- Email: [email protected]
The first American medical school: the formative years
Perspectives
The art of medicine The first American medical school: the formative years In 1765, students were admitted to “anatomical lectures” and a course on “the theory and practice of physik” at the College of Philadelphia. Thus began the first medical school in the USA—at that time, of course, “America” simply consisted of 13 colonies. Eventually, after various convulsions and name changes, the College of Philadelphia would transmute into the University of Pennsylvania and the two courses of lectures into the university’s Perelman School of Medicine. In Europe during the 18th and 19th centuries, small groups of physicians sometimes gathered together to create proprietary medical schools, offering lectures and collecting fees from the students. For the professors, these fees helped supplement their incomes from private practice. In addition, a young man (no women allowed) seeking a career in medicine could serve as an apprentice, working with an established physician, until he was regarded as sufficiently competent to set up his own practice. At the best medical schools in London, Edinburgh, and Paris, students could also experience practical bedside teaching in hospitals. The founders of the medical school in Philadelphia, John Morgan and William Shippen, Jr, had received their medical education in the UK at the University of Edinburgh. As students, they had discussed the need for some such training in the USA. Shippen, who left Europe first, waited for Morgan to return, and was furious when Morgan, acting alone, proposed to the Trustees of the College of Philadelphia that they establish a medical school with himself as its founder and first professor. The competition and hostility between these two men was to last for the rest of their lives. After Morgan had completed his plans for the school, he did appoint Shippen as professor, although clearly in a secondary role. Morgan taught the theory and practice of physic, while Shippen gave lectures on anatomy, surgery, and midwifery. At first, Morgan also lectured on chemistry, botany, and materia medica (pharmacology), but these subjects were soon turned over to a new professor, Adam Kuhn. The most famous of subsequent professors was Benjamin Rush who arrived in 1769. Rush is often remembered as a signer of the US Declaration of Independence, but he was also notable as a founder of psychiatry and for his enthusiastic advocacy of a treatment regimen of bleeding and purging. Known for his dedication to his patients, Rush also worked to humanise the treatment of patients with mental illness in American hospitals, established the Philadelphia Dispensary to provide medical care for the poor, supported female education and racial equality, opposed capital punishment, and served as President of the Pennsylvania Society for Promoting the Abolition of Slavery. The Medical College of Philadelphia offered two degrees, Bachelor of Medicine and Doctor of Medicine. For a Bachelor 1940
of Medicine degree, the student had to take one course of lectures in anatomy, materia medica, chemistry, the theory and practice of physic, and clinical lectures, attend the practice of the Pennsylvania Hospital for a year, serve an apprenticeship to “some reputable practitioner in Physic”, show his knowledge of Latin and mathematics, and pass a public examination. For a doctorate, the student had to be 24 years old, to have acquired a bachelor’s degree in medicine at least 3 years earlier, and to write and publicly defend a thesis (to be published at his own expense). It seems that many students did not choose to fulfil all these requirements, since the number of students who attended lectures was far greater than the number of graduates. The students apparently wanted the knowledge provided by the lectures but realised that success in practice would matter much more to their future careers than the mere possession of a medical degree. If they could avoid the onerous requirements of a degree, so much the better. The American Revolution had a lasting effect on the college. During the war, Morgan was appointed directorgeneral of the army’s hospital in Boston. But with limited supplies, an outbreak of smallpox, and a general lack of understanding of health issues among Congress, military officers, and the soldiers themselves, it was difficult for him to establish and organise a medical service. Inevitably, Morgan was blamed for these problems and Shippen, his old rival and enemy, managed to push Morgan aside and take over the position. Morgan retaliated by charging Shippen with fraud and speculation in hospital supplies; as a result, Shippen was court-martialled and resigned in 1791. During the Revolutionary War, most of the medical faculty supported the revolution, but Kuhn and the college provost, William Smith, had sympathies for the British cause. Once the war ended, the newly created Pennsylvania legislature punished the college by revoking its charter and establishing a new school, the University of the State of Pennsylvania, endowed by the sale of estates confiscated in the war. The college faculty who denounced these actions as unconstitutional, illegal, and immoral were mollified by being offered positions in the university. But in 1789, the legislature decided that their predecessors had been unjust and restored the college. Now there were two institutions: the College of Philadelphia and the University of Pennsylvania, each with its own medical school and its own medical professors. The college, university, and their rival medical schools were formally united as the University of Pennsylvania in 1791, although friction between the faculties persisted. Professors of the two previous institutions all had to be included in the reconstituted university, leading to much shuffling of staff, irritation, and distress. www.thelancet.com Vol 385 May 16, 2015
After all had settled down, the faculty modified the requirements for obtaining a medical degree. Students were now required to take two (identical) courses in each subject on the grounds that they would forget the information if they only heard it once but would be more likely to remember it if hearing the same thing a second time. The Medical Hall used for teaching contained many cabinets that displayed oil paintings, diagrams, ingenious wax models of diseased body parts, preserved specimens, and instruments of various types. Its three lecture rooms were capable of seating 600 students. One, for chemistry, boasted a well equipped laboratory, one was reserved for lectures not requiring space for experiments and demonstrations, and the third consisted of an anatomical theatre with banks of seats arranged in a circular manner, so that every student would be able to see the anatomical demonstrations and dissections below. This arrangement is shown in Thomas Eakins’ splendid painting of 1889 of Hayes Agnew performing a partial mastectomy with students watching attentively (figure). In advertising these facilities, university representatives emphasised the plentiful supply of skilful private teachers whose practical teaching could supplement the more formal lectures and demonstrations. Also regarded as a benefit was the availability of a nearby Alms House Hospital in which a clinical professor, using the bodies of the poorer patients— who were wheeled in their hospital beds into a lecture hall— could do surgical operations and make clinical observations within the full view of the students. Students were assured of fine medical libraries, excellent accommodations, and a remarkably low cost of living for a large city. No wonder the university and the medical school thrived. By the mid-19th century, European laboratories and hospitals were producing much new medical knowledge and, feeling that there was now more needing to be taught, the medical professors decided, in 1847, to lengthen the courses of lectures from 5 months to 6. After a 6-year trial, however, they reversed their decision, probably because the students did not want to study for such a long time or pay larger tuition fees and might prefer to apply to one of the less demanding medical schools. By the 1860s the professors again altered course, and required students to attend a full year of classes. But this was a time of national upheaval, and teaching was disrupted by war. The medical school had a difficult time during the Civil War. Almost half of the students came from the southern states and formed a sizeable contingent of southern sympathisers. Pennsylvania’s Governor encouraged them to return home, and most did so. Many of those from the northern states went off to join the Union Army, so the student body was depleted. The faculty suffered also because they were still individually dependent on fees from students: they were not paid salaries and the more students a professor had, the higher his income. When the www.thelancet.com Vol 385 May 16, 2015
Courtesy of the University of Pennsylvania Art Collection
Perspectives
Figure: Thomas Eakins, The Agnew Clinic (1889) Commissioned by the University of Pennsylvania’s Medical School Class of 1889, the translated Latin inscription for the painting reads: “D. Hayes Agnew M.D. Most experienced surgeon, clearest writer and teacher, most venerated and beloved man.”
war ended in 1865, this system was changed and the faculty could now depend on steady, if not necessarily large, incomes. The change to a salaried professoriate had another consequence: as medical professors concentrated less on teaching and appealing to students, they began increasingly to do their own research, emulating the science-oriented faculty of many of the European medical schools. The Flexner Report of 1910, Medical Education in the United States and Canada: a Report to the Carnegie Foundation for the Advancement of Teaching, was extremely critical of many American medical schools. It had, however, great praise for the medical department of the University of Pennsylvania, especially for laboratory instructors who devoted full time to teaching and research; fine laboratories in five separate well equipped buildings; a “deservedly famous” anatomical museum (now the Mütter Museum and still fascinating); the Wistar Institute open to graduate students for research in anatomy; an “admirable library”; a university hospital available for teaching, and considerable use of other hospitals; and “abundant” medical material at two dispensaries for the poor. The Medical School (then called a department) was clearly one of the leading medical schools in the country, possessing fine facilities for both research and clinical teaching. As its students and alumni can attest, the University of Pennsylvania’s Perelman School of Medicine has continued to develop as an excellent institution for medical education and research.
Elizabeth Fee National Library of Medicine, Bethesda, MD 20894, USA [email protected]
Further reading Bonner TN. Becoming a physician: medical education in Great Britain, France, Germany, and the United States, 1750–1945. New York: Oxford University Press, 1996 Flexner A. Medical education in the United States and Canada: a report to the Carnegie Foundation for the advancement of teaching. Boston: The Merrymount Press, 1910 Golden J, Rosenberg CE. Pictures of health: a photographic history of health care in Philadelphia, 1860–1945. Philadelphia: University of Pennsylvania Press, 1991
I thank the staff of the University Archives of the University of Pennsylvania for their invaluable collections, exhibitions, and websites upon which much of this essay is based, and Heather Moqtaderi for her assistance in obtaining the image of the Agnew Clinic.
1941
The art of medicine The first American medical school: the formative years In 1765, students were admitted to “anatomical lectures” and a course on “the theory and practice of physik” at the College of Philadelphia. Thus began the first medical school in the USA—at that time, of course, “America” simply consisted of 13 colonies. Eventually, after various convulsions and name changes, the College of Philadelphia would transmute into the University of Pennsylvania and the two courses of lectures into the university’s Perelman School of Medicine. In Europe during the 18th and 19th centuries, small groups of physicians sometimes gathered together to create proprietary medical schools, offering lectures and collecting fees from the students. For the professors, these fees helped supplement their incomes from private practice. In addition, a young man (no women allowed) seeking a career in medicine could serve as an apprentice, working with an established physician, until he was regarded as sufficiently competent to set up his own practice. At the best medical schools in London, Edinburgh, and Paris, students could also experience practical bedside teaching in hospitals. The founders of the medical school in Philadelphia, John Morgan and William Shippen, Jr, had received their medical education in the UK at the University of Edinburgh. As students, they had discussed the need for some such training in the USA. Shippen, who left Europe first, waited for Morgan to return, and was furious when Morgan, acting alone, proposed to the Trustees of the College of Philadelphia that they establish a medical school with himself as its founder and first professor. The competition and hostility between these two men was to last for the rest of their lives. After Morgan had completed his plans for the school, he did appoint Shippen as professor, although clearly in a secondary role. Morgan taught the theory and practice of physic, while Shippen gave lectures on anatomy, surgery, and midwifery. At first, Morgan also lectured on chemistry, botany, and materia medica (pharmacology), but these subjects were soon turned over to a new professor, Adam Kuhn. The most famous of subsequent professors was Benjamin Rush who arrived in 1769. Rush is often remembered as a signer of the US Declaration of Independence, but he was also notable as a founder of psychiatry and for his enthusiastic advocacy of a treatment regimen of bleeding and purging. Known for his dedication to his patients, Rush also worked to humanise the treatment of patients with mental illness in American hospitals, established the Philadelphia Dispensary to provide medical care for the poor, supported female education and racial equality, opposed capital punishment, and served as President of the Pennsylvania Society for Promoting the Abolition of Slavery. The Medical College of Philadelphia offered two degrees, Bachelor of Medicine and Doctor of Medicine. For a Bachelor 1940
of Medicine degree, the student had to take one course of lectures in anatomy, materia medica, chemistry, the theory and practice of physic, and clinical lectures, attend the practice of the Pennsylvania Hospital for a year, serve an apprenticeship to “some reputable practitioner in Physic”, show his knowledge of Latin and mathematics, and pass a public examination. For a doctorate, the student had to be 24 years old, to have acquired a bachelor’s degree in medicine at least 3 years earlier, and to write and publicly defend a thesis (to be published at his own expense). It seems that many students did not choose to fulfil all these requirements, since the number of students who attended lectures was far greater than the number of graduates. The students apparently wanted the knowledge provided by the lectures but realised that success in practice would matter much more to their future careers than the mere possession of a medical degree. If they could avoid the onerous requirements of a degree, so much the better. The American Revolution had a lasting effect on the college. During the war, Morgan was appointed directorgeneral of the army’s hospital in Boston. But with limited supplies, an outbreak of smallpox, and a general lack of understanding of health issues among Congress, military officers, and the soldiers themselves, it was difficult for him to establish and organise a medical service. Inevitably, Morgan was blamed for these problems and Shippen, his old rival and enemy, managed to push Morgan aside and take over the position. Morgan retaliated by charging Shippen with fraud and speculation in hospital supplies; as a result, Shippen was court-martialled and resigned in 1791. During the Revolutionary War, most of the medical faculty supported the revolution, but Kuhn and the college provost, William Smith, had sympathies for the British cause. Once the war ended, the newly created Pennsylvania legislature punished the college by revoking its charter and establishing a new school, the University of the State of Pennsylvania, endowed by the sale of estates confiscated in the war. The college faculty who denounced these actions as unconstitutional, illegal, and immoral were mollified by being offered positions in the university. But in 1789, the legislature decided that their predecessors had been unjust and restored the college. Now there were two institutions: the College of Philadelphia and the University of Pennsylvania, each with its own medical school and its own medical professors. The college, university, and their rival medical schools were formally united as the University of Pennsylvania in 1791, although friction between the faculties persisted. Professors of the two previous institutions all had to be included in the reconstituted university, leading to much shuffling of staff, irritation, and distress. www.thelancet.com Vol 385 May 16, 2015
After all had settled down, the faculty modified the requirements for obtaining a medical degree. Students were now required to take two (identical) courses in each subject on the grounds that they would forget the information if they only heard it once but would be more likely to remember it if hearing the same thing a second time. The Medical Hall used for teaching contained many cabinets that displayed oil paintings, diagrams, ingenious wax models of diseased body parts, preserved specimens, and instruments of various types. Its three lecture rooms were capable of seating 600 students. One, for chemistry, boasted a well equipped laboratory, one was reserved for lectures not requiring space for experiments and demonstrations, and the third consisted of an anatomical theatre with banks of seats arranged in a circular manner, so that every student would be able to see the anatomical demonstrations and dissections below. This arrangement is shown in Thomas Eakins’ splendid painting of 1889 of Hayes Agnew performing a partial mastectomy with students watching attentively (figure). In advertising these facilities, university representatives emphasised the plentiful supply of skilful private teachers whose practical teaching could supplement the more formal lectures and demonstrations. Also regarded as a benefit was the availability of a nearby Alms House Hospital in which a clinical professor, using the bodies of the poorer patients— who were wheeled in their hospital beds into a lecture hall— could do surgical operations and make clinical observations within the full view of the students. Students were assured of fine medical libraries, excellent accommodations, and a remarkably low cost of living for a large city. No wonder the university and the medical school thrived. By the mid-19th century, European laboratories and hospitals were producing much new medical knowledge and, feeling that there was now more needing to be taught, the medical professors decided, in 1847, to lengthen the courses of lectures from 5 months to 6. After a 6-year trial, however, they reversed their decision, probably because the students did not want to study for such a long time or pay larger tuition fees and might prefer to apply to one of the less demanding medical schools. By the 1860s the professors again altered course, and required students to attend a full year of classes. But this was a time of national upheaval, and teaching was disrupted by war. The medical school had a difficult time during the Civil War. Almost half of the students came from the southern states and formed a sizeable contingent of southern sympathisers. Pennsylvania’s Governor encouraged them to return home, and most did so. Many of those from the northern states went off to join the Union Army, so the student body was depleted. The faculty suffered also because they were still individually dependent on fees from students: they were not paid salaries and the more students a professor had, the higher his income. When the www.thelancet.com Vol 385 May 16, 2015
Courtesy of the University of Pennsylvania Art Collection
Perspectives
Figure: Thomas Eakins, The Agnew Clinic (1889) Commissioned by the University of Pennsylvania’s Medical School Class of 1889, the translated Latin inscription for the painting reads: “D. Hayes Agnew M.D. Most experienced surgeon, clearest writer and teacher, most venerated and beloved man.”
war ended in 1865, this system was changed and the faculty could now depend on steady, if not necessarily large, incomes. The change to a salaried professoriate had another consequence: as medical professors concentrated less on teaching and appealing to students, they began increasingly to do their own research, emulating the science-oriented faculty of many of the European medical schools. The Flexner Report of 1910, Medical Education in the United States and Canada: a Report to the Carnegie Foundation for the Advancement of Teaching, was extremely critical of many American medical schools. It had, however, great praise for the medical department of the University of Pennsylvania, especially for laboratory instructors who devoted full time to teaching and research; fine laboratories in five separate well equipped buildings; a “deservedly famous” anatomical museum (now the Mütter Museum and still fascinating); the Wistar Institute open to graduate students for research in anatomy; an “admirable library”; a university hospital available for teaching, and considerable use of other hospitals; and “abundant” medical material at two dispensaries for the poor. The Medical School (then called a department) was clearly one of the leading medical schools in the country, possessing fine facilities for both research and clinical teaching. As its students and alumni can attest, the University of Pennsylvania’s Perelman School of Medicine has continued to develop as an excellent institution for medical education and research.
Elizabeth Fee National Library of Medicine, Bethesda, MD 20894, USA [email protected]
Further reading Bonner TN. Becoming a physician: medical education in Great Britain, France, Germany, and the United States, 1750–1945. New York: Oxford University Press, 1996 Flexner A. Medical education in the United States and Canada: a report to the Carnegie Foundation for the advancement of teaching. Boston: The Merrymount Press, 1910 Golden J, Rosenberg CE. Pictures of health: a photographic history of health care in Philadelphia, 1860–1945. Philadelphia: University of Pennsylvania Press, 1991
I thank the staff of the University Archives of the University of Pennsylvania for their invaluable collections, exhibitions, and websites upon which much of this essay is based, and Heather Moqtaderi for her assistance in obtaining the image of the Agnew Clinic.
1941