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showing an intermingling of high ideals and great aspirationswith the lower motives of opportunism and commercialism.1'" Borden's statement clearly describes the development ofAmerican medical education to that time.That medical education was prostituted cannot be easilydenied.Yet its beginnings, although short-sighted, wereambitious and hopeful.Nowhere in the world was eighteenthcentury medical practice or medical education based on purescience.Much of it was flagrant superstition.Even so,formal medical education in the United States began as auniversity discipline.For Flexner, the importance of thisfact could not be overemphasized.He argued persuasivelythat getting away from the university proved detrimental tomedical education, to the medical profession, and, ultimately,to the people.For good reasons, Flexner believed thatmedical education, had it remained an integral part of theuniversities where it originated, would have improved alongwith them.- However, before medical education moved into the university, physicians received their training from preceptors.The preceptorial system, William F. Norwood writes inl wiHiam C* Borden, "The Trend of Medical Education inthe United States," New York Medical Journal, XCII (July 2,1910),1.l Erwin H. Ackerknecht, A Short History of Medicine(New York, 1955) , pp. 204-207; Borden" "The" Trend of MedicalEducation in m e Onitea States," 1; r'iexuer, The FlexnerReport, pp. 4, 6, 20.

Medical Education in the Limited Sbates Before the Civil War,"was not only well adapted to the unpolished state ofsociety but was to some extent a product of the wildernessculture." Necessary, useful, and practical, the precep-torial system was typically American.supplied most of the nation's doctors.For many years itIt has been esti-mated that in 177 5, a decade after the first medical schoolopened, only four hundred of the nation's thirty-fivehundred physicians were university trained; the vast majority of those holding degrees earned them in Europe.Sincemost Americans aspiring to a medical profession could notafford an European education, they had to settle fora preceptor."'" Each preceptor decided for himself what preliminaryeducation suited a man for a physician's training.Gener-ally, however, the students had to possess some knowledgeof classical languages, particularly Latin.They, had to becompetent in mathematics and English grammar, and a17familiarity with natural history was beneficial.As willbe seen shortly, these requirements were vastly superior to William F. Norwood, Medical Education in the UnitedStates Before the Civil War (Philadelphia, 1944), p. 37.Hereinafter cited as Civil War.l Ackerknecht, A Short HistoryMedicine, pp. 204205. The preceptorial system was a reversion to ancientGreek and Indian methods of medical education. Norwood, Civil War, pp. 32-33.

8those of many medical schools in the. first decade of thetwentieth century.Flexner thought the preceptorial system was well suitedto the training of physicians.The very nature of thetraining, involving the students in the life and deathstruggle immediately, let students experience the joys andsorrows of medical practice.Immediate, practical, intense— preceptorial training was the best kind of education; andreturning the student to the patient became one of the18primary goals of the reform movement.Like Flexner, Norwood thought the preceptorial systemwas a practical teaching method suited to the times.But hewas more willing to admit that the system had serious flaws:The chief virtue of the preceptorial system wasthat the students so trained were not inclined to bemere theorists. The practical clinical experienceand observation which most students had from thefirst, though too often they were ill-prepared toappreciate what they saw, built into the Americanmedical profession that spirit of self confidence andpracticality which has characterized it down bo thepresent time.19The preceptorial system, by failing to prepare studentsfor their learning experiences, failed to achieve, much lessmaintain, a pinnacle of quality better medical practitionersexpected.Moreover, since there were no generally acceptedor enforced rules or regulations on the training of doctors,Flexner, The Flexner Report, p. 20.19Norwood, Civil War, pp. 36-37.Italics mine.

instruction varied greatly from preceptor to preceptor.Some of the preceptors were demanding, efficient, and responsible while others misused their students, putting them towork at menial, non-medical chores like greasing buggywheels and currying horses.Time could have been better20spent reading.The preceptorial system undoubtedly trained betterdoctors at its inception than it did in later years.Mostof the original preceptors had had some schooling beforeemigrating from their homelands.They tried to pass theirschooling on to their students; but the new doctors, entering actively into the'profession, took on students themselves;and training slowly but surely deteriorated.The systematicand comprehensive demands associated with educational institutions were missing.As deterioration became more and moreprevalent, members of the profession who objected joinedforces and asked their fellow physicians to refuse studentsunless they could be provided with an ample supply of books,diagrams, clinical experience, and other paraphernaliadeemed essential in providing sound medical knowledge.Many21doctors ignored the request.Attempts to supplement and improve upon preceptorialtraining were initiated as early as 17 50, when classes inanatomy were offered. In 1762 William Shippen, who had Jbid., pp. 32, 38-39. Ibid., pp. 32-39.

10been educated at Edinburg, lectured on midwifery, hoping toshare some of his European training with physicians lessfortunate than himself.Flexner maintained that the firstmedical school in the colonies grew out of these lectures.According to Flexner, Shippen and John Morgan, also educatedat Edinburg, opened the Philadelphia Medical School in 176522under the auspices of the University of Philadelphia.Norwood, in his more detailed history of early Americanmedical education, presents a much different story.and Shippen were both reared in Philadelphia.MorganShippen, alittle older, was completing his medical course just asMorgan was beginning his.The two probably got together atEdinburg and talked about organizing a school back home.For reasons unknown, however, friendship waned and planswere interrupted.But Morgan went on with the plans alone.Winning the confidence of the trustees of the University ofPhiladelphia, Morgan was permitted to organize a medicaldepartment there in 1765.After the school had been started,Shippen claimed the idea for the school was originally his.Be that as it may, Norwood gives Morgan credit for organizing23the first medical school in the colonies. Flexner,The Flexner Report, p. 3. N o r w o o d , Civil War, pp. 4-6; There is much conflicting opinion on this point. F. R. Packard supports Shippenin F. R. Packard, "Early Methods of Medical Education inNorth America," Journal of the American Medical Association,XXXII (January 12,- 1899), 636, yet Ackerknecht, A ShortHistory of Medicine, pp. 204-207, supports Morgan.

11In May, 1765, Morgan, energetic, intelligent, andinspired, spoke at the commencement exercises of theUniversity of Philadelphia.His subject was reforming themedical profession in the colonies through improved medicaleducation.Morgan stated frankly that a doctor without aformal education was dangerous because he possessed toolimited a knowledge of medicine to be responsible for humanlife.Emphasizing the importance of appropriate pre-medicaleducation, Morgan outlined a course of medical study thatincluded a systematic classification of medical branches tobe studied.While describing the condition of medical prac-tice in the colonies,' he gave convincing arguments for theneed of a medical school.He outlined the advantages theuniversity could expect from such a department and concludedby asking that prospective medical students be counseledbefore they entered their training to determine their qualifications, interests, and motives.On May 3, 1765, thetrustees elected Morgan the first Professor of the Theory24and Practice of Medicine in British North America.At Philadelphia Morgan established many precedents towhich twentieth century reformers looked for support.Ofparticular importance were those concerning entrance anddegree requirements.A student had to apprentice himself toa reputable physician.If the student held no degree, hehad to satisfactorily demonstrate to the trustees and the Norwood, Civil War, pp. 2-7

12professors that his abilities in Latin, mathematics, andnatural and experimental philosophy indicated the possibility of his completing the medical course; successfully.Requirements for the Bachelor of Medicine degree werestrenuous.Besides preceptorial training, they included atleast one course of lectures in anatomy, chemistry, materiamedica, and the theory and practice of medicine.This wasfollowed by a course of clinical lectures and one year ofpractice at the Pennsylvania Hospital, the best hospital inthe colonies.In all, a three-year course, exclusive of pre-ceptorial training, was organized.After completing thecourse, the student was required to pass examinations.Eventhen, however, he received his degree only if the trusteesand the professors were satisfied with his work.The Doctorof Medicine degree required three years of study beyond theBachelor's degree.The candidate had to be at least twenty-four years old and had to publicly defend his thesis, writtenin Latin.The thesis had to be published.Unfortunately, these requirements were short-lived.Unprofessional quarrels between faculty members, involvementin the politics of the American Revolution, and the inabilityof the university to attract doctors to take the higherdegree precipitated a lowering of standards.The school didaway with the Bachelor of Medicine degree and, except for Ibid. , pp. 65-66.

13natural and experimental philosophy, all of its preliminaryeducation requirements.The required course, shortened fromthree to two years, could be satisfied simply by repeatingeach subject area lecture in the second year.The schoolretained apprenticeship but dropped the hospital year completely.A thesis in English or Latin was acceptable.Thestudent, after completing this watered-down course, received*? fithe degree, Doctor of Medicine.Harvard, Yale, and.King's College followed the exampleof the University of Philadelphia in organizing medical77departments.But "American medical education was yet inits cradle," for many'of the degrees conferred were28honorary.Norwood summed up eighteenth century medicaleducation:The eighteenth century, with reference to medicaleducation in the colonies and the young republic, wasa period of orientation. A race of pioneers, devotedto the building of a nation, practiced the arts ofstatesmanship and theology but left the art of healingto Providence and practitioners, many of whom were illtrained. Legislators gave transitory attention toregulation and protection of the profession. Organizededucation took no cognizance of medicine as a branch oflearning. Practitioners trained apprentices. Each preceptor produced, after his kind, fledglings in the artof physic. Few were equipped to act as master. Throughthe agency of European-trained physicians and the writings of their masters, the profession in America emergedfrom fallow years. Lecture courses in midwifery andanatomy were given, dissections were made, hospitals Ibid. , pp. 67-68. Flexner, The Flexner Report, pp. 4-5. Norwood, Civil War, p. 60.

14were started. The profession served admirably throughseven years of bloodshed and gathered from the experience scientific improvement and professionalconsciousness. Medicine was moving forward, butorganized instruction was yet in its formative years.Schools were few and poorly equipped. Attendance, onthe whole, was small. The practitioners office wasstill the school of medicine.29Looking to the origins of medical education in theeighteenth century to find support for arguments against themedical schools of his own day, Flexner regretted that the"sound start of these early schools was not long maintained.Their scholarly ideals," he wrote, "were soon compromisedand then forgotten." 0But Flexner, less inclined thanNorwood to accept the lowering of standards at Philadelphiaas the inauguration of decline in American medical education, blamed degeneration on the University of Maryland andher establishment of a commercial medical school in 1812.Both Flexner and Norwood considered chartering the Marylandschool a tragedy because it tried to make a medical schoolthe nucleus for the entire university, grafting schools oflaw and theology onto it.The university was proprietary innature and there was no central governing body.Since theprofessors ruled the university, they could maintain theirpositions indefinitely.But regardless of how commercialmedical schools got their start or how well some few of themserved the medical profession, in the view of twentieth29ibid., p. 62,30Flexner,TheFlexnerReport, p. 5.

15century reformers commercial, medical education was a cancerous growth.Commercial medical schools gave birth to allthat was pernicious and corrupt in medical education and in 5 1the medical profession.Although commercial- schools rose and fell constantly,after 1812 the number multiplied disgracefully.Norwoodmade the following observation:Schools sprang up like mushrooms in coastal cities, ininterior valleys' of the Piedmont, and in the expansivetrans-Appalachian area from Michigan and Wisconsin toAlabama and Louisiana. Under the impetus of far-westernexpansion the movement reached the pacific coast in 185 8with the establishment in San Francisco of the Universityof the Pacific.32In 1810 there were five medical schools.later the number had doubled.A decadeAnother decade saw the numberdouble again as an average of one new school was organizedeach year.In 1850 there were fifty-two schools, and by theoutbreak of the Civil War the number had reached sixty-five.Although twenty schools failed to survive the war, therewere one hundred medical schools in 1880.there were thirty-three more.attained in 1906.Ten years laterThe largest number, 161, wasThereafter the number declined slowlyuntil the publication of the Flexner Report in 1910 precipitated many closures throughout the United States.Apparently31ib.id. ; Norwood, Civil War, pp. 240-241; Billings,"Medical Education in the United States," 1271-1276; Flexner,The Flexner Report, Pritchett's Introduction, p. x.- Norwood, Civil War, p. 429.

16several school administrators saw the coming fury.At anyrate, there were 131 schools doing business at the close of1910.33Although many of these schools were nominally affiliated with established and oftentimes highly respecteduniversities, most of them were commercial institutions.The universities supplied little more than their names, providing neither administrative nor financial support.Henry S. Pritchett and Lewellys F. Barker, to name only two,reprimanded the universities for their disastrous dereliction of duty.3 An irate Abraham'Flexner described the expansion ofmedical schools thusly:These enterprizes—for the most part they can be calledschools or institutions only by courtesy- were fre— quently set up regardless of opportunity or need: i n small towns as readily as large, and at times almost mthe heart of the wilderness.35Whenever a handful of practitioners without school affiliations got together, the likelihood of a new school emergingwas great.33A school needed only a faculty to open.Ibid.,United StatesConnectlcuttTFinal Report,Thepp. 139-140; The Statistical History of thefrom Colonial Times to the Present (Stamford,1965), p. 34; Commission on Medical Education,Appendix, Table 104.34piexner, The Flexner Report, p. 8; Bevan, "Medical Education in the"United States: Need for Uniform Standards,566- Pritchett, "The Obligations of the University toMedical Education," 1110; Barker, "Medicine and theUniversities," 147.35Flexner, The Flexner Report, p. 6.

17faculty did not have to be a good one, just one composed ofmen who were willing to teach in filthy, badly lightedbuildings without books, laboratories, or clinics.Commercial medical education expanded rapidly for anumber of reasons, chief among them being the failure ofstate legislatures to accept their responsibility of controlling it.In some cases they were unable to do so.Forexample, in New York before the Civil War, the Regents ofthe University of the State of New York were delegatedsupervisory powers over chartered institutions.The Regents,however, found it impossible to control the spread ofcommercial medical schools in their state, primarily becausestate medical societies, by lying about the quality of education the schools offered, encouraged and perpetuated theiro7contagion."It is clear . . . " Norwood wrote, "that nouniform system of establishing or governing medical schoolsOOexisted at the time."This was true all over the Country.Rather than enact legislation aimed at controlling theorganization of medical schools, state governments tried toregulate the practice of medicine.This, of course, onlyindirectly affected medical education.Laws with the inten-tion of eliminating quackery were passed in the second half Ibid., pp. 6-7.37jsiorwood, Civil War, p. 385.33lbid.

18of the eighteenth century.Ultimately, state medicalsocieties were entrusted with licensing powers, and theybecame responsible for medical education when they acceptedthe Doctor of Medicine degree as sufficient proof of medicalknowledge.Any man possessing a degree from a "recognized"school could practice medicine in any state without furtherproof of knowledge or ability.Even without a degree,candidates were licensed if they passed an examination thatsatisfied the medical societies.But these restrictionswere nullified considerably when all but four states repealed39their medical practice acts after 1842.By 1888 the American Medical Association was demandingeffective state legislation to protect the public and themedical profession from quackery in all its forms whetherpsuedo-scientific or religious.It was, responsible physi-cians argued, the right and the duty of the stat

That medical education was prostituted cannot be easily denied. Yet its beginnings, although short-sighted, were ambitious and hopeful. Nowhere in the world was eighteenth century medical practice or medical education based on pure science. Much of it was flagrant superstition. Even so, formal medical education in the United States began as a