Reform of Medical Education
The preeminent issue facing the Medical College of the Pacific in 1872, and American medical schools generally, was the reform of medical education. We shall therefore mention some of the factors contributing to the persistence of low standards, and then discuss efforts to improve them.
Medical Schools Resist Reform
The organizational structure of American medical colleges was the major impediment to raising standards. Curriculum, graduation requirements and dependence on student fees for financing had changed little since the founding of the nation's earliest schools in Philadelphia, New York and Boston a century earlier. Educational programs were stagnant, and were widely criticized within and without the profession.
Virtually all American medical schools in 1872 were "proprietary." That is, they were privately owned and operated by the Faculty. Schools acquired the capacity to award the M. D. degree either by charter from the state, or by affiliation with a college or university. In either case the Faculty was essentially autonomous. The Medical College of the Pacific was a typical example of a medical school affiliated with a college. Only the Board of Trustees of the parent institution (University [City] College), had the authority to appoint professors and award M. D. degrees. However, in affiliations such as this, recommendations by the Medical Faculty were normally approved without question. Compliant Trustees rarely exercised their latent jurisdiction over the standards of medical education. The College assumed no fiscal responsibility for, and had no financial leverage over, the medical school which was completely self-supporting, mainly by student fees.
Such marriage of convenience between an American College and a medical school was a widely adopted and mutually agreeable arrangement because the medical school acquired the mantle of an institution of higher learning and was spared the necessity to obtain a charter from the State to award the M. D. degree. The College enjoyed the prestige of alliance with a professional school. Under these circumstances, and also in the case of medical schools chartered by the State, the net result was that Medical Faculties were insulated from pressure to raise standards. Since they depended on student fees for survival, they were actually deterred from adopting reforms by the assumption that schools that raised standards would lose students to those that did not.
Contribution of Universities to Reform.
It is important to point out that there were some notable exceptions to the prevalent stagnation of American medical schools, but in 1872 the Medical College of the Pacific was not among them. There is no indication that the Trustees of University (City) College, when they adopted the Cooper school, showed any interest in the standards of medical education. They were doubtless unaware that in 1871 President Charles Eliot of Harvard, with the support of his Board of Trustees (Harvard Corporation), had shocked the Harvard Medical Faculty by instituting basic reforms over vehement faculty objection. The reforms required candidates for admission to show evidence of prior educational achievement; the annual session was increased from four to nine months; and a three-year curriculum of progressively advanced courses was instituted, each year being concluded with a written examination. President Eliot's initiatives at Harvard, to which we referred briefly in a previous chapter, had the effect of reinforcing nation-wide the influence of similar changes introduced at the less-prestigious Chicago Medical School by Dr. Nathan Davis in 1862, and of reforms more recently adopted by the Female Medical Colleges in Philadelphia and New York. In due course, the Universities of Pennsylvania, Syracuse, and Michigan followed suit, but progress among the great majority of medical colleges was impeded by the fear that raising standards would result in decreased enrollment and income.   
Professor Oliver Wendell Holmes of Harvard commented that "Our new President, Eliot, has turned the whole University over like a flapjack. There never was such a bouleversement as that in our medical faculty."  It was too much to expect that many other colleges and universities would soon move, like Eliot's Harvard, to demand sweeping reforms from the Faculties of their affiliated medical schools, or that State Legislatures would be interested to joust over standards with the self-sufficient and hypersensitive Faculties of their chartered medical colleges.
In 1876 the vital contribution of Universities to the comprehensive reform of American medical education was again foreshadowed. The occasion was the inaugural address of Daniel C. Gilman, first President of Johns Hopkins University. During Dr. Gilman's brief and stormy tenure (1872-1874) as first President of the University of California, he was exposed to the unpleasant bickering of two rival medical schools. That experience acquainted him with their admission requirements and their teaching programs, leading him to include the following declaration in his inaugural address at Hopkins on 22 February 1876: 
When we turn to the existing provisions for medical instruction in this land and compare them with those of European universities; when we see what inadequate endowments have been provided for our medical schools, and to what abuses the system of fees for tuition has led; when we see that in some of our very best colleges the degree of Doctor of Medicine can be obtained in half the time required to win the degree of Bachelor of Arts; when we see the disposition of the laymen at home and the profession abroad to treat diplomas as blank paper; and the prevalence of the quackery vaunting its diplomas; when we read the reports of the medical faculty in their own professional journals; and when we see the difficulties that have been encountered in late attempts to reorganize the existing medical schools, it is clear that something should be done. . .
When the medical department (of Johns Hopkins University) is organized it should be independent of the income derived from student fees, so that there may not be the slightest temptation to bestow the diploma on an unworthy candidate; or rather let me say, so that the Johns Hopkins diploma will be worth its face in the currency in the world.
President Gilman was particularly concerned with the lax admission standards of American medical schools. He did not allow the matter of providing intensive preparation for the study of medicine to wait until the Hopkins School of Medicine opened in 1893. Instead, during 1876-77, the first year of teaching at Johns Hopkins University, he planned a preliminary course of three years' duration designed "to impart that knowledge and skill which will be subservient to future professional work, and, at the same time, to develop the intellectual powers, upon a liberal and comprehensive plan." The course was inaugurated in 1867-78. According to the announcement of the course, published in the Johns Hopkins University Circular in 1877, "Physics, Chemistry and Biology, with Latin, German, French and English, form the principal elements of this course, with opportunities for the study of Psychology, Logic, History, and other branches of knowledge, according to the requirements of the scholar."
The Hopkins "preliminary course" set the standard for American premedical education in the decades ahead and was the first step toward the eventual common practice of requiring a bachelor's degree for admission to medical school. We have referred elsewhere to the Johns Hopkins Medical School as also a fertile source of innovation in medical education at the doctoral and postdoctoral levels.  
Before further consideration of the standards of American medical education, we should comment on a major internal deterrent to reform, i. e. , the faculties of the medical schools. Many, probably most, medical professors were of the opinion that existing admission and program requirements were well suited to conditions in America, and were reluctant to see them made more demanding. .
Dr. Henry J. Bigelow, Professor of Surgery at Harvard, was an extreme but interesting example of faculty resistance to change. He was the most vehement critic of President Eliot's reforms at Harvard. He was also a presumptuous man with low regard for professional amenities, as indicated by the following incident.
Dr. Bigelow was a mere bystander in the operating room when his colleague, Dr. John Collins Warren, also a Professor of Surgery at Harvard, successfully carried out the first public demonstration of ether anesthesia at the Massachusetts General Hospital on the 16th of October in 1846 to which we have previously referred.
On 3 November 1846, recognizing the immense significance of this event and determined to identify himself with it, Dr. Bigelow read before the American Academy of Arts and Sciences the abstract of a paper entitled: "Insensibility During Surgical Operations Produced by Inhalation. The First Public Announcement of the Discovery of Surgical Anesthesia."
On 9 November 1846, Dr. Bigelow read the full text of the above paper before the Boston Society for Medical Improvement.
Finally, on 18 November 1846, he published the full text of the article in the Boston Medical and Surgical Journal.  This hasty flurry of presentations by Bigelow was designed to give the impression that he was prime mover and patron of the demonstration. In making the precipitous "first public announcement of the discovery of surgical anesthesia," Dr. Bigelow's sole acknowledgment of the role of the responsible surgeon was the statement: "The present operation was performed by Dr. Warren."
On 9 December 1846 in the Boston Medical and Surgical Journal, Dr. John C. Warren published a carefully considered and definitive report of this historic case in a paper entitled "Inhalation of Ethereal Vapor for the Prevention of Pain in Surgical Operations, " being an account of the partial ligation of a cavernous hemangioma in the left neck of a man, aged 20, named Gilbert Abbott under ether anesthesia on 16 October 1846.
Dr. Warren included in his report the description of several subsequent cases successfully anesthetized by Dr. Morton and operated by surgical colleagues at the Massachusetts General Hospital He concluded the article by generously "congratulating my professional brethren on the acquisition of a mode of mitigating human suffering which may become a valuable agent, in the hands of careful and well-instructed practitioners, even if it should not prove of such general application as the imagination of sanguine persons would lead them to anticipate.  
In 1869, near a quarter century later, President Eliot was to collide head-on with Professor Bigelow whose imperious and self-serving manner had not been softened by the intervening years. Their first difference was over admission standards. Eliot proposed that candidates for admission to Harvard Medical School be required to show evidence of academic achievement. Bigelow retorted that this criterion was arbitrary, and might exclude a genius who had not conformed to the approved academic pattern. Moreover, Bigelow claimed that academic performance was irrelevant, since physicians and surgeons are born and not made. Furthermore, great medical discoveries are not born in the academic environment of university laboratories. (Here he doubtless had in mind the discovery of ether anesthesia, the credit for which he unscrupulously maneuvered to share.)
When Bigelow learned that Eliot had submitted the recommendation for revised entrance requirements to the Harvard Corporation for approval, he was outraged. "Does the Corporation hold opinions on medical education? Who are the Corporation? Does Mr. Lowell know anything about medical education? or Reverend Putnam? or Judge Bigelow? Why Mr. Crowninshield carries a horse-chestnut in his pocket to keep off rheumatism! Is the new medical education to be best directed by a man who carries horse-chestnuts in his pocket to cure rheumatism?" 
Fortunately for Harvard, and for American medical education, President Eliot had strong allies on the faculty. He survived the contemptuous criticism of Bigelow; precedent-setting reforms were adopted; and Harvard Medical School came firmly under the control of the University.
The conservative viewpoint that American Medical Education required no major reformation was eloquently expressed by Henry Gibbons, Sr., in his address to the California State Medical Society in October 1872 at the expiration of his term as second President of the revived Society: 
There has been much lachrymation of late over the low standard of medical education in America. There are too many schools, and the schools make too many doctors. The complaint may be true, but then one gets sick of the everlasting whine. It is perfectly natural that persons accustomed to the long and laborious education of the old world, should deem it quick work to make a doctor out of new material in less than the standard European time for the preliminary drill. But the circumstances of the two worlds are widely different, and they create necessities of their own. There, you behold forty millions of souls concentrated upon a spot that is covered with the end of your finger on the map. Here, the forty millions are scattered over a continent reaching from ocean to ocean, and from the Arctic circle to Cancer. There, in the climacteric of the nations, wealth, leisure and luxury abound. Here, in our obstreperous boyhood, there is no capital to be spared from physical development, no time to be spared from art and trade. There, the population is compact and fixed, and a doctor's patients are near his door. Here, except in a few ancient centres, they are widely scattered, and a resistless centrifugal force adds every year immensely to the range of practice and the demand for practitioners.
It is folly to talk of supplying this illimitable field with physicians who have invested five years of their life and five thousand dollars in an education. Such men do not like to ride from five to fifty miles to visit a patient, and run the risk of starving unless they have learned, in addition to medical science, the art of raising cabbages. The practice of medicine in the rural districts of America demands an adaptation, a fertility of resource, a tact, not acquired in the schools. The high-bred graduate, with the Bodleian library and all the medical lore of Vienna and Berlin in his head, would stumble on the problem of Nicodemus, and find a new departure necessary to qualify him for his new field of labor.
Notwithstanding the easy path to the doctorate furnished by the half-hundred rival schools of America, the path is still too difficult for many of the aspirants. In the absence of candidates possessed of wealth and pursuing knowledge for its own sake, the classes are composed mainly of students of moderate or slender means, in search of a living in a profession chosen by themselves and not by their parents. Ambition and perseverance are required to enable them to struggle through their difficulties. How many of our best practitioners, the most capable and the most honorable, have trod this thorny path! How many have been compelled to teach school or to perform some other service during their term of study, in order to obtain the means of education! How many have been forced by misfortune, or necessity in some form, to abandon the college before reaching the goal!
In a new country like ours, there is some propriety in conferring degrees in certain cases where the required curriculum of studies has not been completed. If an individual who has practiced without a diploma and established an honorable reputation, and who may be unable to leave his home to complete the formulated course of study, should be able to pass a satisfactory examination in the several branches, what reasonable objection can be urged against admitting him to the doctorate? His fidelity has been proved, and his past life is a guaranty that the profession will suffer no discredit or disgrace from his membership. There can be no such assurance in the case of young men who pass through the complete curriculum, without having had an opportunity of resisting the temptation to play the charlatan. A diploma, be it ever so well earned, will not deter a man devoid of principle from abandoning the path of honor and wallowing in the filth of quackery. Of this we have frequent illustrations in British and European graduates, who are often the most villainous of advertising charlatans in this country.
Dr. Gibbons' nostalgic soliloquy was an elegy for the status quo, and a memorial to the self-reliant men of his generation who, like Elias Cooper (he surely had him in mind), "trod a thorny path" before ultimate acceptance into the profession. Nevertheless, in spite of his fondness for the traditional program, when Dr. Gibbons learned of President Eliot's installation of higher admission standards, a three-year graded curriculum, and other reforms at Harvard, he observed, "We may expect before many years to see this system, or a modification of it, adopted universally." We shall soon see that the Medical College of the Pacific had already begun taking prudent steps to strengthen its program.