation approved the plans, however, Winternitz weent so far as to propose a Clinical Sociology section. In his files an undated note reads, "The educational program at Yale University School of Medicine is based on the belief that medicine is a social science and that its ultimate purpose in common with other social sciences, is the promotion of human welfare. The particular avenue by which medicine approaches the general objective is that of physical health." 

  Hubris was not hard to find as Angell and Winter buoyantly claimed that the IHR would work a revoliution. That takes self-confidence, but Winter mistook dreams for reality., and went on giving talks to lay groups in which he would say things like, "Your interest is not primarily in your physical well-being but in your happiness and usefulness. How can medicine go on specializing and obtain a greater knowledge of all parts of you and at the same time bring those parts together and correlate them to your happiness, to your well-being as an individual?" 

  The College and Medical School faculties were afraid of Winter's dictatorial attitude, always his Achillers heel, and they just didn't trust his word or his motives. There were what President Angell politely termed "jurisdictional" disputes, until finally the medical faculty forced his resignation, the Institute for Social Relations was turned into a psychiatric hospital and now into a genetics laboratory, and Winternitz is just about forgotten, along with the other giants of social medicine. Welch is best remembered for bringing German science to America, Ryle more for his tube than for his failed institute of social medicine, and at Yale few know much about Winternitz's Institute for Human Relations. Yet its name, incised into the fašade on Cedar Street, would greet you as you pass through the main entrance of the medical school if only you looked up--and to the left. Milton Winternitz deserves a more lasting memorial.

Published: October 11, 2001