Changing Student Populations in the Late Nineteenth and Early Twentieth Century

By the turn of the twentieth century, the drive to make medicine more scientific and comprehensive and to limit its ranks to the well prepared had had a profound effect on student populations. Almost universally, students were now older, better educated, more schooled in science, less rowdy, and able to spend larger amounts of time and money in study than their counterparts in 1850 had been. Their ranks, now including a growing number of women, were also likely to include fewer representatives of working- and lower-middle-class families, especially in Britain and America, than a half-century before. Nations still differed, sometimes sharply, in their openness to students from different social classes. The relative openness of the German universities to the broad middle classes, as well as their inclusion of a small representation of “peasantry and artisans,” wrote Lord Bryce in 1885, was a sharp contrast with “the English failure to reach and serve all classes.” The burgeoning German enrollments, he noted, were owing to “a growing disposition on the part of mercantile men, and what may be called the lower professional class, to give their sons a university education.” More students by far from the farm and working classes of Germany, which accounted for nearly 14 percent of medical enrollment, he observed, were able to get an advanced education than were such students in England. A historic transformation in the social makeup of universities, according to historian Konrad Jarausch—from “traditional elite” to a “modern middle-class system”—was taking place in the latter nineteenth century. In France, rising standards in education, together with the abolition of the rank of officiers de santé—which for a century had opened medical training to the less affluent—were forcing medical education into a middle- class mold. In the United States, the steeply rising requirements in medicine, along with the closing of the least expensive schools, narrowed the social differences among medical students and brought sharp complaints from the less advantaged. The costs of medical education in some countries threatened to drive all but the most thriving of the middle classes from a chance to learn medicine.

Toward a University Standard of Medical Education, 1890-1920

In the waning years of the nineteenth century, despite (or perhaps because of) the inroads of laboratory science, uncertainty still hung heavy over the future shape of the medical curriculum. Although currents of change now flowed freely through the medical schools and conditions of study were shifting in every country, agreement was far from universal on such primary questions as the place of science and the laboratory in medical study, how clinical medicine should best be taught, the best way to prepare for medical study, the order of studies, minimal requirements for practice, and the importance of postgraduate study. “Perturbations and violent readjustments,” an American professor told his audience in 1897, marked the life of every medical school in this “remarkable epoch in the history of medicine.” Similar to the era of change a century before, students were again confronted with bewildering choices. Old questions long thought settled rose in new form. Did the practical study of medicine belong in a university at all? Was bedside instruction still needed by every student in training, or was the superbly conducted clinical demonstration not as good or even better? Should students perform experiments themselves in laboratories so as to understand the real meaning of science and its promise for medicine, or was it a waste of valuable time for the vast majority? And what about the university—now the home of advanced science, original research work, and the scientific laboratory—was it to be the only site to learn the medicine of the future? What about the still numerous hospital and independent schools, the mainstay of teaching in Anglo- America in 1890—did they still have a place in the teaching of medicine? Amidst the often clamorous debates on these and other questions, the teaching enterprise was still shaped by strong national cultural differences. In the final years of the century, the Western world was experiencing a new sense of national identity and pride that ran through developments in science and medicine as well as politics. The strident nationalism and industrial-scientific strength of a united Germany, evident to physicians studying there, thoroughly frightened many in the rest of Europe.

Changing Patterns of Medical Study Before 1800

For the traditional physician of the eighteenth century, medicine was above all a humane study, mastered largely through books and the careful examination of medicine’s past and leavened now by a growing concern to know something firsthand of the feel of the human body in sickness and in health. To be a French or German or British physician in these years was to be a member of a cultural elite who, like other university graduates, found the truth in the rich treasures of ancient Greek and Latin writings. A degree in medicine was a testament of higher learning, not merely a professional qualification, and Latin was the visible symbol of that learning. Medicine was valued not so much for its efficacy in curing patients as for the knowledge it implied about the universe and humankind. Such notable figures as Quesnay, who had a medical degree, and Diderot, Voltaire, and Rousseau studied medicine as an integral part of a broad, humanistic culture. The character of a physician, wrote an English practitioner in 1794, “ought to be that of a gentleman, which cannot be maintained . . . but by a man of literature. He is much in the world, and mixes in society with men of every description.” Students were easily converted to the idea of the centrality of classical study in their lives. A young man in Edinburgh, for example, ridiculed his medical professors in 1797 for their ignorance and that of their students, who “could not translate the easiest passage in Latin.” On the Continent, a Munich professor offered at about the same time to instruct a whole class of medical students in liberal studies, since “their knowledge of the Latin language, philosophy, logic, and other general branches of education” brought “shame” to the faculty. Such complaints were frequent by 1800, revealing the growing tension between the ideal and the real in the classical training of students and professors. What kind of education, then, was suitable for a late-eighteenth-century physician? The mastery of ancient literature and medical texts was still essential to one’s status as a gentleman but was no longer regarded as the sole qualification for success as a physician.

The Laboratory Versus the Clinic: The Fight for the Curriculum, 1870-1890

What was most compelling in the case for science in medicine after 1870 were the stunning achievements in laboratory medicine by that time. During the preceding decades, the work of laboratory scientists, especially in France and Germany, had brought a far more sophisticated understanding of the physical and chemical makeup and functioning of the human body and had produced a host of new tests, instruments, and techniques that were being increasingly used to study the sick patient. The role of bacteria in fermentation and then in wound pus had been demonstrated in the years preceding 1870, and they were now claimed to be responsible for a number of specific diseases. These discoveries, in turn, stimulated a great burst of energy in surgery, eventually gave a new and more certain basis to public health work, infused new optimism into the search for pharmacological remedies, and opened up new possibilities of protection against illness through deliberate immunization. Virtually no subject in the medical curriculum was untouched by the changes in medical knowledge, as dozens of new courses were created to teach the new viewpoints in disease. The new viewpoints were deemed necessary for students to master, even though they had as yet little impact on therapy. Contrary to some later critics, medicine has always been more than the simple application of “cures” to human ailments. For thousands of years as well as in our own time, the understanding of disease, its origins and causes, its transmission, and its prevention, prognosis, and palliation have been principal reasons for consulting a physician. In the years around 1870, in particular, science made enormous gains in understanding ancient afflictions and was gaining in ways to control, alleviate, and, in a few cases, to cure them. Was science important to medicine in these years, despite the slow pace of therapeutic change? Indeed it was, even if much of ordinary medical practice, especially the healing of many illnesses, was not immediately affected by what students learned. The rapid-fire developments of these years created a vision of an experimentally based, irresistible medical science that would soon sweep all doubts before it.

Toward New Goals for Medical Education, 1830-1850

The years around 1830, as just described, were a turning point in the movement to create a more systematic and uniform approach to the training of doctors. For the next quarter-century, a battle royal raged in the transatlantic countries between those seeking to create a common standard of medical training for all practitioners and those who defended the many-tiered systems of preparing healers that prevailed in most of them. At stake were such important issues as the care of the rural populations, largely unserved by university-trained physicians, the ever larger role claimed for science and academic study in educating doctors, the place of organized medical groups in decision making about professional training, and the role to be played by government in setting standards of medical education. In Great Britain, the conflict over change centered on the efforts of reformers, mainly liberal Whigs, apothecary-surgeons, and Scottish teachers and practitioners, to gain a larger measure of recognition for the rights of general practitioners to ply their trade freely throughout the nation. Ranged against them were the royal colleges, the traditional universities, and other defenders of the status quo. Particularly sensitive in Britain was the entrenched power of the royal colleges of medicine and surgery— “the most conservative bodies in the medical world,” S. W. F. Holloway called them—which continued to defend the importance of a liberal, gentlemanly education for medicine, as well as their right to approve the qualifications for practice of all other practitioners except apothecaries. Members of the Royal College of Physicians of London, the most elite of all the British medical bodies, were divided by class into a small number of fellows, almost all graduates of Oxford and Cambridge, and a larger number of licentiates, who, though permitted to practice, took no part in serious policy discussions and could not even use such college facilities as the library or the museum. “The Fellows,” claimed a petition signed by forty-nine London physicians in 1833, “have usurped all the corporate power, offices, privileges, and emoluments attached to the College.”

A Bird’s Eye View of Medical Education in 1830

The changes under way in medical training in the transatlantic world by 1830 owed much to the political and social transformations of the preceding half-century. The political revolutions of the old century, which ushered in a long period of turmoil and conflict, had been followed by a period in the early nineteenth century of reaction and consolidation, new industrial growth and the spread of cities, commercial expansion and rising prosperity, and a high degree of political turbulence in every country. No nation escaped the impact of rapid population changes, of buoyant capitalistic enterprise, of the spreading democratic tide, or of the efforts of reformers to help those most adversely affected by the urban-industrial revolution. The training of doctors was inevitably influenced by the rising power of the middle classes in Europe and America as they demanded more medical services and a higher standard of medical competence. The continued growth of industrial cities, notably in Britain, posed serious problems of public health and the medical care of the poor. By 1831, London’s population was already approaching a million and a half, and nearly half the remaining population were now living in towns of more than five thousand. The doctors most in demand in these conditions were those who joined a skill in practical medicine with a knowledge of the new practical sciences. The new studies of science, it was increasingly believed by laypeople, gave the physician a surer command of diagnosis and a better understanding of the disease process, and his practical skills assured the patient of the best possible treatment. Medicine as a practical science, in short, was seen by the public as an important advance over both the old humanistic medicine of the universities and the crude empiricism of the earlier practical schools. The triumph of the clinic and the rise of the new sciences together created a new confidence in medical education. The schools themselves were becoming more alike.

An Uncertain Enterprise: Learning to Heal in the Enlightenment

There was no more turbulent yet creative time in the history of medical study than the latter years of the eighteenth century. During this troubled era, familiar landmarks in medicine were fast disappearing; new ideas about medical training were gaining favor; the sites of medical education were rapidly expanding; and the variety of healers was growing in every country. Student populations, too, were undergoing important changes; governments were shifting their role in medicine, especially in the continental nations; and national differences in educating doctors were becoming more pronounced. These transformations are the subject of the opening chapters of this book. These changes in medical education were a reflection of the general transformation of European society, education, and politics. By the century’s end, the whole transatlantic world was in the grip of profound social and political movement. Like other institutions, universities and medical schools were caught up in a “period of major institutional restructuring” as new expectations were placed on teachers and students. Contemporaries spoke of an apocalyptic sense of an older order falling and new institutions fighting for birth, and inevitably the practice of healing was also affected. From the middle of the century, the nations of Europe and their New World offspring had undergone a quickening transformation in their economic activity, educational ideas, and political outlook. By 1800, in the island kingdom of Great Britain, the unprecedented advance of agricultural and industrial change had pushed that nation into world leadership in manufacturing, agricultural productivity, trade, and shipping. Its population growth exceeded that of any continental state, and in addition, nearly three-fourths of all new urban growth in Europe was occurring in the British Isles. The effects on higher education were to create a demand for more practical subjects, modern languages, and increased attention to the needs of the thriving middle classes. Although Oxford and Cambridge, the only universities in England, were largely untouched by the currents of change, the Scottish universities, by contrast, were beginning to teach modern subjects, to bring practical experience into the medical curriculum, and to open their doors to a wider spectrum of students.

A Closing Word

Despite all the changes in undergraduate medical education after World War II, especially in its core of scientific training, it actually had shifted only slightly in essential ways by the end of the twentieth century. If a student from an earlier era sat down in the classrooms and clinics of the 1990s—although doubtless overwhelmed by the new knowledge and technology—he or she would still find much that was familiar in the teaching methods, curriculum, conduct of clinics, bedside training, laboratory instruction, and educational preparation of fellow students. “The medicine of 1900,” writes William Bynum, “[is] closer to us almost a century later than it was to the medicine of 1790.” The historic differences among nations in teaching methods, too, though less striking than in earlier times, were still visible in the characteristic responses of medical educators and students to the social and scientific changes. Alone among the professions, education for medicine had come to combine a long period of theoretical study with an intensely practical experience in the observation, handling, and treatment of patients. The resulting tension and shifting balance between academic study and clinical training, between theory and practice, between medicine as art and medicine as science, has been the perpetual condition of medical pedagogy since the Enlightenment. That a different balance was struck at different times in different nations because of differing social and political circum- stances is the underlying theme of this book. In the first half of this century, if a boundless faith in science and the ultimate rationality of medicine came to dominate nearly everywhere, that faith has been overwhelmed in our own time by postmodern doubts about human progress and the explanatory powers of science. But the pendulum will doubtless swing again. In any case, for most educators and students, the ideal remains what it has been for most of the period covered in this book—a unity of systematic academic study, especially in the sciences, with hands-on experience to create a physician who thinks critically, can solve problems, possesses a wide knowledge of underlying disease processes, and is skilled at applying what has been learned to real-life situations.

Consolidation, Stability, and New Upheavals, 1920-1945

By the end of World War I, the basic structures of undergraduate medical education in both Europe and America were largely in place. Future practitioners on both sides of the Atlantic now began their training with a lengthy preparation in liberal studies, with special attention to physics, chemistry, and biology, then studied for two or more years in laboratory based courses in the preclinical medical sciences followed by a like period of clinical study, and finally spent at least a year in acquiring practical, hands-on training in a hospital. With few changes, except for the growth of postgraduate education, this basic pattern prevailed everywhere in the interwar years before 1945. In the transatlantic nations, in short, these were years of consolidation of patterns formed well before 1914. The study of medicine now consumed a minimum of five years beyond the school-leaving or college experience and frequently took six to ten years to complete. Except for the hospital schools of London, nearly every medical school in the Western world was attached to a university. Almost no school of medicine was without its teaching hospital where training students was a primary concern. Governments everywhere played an ever larger role in setting basic requirements and providing financial support of medical education. Physicians’ associations became more and more powerful and sometimes dominant in setting standards of education and licensure. And in these postwar years, the practice of medicine became an almost wholly middle-class occupation, exacting high standards of preparation and social expectation and open to only the most exceptional among the less affluent. The costs of study were rising so steeply that it was largely unavailable to the poor, even in the United States. The national differences of a quarter-century before, though evened out in many particulars, were still discernible in 1920. The war, after all, permitted no major changes in instruction, equipment, or curriculum in Europe, and reform efforts after the war were hampered by the need to restore and rebuild.

The Spread of Laboratory Teaching, 1850-1870

“I still see the narrow, long hallway in the university building,” reminisced Albert von Kölliker, . . . where Henle, for lack of another room for demonstrations, showed us and explained the simplest things, so awe inspiring in their novelty, with scarcely five or six microscopes: epithelia, skin scales, cilia cells, blood corpuscles, pus cells, semen, then teased-out preparations from muscles, ligaments, nerves, sections from cartilage, cuts of bones, etc. . . . Something of the excitement and sense of adventure conveyed to students by the early use of the microscope in teaching is reflectedin Kölliker’s words and those of other students of the 1830s and 1840s. But at that time, few students anywhere had had direct, personal experience in the use of the microscope or other laboratory instruments, and indeed not many teachers believed that such experience was important to the education of the average student of medicine. New improvements in the microscope in the late 1830s had made it feasible to consider using the instrument for teaching purposes, but what were its pedagogical advantages? Of what value was it at the bedside if a physician were skillful in using the microscope and could do simple chemical tests? No one questioned the advantages afforded by the new chemistry and physics to those who used them in research in a special workplace, now called the laboratory, but the “belief that practical experience [in a laboratory] was important for all students, not merely for a small elite” constituted the real pedagogical revolution in the teaching of medicine. Like the earlier shift to clinical teaching, the transition to laboratory teaching, including the use of the microscope, came slowly and sporadically, had roots in the immediate past, was justified by its practical uses, and was shaped by a variety of educational and political circumstances in each country. Just as some contemporaries as well as later admirers reified the French achievement in clinical teaching because of the simultaneous scientific advances and superb opportunities opened to students in the Paris hospitals, so the remarkable pedagogical opening and research achievements of the German laboratory were extravagantly admired by visitors and later writers alike.