May 1, 1911
Dear Mr. Osler,
I have many times wished for your presence and council these past days. We have had some stirring times in the University Medical Board, including, of course, Hospital. We have some of us had a feeling for the last several years that there was a decided need of improvement in our Hospital service and in our handling of the students. This came to a head recently when Dr. Welch on his own initiative saw Mr. Gates in New York and invited Simon Flexner to come over and investigate and report upon the situation in the Medical School. Flexner spent two or more weeks here getting data, first visiting the Laboratories and then the Clinical men. Dr. Williams called to inform me of his projected visit to me but unfortunately he never came and I did not see him until he issued a printed statement to Mr. Gates which was circulated among us and the Trustees. This pamphlet you have doubtless received. If you have not, I will gladly send you a copy, if I can.
It was most frankly critical and of course most private and confidential, but the bunch of copies sent over by Dr. Flexner lay for a week or ten days on Dr. Welch's desk at the Hospital, was opened and three copies abstracted. The tenor of the whole report, its general conclusions were, I think, such as we all agree to. The difficulty comes in working out the situation in a practical way without doing unnecessary injustice to individuals. A million dollars is available if we adopt either of the plans suggested in the report. These are in the nature of two alternatives,
No. 2 is the second in preference, and also second in Mr. Gates' arid Mr.. Flexner's preference, and is that the Laboratories should mainly benefit by the fund, leaving the Clinical Chairs where they are now. There is no doubt but that the Laboratories need the fund, but I think this is the poorest solution.
No. 1 demands that the clinical men shall their entire time to Hospital service, receiving a salary of $7,500, yearly. It also demands that they shall turn over all the private practice which has been coming to them through the Hospital for the purpose of raising this fund and carrying out the plan. It also demands the fusion of my Department with Obstetrics, as a matter of economy in uniting two small cognate specialties. You will at once see the difficulties the situation presents to Barker and me individually and to no others on the Staff; Halstead having his private fortune has never cultivated private practice and is independent of it; Williams is also independent of it, having private resources. Barker is not independent, but having, taken a house and a family and keeping an automobile, a going away in the summer has raised a standard of fixed charges which the income could not possibly meet. Living expenses have increased enormously here in Baltimore since you have left us. Let me here say, and I shall not return to it again, that Barker has taken a stand diametrically opposite that he took when he wrote that little paper for Chicago. Let me add, also that any abuses such as they employed in the newspaper statements a while back which I forwarded marked to you would very readily be cleared by a simple, friendly admonition, I feel that there has been more or less jealousy in the criticism of Barker in this matter.
Finally, as to my personal position. You will recall that I had Ward B exclusively for the Gynecological Department, and kept my patients there, and kept it full until the Hospital began to make its own charges for Surgical service, I found that I could not stand the comparison between the Hospital charges and my charges, say in two patients coming from the same town, so I felt forced to enlarge my Private Hospital facilities and gradually, as far as possible, transferred all my private work to my Sanatorium here, I did not foresee that this would be such a heavy burden or would really seriously interfere with my services to the Hospital and the students, This is no manifest, and I am anxious to correct it.
I wish to return to the status quo ante having Ward B again and controlling my own private patients. I do not wish to fuse with the Obstetrics Department again and to obviate this have shown in the first place that our Department has in two years had 797 abdominal operations while the General Surgical has had 545, thus disposing of the notion that the work in our Department was small. Is all that I, with a Staff of 7 assistants living in the Hospital, can possibly carry and do justice to.
In the second place, I have pointed out that while there are genetic and anatomical associations with Obstetrics, the whole genus of gynecological work is in the major surgical field. It is for this reason that on the whole general surgeons have (and I think with perfect right) been encroaching upon our territory, doing as many operations as they could get. I insist that no academic discussion of this question as to what our affiliations are, can possibly alter this natural evolutionary tendency. A gynecological surgeon when he opens the abdomen must be prepared to do any kind of abdominal operation. This is my almost daily experience.
The historical, natural evolution of gynecology in this country and England has been to develop it as a separate specialty. In its growth we have not followed any precedent of any country but simply natural, healthy tendencies. As to the question of the propriety of the Hospital using its surgeons and medical men as milch cows, I call that a system of peonage similar to nothing else in the world, and inquiring for the reason for such a ruling, I am told that the making of money is dangerous and involves an attitude towards the work which is unscientific and hurtful. This is the only reason I can exact from Dr. Welch or any one else.
It was naturally, then, my opportunity and duty to show just what effect the making of money had had upon me personally, inasmuch as the discussion had narrowed itself to Barker's and my position.
I went carefully over my accounts for a period of 14 years back and found that in this time I had received from the Hospital in salary, $42,000.00. I have returned to the hospital $92,000.00 +.
$71,000.00 of this went to my artist whose work has never been productive in a pecuniary way but has gone to increase the reputation of my Chair there.
Not counting best $71,000.00, which manifestly cannot properly be called charity, I have actually given away for various philanthropic purposes in this time, $131,000.00 besides other thousands not accounted for here owing to the lack of time and the fact that no special records were made.
Furthermore, before any of these discussions came up, a year ago after talking with Mrs. Kelly and the older children and consulting with my lawyer Mr. Brune. I had arranged that for the future I would save no more money but use my surplus for philanthropic purposes.
You will please forgive these personal details but it was necessary to show that this greed and love of money had not contaminated me in the way suggested by my colleagues. I must add to the above that I have saved enough to just half meet my living expenses,
I want to move the Sanatorium over to the Hospital, I want better provision for my Gynecological service in a large building for economy of time on the part of visiting physicians and students in going from one to the other, as well as for more adequate administration of our Board. I want a command of salaries enough to have men like Cullen and Burnam to help me, and to engage an artist, a photographer, or what not, as my interests in my work over there seem to demand.
I write you thus fully as a warm friend, who whatever your views of this particular situation may be, has always been and will remain true. I do not know what your views may be but I am interested to hear. A general meeting will take place tomorrow night.
I feel often and have felt for years, as if the old spirit of our Institution were rapidly departing. There is less hearty regard for the work of others in in the various Departments, more of an undercurrent of criticism, occasional little outbreaks of hostility, and on the side of the Hospital management persistent opposition to any expenditures, however small. In fact this wall of opposition has been the hardest thing I have had to deal with and. greatly hinders the development of our service.
Please give my affectionate regards to Mrs. Osler.
Always affectionately,
Howard A. Kelly