Embryology History - Joseph Marshall Flint

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Introduction

Joseph Marshall Flint
Joseph Marshall Flint (1872-1944)

Dr. Joseph Marshall Flint, for 14 years Professor of Surgery in the School of Medicine of Yale University, died at the age of 72 at Seal Harbor, Maine, on September 16, 1944.

He was offered the Professorship of Anatomy at the University of California (1901 - 1907). During this period, he organized the anatomical laboratory of the university and published in all 12 papers, of which ten concerned the histogenesis and organization of the structures of organs. The adrenal, submaxillary gland, thyroid and parathyroid glands, the lungs, and the oesophagus were thus considered, and the reconstructions of some of these are still classic.

Obituary - Yale Journal Of Biology And Medicine (1945)

  • Yale Journal Of Biology And Medicine, Vol. 17, No. 4. 504

Dr. Joseph Marshall Flint, for 14 years Professor of Surgery in the School of Medicine of Yale University, died at the age of 72 at Seal Harbor, Maine, on September 16, 1944. The graduates of the School since 1921 have been unfortunate in not having had intimate contact with Dr. Flint and they are not sufficiently aware of the important part during his time he assumed in the development of the School.

His education preparatory to that in medical school was obtained at Princeton in 1891-93 where he was a “first-string” member of one of its great foot-ball teams, and at the University of Chicago from which he received the degree of Bachelor of Science in 1895. This transfer to the University of Chicago, newly established in 1892, with science strongly represented in the biological divisions (Whitman in Zoology, Mall and Jordan in Anatomy), indicates Flint’s desire to lay a sound foundation in whatever he undertook. Although Mall had left for Johns Hopkins as Professor of Anatomy at the opening of the school there in 1893, Flint stayed on for a year of post-graduate study (1895-96) with Jordan, who was an instructor in Anatomy from 1893 to 1895 and then Assistant Professor of Bacteriology. Out of this came his first contribution to the medical literature.

From there Flint entered the Johns Hopkins Medical School in 1896. His choice at this time could scarcely have been otherwise. The faculty brought together by Gilman was young and chosen for its future promise rather than upon past accomplishment. It had no traditions to live down to, but could and did make its own, consistent with the viewpoint of the teaching of science, expounded by Huxley, and exemplified in the laboratories of such men in Germany as His, Ludwig, and Cohnheim, where so many of this new faculty had studied as graduate students. Indeed, it was this graduate level of teaching which was transplanted to Baltimore rather than that provided for the medical student in Germany. This program of education attracted in those early years students of exceptional ability and permitted a freedom of opportunity for development which had never obtained before, and sad to say, has rarely since.

The prime mover in this inductive type of learning was Mall, and he from the start not only practised it but constantly preached the philosophy of teaching in the medical school at a university level—a level which but few universities reached either in the school of medicine or elsewhere. This involved the complete devotion of the teacher to the functions of teaching; first of which was research, for without this, science could not be competently taught, being a field of knowledge which constantly changes and expands. While this was fairly readily accepted in anatomy, physiology, and pathology with their ancillary divisions, the application of it to the clinical departments was, and still is, a matter of controversy.

Flint’s first educational contact in Baltimore was in anatomy with Mall, and anatomy remained throughout his stay the inspirational and to a considerable degree his working locus. Several men, who later became well known, were members of the departmental staff, such as Bardeen, Lewellys Barker, and John Bruce MacCallum. Under such circumstances he learned the techniques of anatomical investigation and particularly the use of methods of corrosion and digestion in the study and reconstruction of the functional units in organs, as Mall did so brilliantly in relation to the spleen.

Meanwhile, the Spanish-American War had led to intensive interest in tropical diseases, and Simon Flexner and Lewellys Barker under the auspices of Johns Hopkins University organized a “Commission” for the study of these in the orient where plague was rife. They chose two advanced medical students, Joseph Marshall Flint and Frederick P. Gay to go as volunteers, at their own expense, to assist in the work of the commission. With them went John W. Garrett of Baltimore who subsequently had a distinguished diplomatic career. Barker and Flint returned by the way of India, where they saw a serious epidemic of plague, and then the Mediterranean and England. While the contributions of this commission were considerable, the educational influence upon the members was no less important. Perhaps, most valuable from Flint’s standpoint were the intimate contacts established and the discussions which went on among the group concerning the organization of medical schools on a university basis.

Out of these came, in 1902, Barker’s address, “Medicine and the Universities,” which first expressed publicly the theory of the “whole-time” professor in the clinical divisions, which Mall in a less public manner had discussed previously. The immediate reaction was critical and damning, and it remained for the patient spadework of Welch to bring this to fruition in 1913 at Johns Hopkins. Ironically enough, Barker to whom the chair in medicine was offered on the conditions so enthusiastically proposed by him in 1902, now found it impossible to accept. It is only fair to say that in the meanwhile he had assumed prohibitive responsibilities, and that had the same proposal been made at an earlier date, he very likely would have accepted. In any case, Flint had become by the time of his graduation from the School of Medicine thoroughly saturated and sympathetic with the concept of the “whole-time” teacher in clinical medicine, and the organization of departments on a university level.

In 1900 he received his M.D. from Johns Hopkins and an M.A. from Princeton and took a turn in Leipzig as so many of Mall’s pupils did. Ludwig had died, but His was still active and welcomed those whom Mall sent to him.

Flint’s immediate future was quickly arranged. Barker was offered the Professorship of Anatomy at Chicago, and although expecting ultimately to work in internal medicine, he accepted Mall’s advice that “it would be wise to occupy the chair in anatomy for a time, at least, as even if I went into clinical medicine later I would be all the better prepared for it” and that work in the preclinical sciences was an excellent preparation for clinical medicine. Flint, who likewise had had for some time his heart set on the field of surgery, was similarly advised and went with Barker to Chicago where he was associate in anatomy for the year 1900-01. His stay was short however, for he was offered the Professorship of Anatomy at the University of California which he held from 1901 until 1907 when he came to Yale.

During these years Flint was most productive and achieved advanced standing as an anatomist. He organized the anatomical laboratory of the university and published in all 12 papers, of which ten concerned the histogenesis and organization of the structures of organs. The adrenal, submaxillary, thyroid and parathyroid glands, the lungs, and the esophagus were thus considered, and the reconstructions of some of these are still classic. One contribution having to do with anastomoses in the gastro-intestinal tract revealed his continuing interest in surgery and was published in the Archiv fir klinische Chirurgie in 1906.

By this time he was again in Germany taking a prolonged sabbatical year in further study but chiefly in surgery, at the same time completing his anatomical work on the lungs and esophagus. While surveying most of the university clinics in surgery, he centered most of his activities in Bonn, Munich, and Vienna, at the last of which von Eiselsberg, a pupil of Billroth, was the professor of surgery. As a result, he became thoroughly conversant with German surgery and its literature at a time when it was easily first in fundamentals and in practice. Obviously, Flint was preparing himself for entrance into the field of surgery, having, as he had been advised, first perfected himself in a preclinical discipline.

The opportunity for this transition from anatomy to surgery came at Yale, where Dr. Carmalt, who had been Professor of Surgery since 1881, was retiring in 1907. Having studied under Dalton in physiology in New York, and Waldeyer and Stricker in pathology in Germany, and Knapp in ophthalmology, he came to New Haven to practise in 1876, and in 1879 was appointed on the faculty of the School of Medicine to give instruction in this subject. At that time Francis Bacon, who had succeeded Jonathan Knight as Professor of Surgery, became convinced that it was not feasible to continue the Yale School of Medicine and resigned from its faculty devoting his unusual abilities to the New Haven Hospital where he was dominant until the time of his death in 1912. This divorced the hospital from the school which up to this time had had close affiliations. After an interregnum of three years filled by David P. Smith of Springfield, Massachusetts, a grandson of Nathan Smith, Dr. Carmalt was made Professor of Surgery. While accorded a service in the hospital, the medical school students were there on sufferance, and then only during certain winter months when the professor was on service. At the most they were onlookers not participants. Dr. Carmalt believed firmly in the possibility of the development of an excellent school of medicine in New Haven, and worked throughout his lifetime to this end, supporting Dean Smith in his efforts to improve the faculty and pressing continually for an affiliation of the school with the hospital. With this in mind the University was induced to purchase the properties on Cedar Street opposite the hospital, and there a new building was erected with funds given to the University by Mrs. Thomas G. Bennett, “for the relief of the poor and the advancement of medical science.” In 1907 the teaching of surgery was for the most part carried on there, although the previous year Dr. Carmalt had finally succeeded in getting the hospital to institute a continuous teaching service, one quarter of the surgical patients, some 18, being assigned for this purpose, the remainder remaining for the non-teaching attending staff. To this service was assigned every fourth case admitted, and without a very definite space allocation. A small amphitheater was available for demonstration clinics and beneath it a laboratory for clinical microscopy and chemical examinations. An amphitheater for operations, some twenty years old, was open to the students but only as spectators. None of the clinical departments had offices or laboratories either within the hospital or elsewhere.

Dr. Flint accepted the appointment on condition that laboratories, classrooms, and offices be provided in close contiguity with the hospital and dispensary and that adequate technical assistance be provided for these. While primarily instigated for surgery, on his suggestion these facilities were made available for medicine as well. An old house adjacent to the dispensary was remodeled for these purposes and a two-story brick addition was added to the rear, the first floor being for animal quarters and the second a laboratory classroom. Equipment was installed for chemical, bacteriological, and physiological investigation as well as for surgical pathology. An Austrian trained “diener,” Kellner, who was skilled in many techniques including drawing and photography, was imported. With this, for the first time, the clinical divisions of surgery and medicine were housed with relatively adequate facilities.

Any radical change in the teaching methods could not be made as long as the number of teaching beds was limited to 18, but this was intensified inasmuch as all of Dr. Flint’s time was devoted to this function. In lieu of sufficient clinical material, a course in “dog surgery,” modeled after that which Harvey Cushing gave at Johns Hopkins, was set up and carried out with characteristic thoroughness. As a necessary substitute for experience directly with the patient, it was excellent and enthusiastically received by the students, and here in particular they came into intimate contact with the professor, who by his wide knowledge and comprehension raised them above the textbook level of learning. Particularly was this true of those who were concerned with the investigative work which he encouraged and which he himself carried on. All the essential and basic conditions of a university department on “whole-time” were introduced, and in the Department of Surgery there was no deviation from this from the very start, although it was not as yet an established policy of the School of Medicine. This, of course, excited comment and criticism, as always occurs with an innovation, however creditable it may be. Such a marked deviation from the mores is taken to be a direct reflection on those who conform. Even more disturbing was the appointment as professor of surgery of an anatomist who had not been trained in the customary way by long experience in the clinic. This made Flint particularly vulnerable to criticism by those who had won their way by the practice of surgery. An added irritant was that he was not dependent upon income derived from the care of patients. Overlooked was the fact that a clinical department had here for the first time been placed on a university level as the result of the choice of a man who had spent some seven years in preparing himself for this position, unorthodox as this method may have been. In this instance, the more important qualifications for the purpose were present and clinical experience would come, as it did, relatively rapidly.

It may be that the desire for a broader and more intensive experience, as well as a conviction that much could be learned in the surgery occasioned by war, lay behind Dr. Flint’s three excursions into this field, although he was as far from being non-partisan in international affairs as he was in domestic. In any case, he served for a summer as surgeon to a Greek hospital in Athens during the Greco-Bulgarian War in 1913, as a médicin chef for six months in the French military hospital at Passy, France, in 1915, and most notably as commanding officer of Base Hospital, later Mobile Hospital No. 39 (The Yale Unit), of the A.E.F. in 1917-19. This last is worthy of further note for Dr. Flint was largely responsible for its formation and organization, for the obtaining of funds, and for its functioning during the year and a half that it was in France. For this he was justifiably awarded the Distinguished Service Medal accompanied by a citation which read as follows: “When placed in a position of great responsibility as commanding officer of Mobile Hospital No. 39 at Aulnois-sous-Vertuzey, France, he used extraordinary skill and sound judgment in the organization and operation of that unit, the first of its kind in the American Expeditionary Forces.”

The Yale Unit experienced the customary vicissitudes of an army hospital, with perhaps more than some but less than others. On arriving in France, there was some misunderstanding at general headquarters as to the type of the unit, and consequently it was assigned as a Base Hospital in Limoges. Accepting this assignment without question as any officer should have done, Dr. Flint proceeded with comprehensive plans for the development of a hospital center of 5,000 beds there. Of course at that time and for some months . JOSEPH MARSHALL FLINT 509 after there were few if any wounded of the American Army sent to base hospitals so far in the rear. This was true of all the American Base Hospitals which were not attached to the British. Meanwhile, Flint was designated by the Surgeon-General of the A.E.F. as liaison officer with the French to study their mobile hospitals which had been highly developed as the “auto-chir” and to proceed with negotiations with them for the purchase of the necessary equipment. This was first delayed in production and then was requisitioned for French troops being sent into Italy in support of the Italian armies. Again in January, negotiations were reopened and a definite order placed through the Surgeon-General’s office, and in February equipment began to come through. It was assembled and inspected in Paris, and in April a site was chosen for its activation immediately behind the American forces in the neighborhood of St. Mihiel, where offensive action was expected soon. A model hospital was developed here which was the first “mobile unit” organized by the American forces and was used for demonstration in the development of others.. Some of these saw more violent service at an earlier date as they were thrown directly in along with evacuation hospitals just arriving in Europe in the defensive battles of the spring and early summer between Amiens and the Marne. When the American army went on the offensive at St. Mihiel, surprisingly few casualties were incurred, but the Yale Unit had a busy day or two, and then was relatively quiet again. The following Argonne offensive was well to the west, and hospitals were brought up directly from the rear rather than across lines of communication. Moreover, the second army was being organized to attack toward Metz and Mobile No. 39 was to follow it in, but this was barely started when the armistice occurred. If responsibility rested anywhere for this “hard-luck,” if it was such, it was with the Surgeon-General’s office of the A.E.F. rather than with the commanding officer of the unit who obeyed his orders without protest, as a good officer should. Today General Hospital No. 39 is again in service and is making a record which does the University great credit, as did its predecessor in the previous war.

Out of his war experiences, particularly those in 1913 and 1916, Flint culled material for several papers on military medicine which were of particular value in that they provided information before our own entrance to the war. From the Greco-Bulgarian experience came the “balkan frame,” and much knowledge of value in the suspension methods for treating fractures, which was further developed in 1916 in France. A particularly valuable contribution, still useful in certain situations, was a method for the precise location of foreign bodies by roentgenography. These were preparatory to our own entrance into the war and therefore well timed.

It would be erroneous, however, to give the impression that Flint’s interest and time were largely devoted to war surgery; approximately a total of two years out of the fourteen at Yale was so occupied. The University gained greatly by this activity, and he had seen to it that during his absence the routine work of the department was well covered.

Of early interest to him and following naturally upon his anatomical studies of the lung and esophagus was that of surgery of the thorax. First was the development of an apparatus for the administration of ether vapor within the pharynx, worked out with Herbert Thoms as a student. This was also employed intratracheally after the method of Meltzer, and finally a modification was made by which positive pressure could be maintained, thus making it possible to open the thorax and carry on operations within it. Sauerbruch and Willy Meyer were working with massive chambers for this purpose, but this simple approach was adequate and was the forerunner of the present-day methods employed in thoracic surgery. One of these machines is still employed after 35 years in the operating rooms of the New Haven Hospital for pharyngeal ether anesthesia.

This apparatus was but a means to an end, the experimental study of the effects, anatomical and physiological, of operations within the thorax. A large number of lobectomies and pneumonectomies were successfully done upon dogs, and such physiological observations made as were possible at the time. The capacity of the remaining lung to expand and fill out the thorax was demonstrated. However, this work then seemed to have no very practical application, and it was only after the war of 1914-1918 that the field of thoracic surgery came to the fore.

Likewise, following upon his anatomical studies was an investigation of resection of the small intestine. Experimentally in dogs he determined the amount it was possible to remove with survival, and demonstrated that in extensive resections a compensatory hypertrophy took place in the remaining gut.

His anatomical knowledge also served to clarify a controversial issue of the time (1910-1912) which centered around certain “adhesions” about the ileum, appendix, cecum, and ascending colon currently supposed to be the result of inflammation. Flint’s observations at the operating table, correlated with his knowledge of the development of the large intestine, served to identify these as congenital and developmental. This is demonstrative that his interests were by no means confined to the laboratory, as was also the report of two instances of the cure of acute traumatic subdeltoid bursitis by aspiration, a method of treatment which has been rediscovered in recent years. Similarly, Flint did the first transfusions in the State of Connecticut, by the direct method, and was one of the few privileged to try out the administration of salvarsan on its first introduction into this country.

More intangible than these specific contributions of Dr. Flint, but in the long run perhaps more important, was his influence, direct and indirect, on the changes that took place in the school and hospital during his time.

Dean Smith had fought up-hill against almost insuperable obstacles of apathy and disinterest on the part of the University, of antagonism and prejudice on the part of the hospital. Ferris in anatomy, Henderson in physiology, Bartlett in pathology, Carmalt in surgery and, latterly, Blumer in medicine, with courage and a shoestring only, had faith in the future of the school and with vision laid the foundation for what was to take place. With the appointment of Flint and with Blumer becoming Dean, the first fruits began to appear. A step had been taken which gave evidence of new standards on a university level, and a Dean from the clinical department gave promise of a mobilization of the clinical facilities. The school was brought in touch on the one hand with those greatly concerned about medical education, such as Mall, Welch, and the Foundations, and on the other, had gained a few friends in the University, notably the Secretary, Anson Phelps Stokes, an old and intimate friend of Dr. Flint. The hand of time itself removed some of the obstacles, for as Dr. Carmalt wrote in his centenary address, “Changes in the directorate and in the attending medical staff of the hospital, discussions and papers on the relations of hospitals to medical schools had wrought increased interest in medical education. In 1913 following the report of a committee of the Board of Directors consisting of Dr. George Blumer, Dean of the Yale Medical School, a director of the hospital, a member of the attending staff of the hospital and the Professor of Internal Medicine in the Medical School, and the Rev. Anson Phelps Stokes, Jr., also a director and the Secretary of the Corporation of Yale University, both familiar with the mutual needs and advantages of the situation, an agreement was entered into between the General Hospital Society and Yale University signed by their respective presidents by which, in consideration of the payment by the University of $600,000 the General Hospital Society permitted the use for educational purposes by the University of the general and semi-private wards of the hospital.”

The funds required to activate this agreement were given by the heirs of Anthony N. Brady and with this was built the Brady Laboratory which came to house the Departments of Pathology, Medicine, and Obstetrics and Gynecology. Winternitz was appointed in Pathology, Slemons in Obstetrics and Gynecology, and Underhill in the chemical division of Internal Medicine. These were in effect “whole-time” appointments, and like Flint the incumbents so functioned; before the policy was officially enunciated by the University in June of 1918 in an agreement between it and the General Education Board by virtue of which the latter assisted in the raising of a two-million-dollar endowment for the School by the gift of something over half a million. At the same time the hospital supplemented its previous agreement with the University by turning over its wards for teaching throughout the year, thus giving at last full and complete control of these facilities.

Meanwhile, our entry into the war had intervened, and many of the faculty were absent or engaged in activities concerned with it. This had its usual demoralizing effect and with its end, many changes occurred. Dr. Blumer declined reappointment as Dean and resigned the chairmanship of the Department of Medicine, feeling that the fundamental reorganization of the school and the hospital had been accomplished, and that the future should rest in the hands of others.

By 1920, Henderson had been transferred from the School of Medicine to a new department of Applied Physiology in the University and Slemons had resigned. Flint tendered his resignation in 1920, but at the Dean’s request stayed on until 1921, when he insisted on its acceptance. The desks were then clear for a new crew, but the ship was “well-found,” seaworthy, and able to weather any storm that might lie ahead.

That Flint was of this opinion was shown by his remark that “the future was now assured” when the Corporation in 1920 ruled that all university departments involved to any considerable degree in the teaching of medical students should be housed on Cedar Street in juxtaposition to the Hospital. On another occasion he wrote to a colleague, “My own feeling is that the really difficult part of the job has been done. The ground is ploughed and all that it needs is the proper kind of planting and cultivation to bring about the fruition of the years of labor that you have invested in the School.”

The erection of the Sterling Hall of Medicine with accommodations for Anatomy, Physiology, Physiological Chemistry, and Pharmacology came about shortly in accordance with this ruling. An incidental effect was the tearing down of the “Surgical Laboratory” which as a valuable makeshift had survived since 1907, and the transfer of the activities housed there into “The Army Barracks,” a temporary building erected during the war.

Although this feeling of confidence in the future of the School was of weight in Dr. Flint’s resignation, the primary factor was that of ill health. In the spring of 1919 on returning from France he brought back with him a residual pulmonary infection of the type associated with the current influenza, from which he did not rebound with his customary vigor. This, with the desire for a complete and prolonged disassociation from the responsibilities he had been carrying for fourteen years, and a longing to repeat his “Wanderjahre” of 1905-07 in Europe, led not only to his separation from the School but in the end to a sojourn there of a score of years. His disability increased rather than lessened as the years went on, for quite early in his stay there appeared evidence of the vascular disease to which he finally succumbed. After his return the time, all too short, during which he had opportunity to renew his acquaintances, to rediscover his homeland, and to observe the fruition of those plans of former years gave him the pleasure and satisfaction which he so well deserved.

Samuel Clark Harvey.

Bibliography

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References

Harvey SC. (1945). Joseph Marshall Flint. Yale J Biol Med , 17, 503.b1-515. PMID: 21434224



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