From Wilderness to Wards: How the Flexner Report Revolutionized Modern American Medicine
Medicine Before Flexner
Before 1910, unregulated, profit-driven proprietary schools dominated American medicine. Lacking standardized training, physicians utilized archaic, harmful treatments.
Crests of the University of Pennsylvania, Columbia University, Harvard University, and Dartmouth University,
University of Pennsylvania English Language Programs, 2026
"In the early 1800s, only four colleges in the United States had medical schools affiliated with them, namely Columbia, University of Pennsylvania, Harvard and Dartmouth."
—Thomas Jefferson University, "The Early Years," 2026.
"The period from the 1790s to about 1850 has been designated by historians as the 'age of heroic medicine.' During those years summoning a physician almost certainly meant undergoing treatment that in an earlier or later time might be characterized as torture. Bleeding, blistering, cupping, purging, and sweating were the major techniques the medical profession used."
—Martin Kaufman, "American Medical Education: The Formative Years, 1765-1910," 1976
Civil War heroic medicine-style treatment, "What It Was Like Working in a Civil War Field Hospital," Weird History/YouTube
Without rigorous scientific foundations, practitioners masked their ignorance with dangerous "heroic" interventions.
Gentle Emetic (vomiting) in Heroic Medicine
James Gillray, published by H. Humphrey,
27 St. James’s Street, London, January 26, 1804.
"The public...love to see a physician...know things intuitively; therefore, you must study and practice to be quick in diagnosis. This premium on quick and bold response suggests why doctors were drawn to active and ‘heroic’ intervention [such as aggressive purging and blistering]...when medical knowledge was uncertain."
—Paul Starr, "The Social Transformation of American Medicine," 1982
"[Before Flexner]... a random patient with a random illness consulting a random physician had just about a 50-50 chance of benefiting from that encounter...because the training that many physician received was of very poor quality."
—Dr. Gert Brieger (Johns Hopkins University) and Andrea Seabrook, NPR: "Flexner Report Transformed Med Schools," August 16, 2008
The mortality rate and causes of death among males and females across four age groups (in %) in 19th and Early 20th Century Rochester, New York, KnightScholar
Prioritizing enrollment fees over clinical experience, unregulated proprietary medical schools mass-produced dangerously unqualified doctors.
Requisites for Admission to Washington University’s Medical Department in 1891...published in the medical school’s inaugural 1891-92 annual announcement and course catalog, WashU Medicine
"Medical schools...had no means of preventing other doctors elsewhere in the country from creating medical schools for their own advantage...
The result was unrestrained competition in which the length of the term was kept at a minimal level, requirements were sacrificed, and student fees were driven down. In seeking to raise their status individually, physicians undermined it collectively."
—Paul Starr, "The Social Transformation of American Medicine," 1982
Medical diploma from Harvard University given to John P. Lyman on July 4, 1867, Historic New England
"A century ago, ... [medical] instruction was superficial and brief...after the second term the M.D. degree was automatically given, regardless of a student's academic performance...The schools were owned by the professors, who operated them for profit. For that reason, medical schools were called 'proprietary schools.'"
—Kenneth M. Ludmerer, "Learning to Heal: The Development of American Medical Education," 1985
Lecture Ticket for Anatomy and Surgeery from Brown University, 1817, UPenn Archives
"Over-production of ill trained men is due in the main to the existence of a very large number of commercial [proprietary] schools, sustained in many cases by advertising methods through which a mass of unprepared youth is drawn...into the study of medicine...The conduct of a medical school was a profitable business, for the methods of instruction were mainly didactic [purely lecture-based]."
—Abraham Flexner, "Medical Education in the United States and Canada," 1910
Surgical Amphitheater, early-20th century, UC Libraries, University of Cincinnati
"Curriculum of The Medical School of Maine at Bowdoin College," a school later deemed unfavorable by the Flexner Report, Bowdoin College, 1896
"Medical schools with short terms and a course confined to didactic lectures were at least marginally profitable. Any change to a longer or more sophisticated curriculum was financially risky...
American physicians were too busy earning a living from medical practice to devote time to research, and the United States had almost no full-time medical scientists in this era."
—W. Bruce Fye, The Johns Hopkins University Press: "The Development of American Physiology: Scientific Medicine in the Nineteenth Century," 1987.
"In no...way can medical education in the United States be placed on the same level as that of other civilized countries, and the public be efficiently protected against the disastrous activity of a multitude of untrained and reckless practitioners."
—W. Bruce Fye, The Johns Hopkins University Press: "The Development of American Physiology: Scientific Medicine in the Nineteenth Century," 1987.
Meanwhile, European universities were revolutionizing healthcare through laboratory research and the Germ Theory.
"The active commercial spirit prevailing in this country...represses an intellectual class...[and] the fundamental reason of [American students] going...to Paris, Berlin, Vienna, etc...is that, instead of sitting in a huge lecture-hall...they can join small classes in which they practically demonstrate every fact for themselves... The germ theory of disease and its practical extension, antiseptic surgery, provided...a potent new example of the growing interdependence of scientific research and practical medicine."
—W. Bruce Fye, The Johns Hopkins University Press: "The Development of American Physiology: Scientific Medicine in the Nineteenth Century," 1987.
German medical pioneer Robert Koch in his advanced Berlin laboratory, ResearchGate
"The knowledge thus gathered shows conclusively that there has been an enormous over-production in this country of ill trained doctors... [and that] the imperative need in medicine at the present time is not more medical schools, but fewer and better ones; not more ill trained doctors, but a smaller number of well trained ones."
—"The Carnegie Foundation for the Advancement of Teaching: Fourth Annual Report," October 1909
Trapped in a commercialized system that jeopardized public health, American medical education faced a critical crossroad; it desperately required uncompromising standardizations.