You study medicine for three years, write a thesis, pass oral exams and show you’re a man of morals (no women allowed). Then you’re a doctor, for less than 400 bucks. This was the norm in the United States in 1858, when Elias Samuel Cooper, MD, founded Stanford’s first predecessor in San Francisco, the Medical Department of the University of the Pacific.

Cooper, a practicing physician who arrived in San Francisco in 1855, employed five other physicians for the faculty and opened the first medical school between Iowa and the Pacific Ocean. The original 13 students studied practical subjects, such as physiology, chemistry and drug treatments. They gazed into microscopes and they sliced into corpses and live animals, but they usually watched their teachers attend patients instead of helping. Cooper, a professor and surgeon, wielded a scalpel before antisepsis in surgery was the norm and at a time when such general anesthetics as chloroform were novel and dangerous.

The department taught orthodox medicine or “allopathy.” Allopaths fought diseases with drugs that caused opposite symptoms. Some prescriptions were no-brainers, such as laxatives for constipation. But allopaths also dosed patients with mercury, opium, arsenic and other things you don’t want in your tea. Competing doctors who practiced “homeopathy” stuck mainly to organic drugs that mimicked the disease itself. Many homeopaths diluted their medicines down to practically nothing, which might have saved lives in the 19th century, considering the allopathic alternatives. Homeopaths tried to treat whole diseases at once, disdaining how allopaths zeroed in on single symptoms.

Supporters of both systems had “holier than thou” attitudes, but both were unscientific. Most medical texts in the first half of the century were drug recipe books or collections of lectures, sometimes full of philosophy. Medicine was mostly theory-based until later that century, when Louis Pasteur and Robert Koch revealed the creeping microscopic agents of disease.

A little health competition

Medicine was a battle against obvious symptoms, such as fevers, chills and vomiting, with little grasp of the underlying causes. Nevertheless, medical schools multiplied. In 1864, two years after Cooper died of an undisclosed neurological disease, his school had a rival. Hugh Huger Toland, MD, founded Toland Medical College, which sucked the life out of the Medical Department of the University of the Pacific. Many students and professors from the Medical Department flocked to Toland’s fancier facilities, and the department closed its doors. But in 1870, the Medical Department faculty returned to reopen the school and hired five more professors. Most of Toland’s students followed them.

The rival schools taught similar courses, and most medical schools changed very little each year. They fed on tuition, so no one had a financial lever to reform them. Doctors in the fledgling American Medical Association shook their heads at most of the country’s schools, rattling off lists of recommendations and getting shrugs in return. Most colleges didn’t want to up their standards and risk scaring students — and their money — away.

Though initially slow to upgrade, both rival schools in San Francisco reincarnated under new names, and they enjoyed a truce. The Medical Department of the University of the Pacific separated from that university and joined University College, becoming the Medical College of the Pacific in 1872. A decade later, Levi Cooper Lane, MD, a professor and the founder’s nephew, paid for an impressive new building for the school, incorporated it as an independent institution and named it after his uncle: Cooper Medical College. Meanwhile, in 1873, Toland Medical College had joined the University of California, eventually becoming UC-San Francisco. And a homeopathic school started up in the city in 1883. Called the Homeopathic Medical College of San Francisco, it later became the Hahnemann Medical College. As the 20th century dawned, six medical schools operated in San Francisco, all using its City and County Hospital for clinical instruction. Indeed, throughout the country medical schools crowded cities like pigeons.

Time to come together

In the decade leading up to Stanford’s union with Cooper Medical College in 1908, medicine and basic science also wed. Physicians began examining patients’ sputum with microscopes to catch tuberculosis, and culturing throat bacteria to check for diphtheria. A good test, however, didn’t mean a good cure.

“Surgery was getting much better, but what medicine had been able to achieve by that time was mainly in diagnostics — you know what the problem is, but you don’t know how to solve it,” says John Haller, PhD, professor of history and medical humanities at Southern Illinois University, Carbondale.

“Surgery was getting much better, but what medicine had been able to achieve by that time was mainly in diagnostics”

Science, which gave tantalizing glimpses of the causes of disease, united doctors. Homeopaths and allopaths started shaking hands and making up, believing there was one right way to study the body — scientifically — even if they disagreed on drug treatments. A student at a homeopathic school such as Hahnemann Medical College would probably hear lectures similar to those at Cooper or the University of California. “Their coursework was pretty much the same except for their coursework in materia medica [drug therapies],” says Haller. Eventually, as the traditional practices of homeopathy failed to stand up to the science, homeopaths clinging to old rules and using extremely watered-down medicine became relics, he says.

So did homey, personalized hospitals. Monochrome photos show rooms in the late 1800s with plants, pictures on the walls and rich, dark-colored decor. As the century turned, hospitals grew lighter, cleaner and more institutional. That doesn’t mean the students were a dry bunch — historians describe photos of them grinning or goofing off around the cadavers they dissected.

Things would soon get tougher for a lackadaisical student, however. Reformers in the AMA and the American Association of Medical Colleges wanted every entering medical student to have a high school diploma (some still did not) and to take at least four years of medical school.

By the time Levi Cooper Lane died in 1902, Cooper Medical College was up to these standards and turning out bright doctors, but it lacked one important thing. Cooper, unlike its old rival Toland, hadn’t joined with a university. Toland had become the University of California Medical Department; joining with a university was a common move for medical colleges that wanted to bring students the best of basic science at a research-oriented university.

Cooper’s board of directors and Stanford’s board of trustees sought to combine in 1906. In 1908, Stanford swallowed up Cooper’s facilities. Students, who now needed three years of college, entered the brand-new Stanford Medical Department the next year. And the school entered a revolution of empiricism and scientific research that swept away older, theory-based medicine. American medical education as we know it began taking shape, and more students walked clinic halls, no longer confined to lecture rooms and amphitheaters.

The critic and the clinic

That first medical class, however, copied their cooper predecessors, immersing themselves in basic sciences for two years followed by two more of hospital training in San Francisco. Students weren’t thrown into the clinical fray as they are today.

“The teaching hospital as we recognize it today had been created but hadn’t become widespread. The only true teaching hospital of any import was the Johns Hopkins teaching hospital,” says professor of medicine and history Kenneth Ludmerer, PhD, at Washington University. Most students might culture bacteria, examine tissues with microscopes or dissect pig embryos in the lab, but rarely would the average student sit by a hospital bed and ask, “Where does it hurt?”

This problem was most serious at the old-fashioned, profit-driven schools, where students spent their days “observing operations and listening to lectures, but the amount of participation would be minimal,” says Haller. Stanford’s Department of Medicine, on the other hand, offered some clinical “learning by doing.” Older students handled hospital cases by analyzing patients’ blood, urine, feces and stomach contents. Students sometimes helped to dress wounds, deliver babies or examine patients, and they logged medical histories. But this was not enough for the harshest critic of the day.

Abraham Flexner, funded by the Carnegie Foundation, wrote the damning critique Medical Education in the United States and Canada (sometimes called the Flexner Report), published in 1910, which shot down individual schools he considered too lax or poorly endowed. Flexner said of Stanford’s medical school, “Its organization, from the teaching point of view, is seriously defective.” He called the University of California’s clinical facilities “inadequate” and underfunded. And these were the schools that survived.

Flexner tore into for-profit schools. Because of him and other reformers, 36 of these schools died out between 1910 and 1915. Flexner also had no sympathy for competing theories of medicine. Modern medicine, he said “wants not dogma, but facts.” A homeopath, allopath or member of another fragmented group doesn’t look at scientific evidence, he said, but “begins with his mind made up.” For Flexner and later reformers, empirical research was the key to effective medicine.

Stanford, imperfect in its infancy, adapted to a world driven by research and hands-on learning, as did other survivors of this intellectual storm. The tools for science-based medicine were there — the stethoscope and the microscope, bacteriology, antiseptics and the pillars of basic science. Now medical students must take them in hand, Flexner said. “Society reaps at this moment but a small fraction of the advantage which current knowledge has the power to confer.”