Rockefeller Foundation Funding and Medical Education in Toronto, Montreal, and Halifax 9780773572898

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ROCKEFELLER FOUNDATION FUNDING AND MEDICAL EDUCATION IN TORONTO, MONTREAL, AND HALIFAX

MCGILL-QUEEN S ASSOCIATED MEDICAL SERVICES

Studies in the History of Medicine, Health, and Society Series Editors: S.O. Freedman and J.H. Connor Volumes in this series have financial support from Associated Medical Services, Inc. (AMS). Associated Medical Services Inc. was established in 1936 by Dr Jason Hannah as a pioneer not-for-profit health care organization in Ontario. With the advent of medicare, AMS became a charitable organization supporting innovations in academic medicine and health services, specifically the history of medicine and health care, as well as innovations in health professional education and bioethics. 1 Home Medicine The Newfoundland Experience John K. Crellin 2 A Long Way From Home The Tuberculosis Epidemic among the Inuit Pat Sandiford Grygier 3 Labrador Odyssey The Journal and Photographs of Eliot Curwen on the Second Voyage of Wilfred Grenfell, 1893 Edited by Ronald Rompkey 4 Architecture in the Family Way Doctors, Houses, and Women, 1870-1900 Annmarie Adams 5 Local Hospitals in Ancien Regime France Rationalization, Resistance, Renewal, 1530-1789 Daniel Hickey 6 Foisted upon the Government? State Responsibilities, Family Obligations, and the Care of the Dependant Aged in NineteenthCentury Ontario Edgar-Andre Montigny

7 A Young Man's Benefit The Independent Order of Odd Fellows and Sickness Insurance in the United States and Canada, 1860-1929 George Emery and J.C. Herbert Emery 8 The Weariness, the Fever, and the Fret The Campaign against Tuberculosis in Canada, 1900-1950 Katherine McQuaig 9 The War Diary of Clare Gass, 1915-1918 Edited by Susan Mann 10 Committed to the State Asylum Insanity and Society in Nineteenth-Century Quebec and Ontario James E. Moran 11 Jessie Luther at the Grenfell Mission Edited by Ronald Rompkey

12 Negotiating Disease Power and Cancer Care, 1900-1950 Barbara Clow

19 The Ontario Cancer Institute Successes and Reverses at Sherbourne Street E.A. McCulloch

13 For Patients of Moderate Means A Social History of the Voluntary Public General Hospital in Canada, 1890-1950 David Gagan and Rosemary Gagan

20 Island Doctor John Mackieson and Medicine in Nineteenth-Century Prince Edward Island David A.E. Shephard

14 Into the House of Old A History of Residential Care in Ontario Megan J. Davies 15 St Mary's The History of a London Teaching Hospital E.A. Heaman 16 Women, Health, and Nation Canada and the United States since 1945 Edited by Georgina Feldberg, Molly Ladd-Taylor, Alison Li, and Kathryn McPherson 17 The Labrador Memoir of Dr Henry Paddon, 1912-1938 Edited by Ronald Rompkey 18 J.B. Collip and the Development of Medical Research in Canada Extracts and Enterprise Alison Li

21 The Struggle to Serve A History of the Moncton Hospital, 1895 to 1953 W.G. Godfrey 22 An Element of Hope Radium and the Response to Cancer in Canada, 1900-1940 Charles Hayter 23 Labour in the Laboratory Medical Laboratory Workers in the Maritimes Peter L. Twohig 24 Rockefeller Foundation Funding and Medical Education in Toronto, Montreal, and Halifax Marianne P. Fedunkiiv

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Rockefeller Foundation

Funding and Medical Education in Toronto,

Montreal, and Halifax M A R I A N N E P. F E D U N K I W

McGill-Queen's University Press Montreal & Kingston • London • Ithaca

c McGill-Queen's University Press 2005

ISBN 0-7735-2897-0 Legal deposit second quarter 2005 Bibliotheque nationale du Quebec Printed in Canada on acid-free paper that is 100% ancient forest free (100% post-consumer recycled), processed chlorine free. This book has been published with the help of a grant from the Canadian Federation for the Humanities and Social Sciences, through the Aid to Scholarly Publications Programme, using funds provided by the Social Sciences and Humanities Research Council of Canada. McGill-Queen's University Press acknowledges the support of the Canada Council for the Arts for its publishing program. It also acknowledges the financial support of the Government of Canada through the Book Publishing Industry Development Program (BPIDP) for our publishing activities.

Library and Archives Canada Cataloguing in Publication Fedunkiw, Marianne P., 1965Rockefeller Foundation funding and medical education in Toronto, Montreal and Halifax / Marianne P. Fedunkiw. (Studies in the history of medicine, health and society ; 24) Includes bibliographical references and index. ISBN 0-7735-2897-0 1. Medicine - Scholarships, fellowships, etc. - Canada - History. 2. Medical education - Canada - Finance - History. 3. Rockefeller Foundation - History. 4. Medical education - Canada - History. I. Title. II. Series: McGill-Queen's/Associated Medical Services (Hannah Institute) studies in the history of medicine, health, and society : 24. R749.A6F43 2005

610'.7i'i7i

C2004-906278-6

Typeset in 10/12 Palatino by True to Type

To my family

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Contents

Figures and Tables xi Acknowledgments

xiii

Introduction: A Tale of Three Cities 3 1 Ripe for Change: Medical Education in Flux 7 2 Rockefeller Aid: Which "Peaks to Make Higher"? 3 Turmoil in Toronto: The Provincial University

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49

4 Building on Strengths at McGill: The Nation's University 85 5 Bouncing Back at Dalhousie: A Regional University 109 Conclusion: Medical Education Transformed 131 Notes 151 References Index 193

179

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Figures and Tables

FIGURES

1.1 Tuition fees for medical programs at Toronto, McGill, and Halifax Medical College / Dalhousie, 1894-1925 16 1.2 Enrolment in medical programs at Toronto, McGill, and Halifax Medical College / Dalhousie, 1890-1920 17 TABLES

1.1 Canadian medical schools / faculties, with dates of founding(s), 1824-1970 14 1.2 Income from fees and teaching ratios at Toronto, McGill, and Halifax Medical College, 1909 25 1.3 Selected U.S. and Canadian medical schools, ranked by average fees, 1909 26 1.4 Presidents and deans of medicine at Toronto, McGill, and Dalhousie 28 5.1 Faculties at Dalhousie, 1912 120 5.2 Population of Toronto, Montreal, and Halifax, 1921 128

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Acknowledgments

I would like to thank three scholars who advised me and offered their support on this project from my earliest days at the University of Toronto's Institute for the History and Philosophy of Science and Technology (IHPST): Trevor Levere, Michael Bliss, and Pauline Mazumdar. Their experience and insight exemplified much that is noble in academia. I would also like to thank those who read earlier drafts and whose comments strengthened this final product including Andrew Baines, Michael Hubenstorf, and A.B. McKillop. I am fortunate to have had three female mentors in Marianne Gosztonyi-Ainley, Elizabeth Badley, and Alison Li. They have taught me much about research, teaching, leadership, and kindness, and Alison's book on J.B. Collip was my benchmark as I prepared this manuscript for publication. I am also grateful to Mark Harrison, Carol Brady, Belinda Michaelides, and Carol Phipps, who gave me a scholarly home to edit this work while I was on a postdoctoral fellowship from the AMS/Hannah Institute for the History of Medicine at the Wellcome Unit for the History of Medicine at Oxford (WUHMO). The intellectual community at WUHMO and in Oxford during my two years there has left me with fond memories, fine scholarship, and wonderful friends, among whom I count: Pratik Chakrabarti, Kati diGleria, Debbie Emmitt, Bunia Gorelick, Vi and Nigel Hiscock, Krista Maglen, Sloan Mahone, E. Huw Price, Jo Robertson, John Senior, Nina Staehle, Helen Tilley, Ruth Brown, and Bob Smith and my wickedly witty officemates Margaret Jones and Helen Sweet. I am grateful to Antoni

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Acknowledgments

Malet for his excellent advice to make the most of my postdoctoral fellowship. Thanks too to the women of the Oxford Women's Ice Hockey Club, 2001-03. These Blues lured me away from my computer for midnight practices, weekend matches all over southern England, and the opportunity to play in goal as the team's aged "leaping salmon." Finally, I would like to thank Sir John Hanson, Jeffrey Burley, and the scholars at Green College, Oxford, for offering me another intellectual and social home while in England. I could not have researched this book without the assistance of a wonderful group of archivists: Darwin Stapleton, Ken Rose, Tom Rosenbaum, Erwin Levold, and my trusty "keeper" on each visit, Michele Hiltzik, at the Rockefeller Archive Center (RAC) in New York; Tina Ann Bradford at the Dalhousie University Archives in Halifax; Johanne Pelletier at the McGill University Archives in Montreal; and Harold Averill at the University of Toronto Archives. I am grateful to the RAC for three research grants in 1994,1996, an 2002. John Parry of McGill-Queen's University Press masterfully edited the manuscript, and his keen and meticulous eye was much appreciated. Roger Martin and Joan McGilvray graciously shepherded this work through to publication, and I would like to thank the individuals who reviewed the manuscript and whose suggestions improved my work. Thanks are also due to fellow scholars at IHPST and friends in Toronto who heard talks of early drafts and who offered cogent criticism and support: Tara Abraham, Gordon Baker, Jennifer Keelan, Jill Lazenby, Rebecca Levere, Elizabeth and Wilf Lockett, Wendy Rowney, M.H. Stevens, Ed Tracy, Steven A. Walton, and Joanne Woiak, as well as Muna Salloum, Denise Horsley, and Bill Zaget. Special thanks to my Toronto confidant(e)s, Terry Black, Beth-Lynn Bow George Dutton, and Adrienne Galway, as well as to Alex Isbister and Pamela Lenkov, who have helped me beyond measure, Bert S. Hall has taught me much about research, perseverance, and academia, for which I am truly grateful. Finally, my family deserves credit for fostering in me a passion for learning and an undimmed inquisitiveness. I will always be grateful to Leona and Stephen Fedunkiw and Mary Tataryn for their encouragement. I must also thank my sister, Lisa Fedunkiw, and my brother-in-law, Jonathan Reid, for their support, and my nephew, Zachary, for being a model of quiet determination.

ROCKEFELLER FOUNDATION FUNDING AND MEDICAL EDUCATION IN TORONTO, MONTREAL, AND HALIFAX

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INTRODUCTION

A Tale of Three Cities

This book tells a story that has been buried in various archives, largely untold, for more than eighty years. It is a story of family connections, great wealth, public scandal, and the scientization of professional medical education. The goal of this work is not only to explain how Rockefeller millions helped Toronto, Montreal, and Halifax to finance changes in medical teaching, but also to show how perceptions and practices in medical science changed after the First World War, largely as a consequence of substantial financial support provided by donors putting long-desired teaching improvements into action. I do not tell the complete story of all the gifts. Eleven potential recipients were considered: the Faculties of Medicine at Dalhousie University, Laval University, McGill University, Universite de Montreal, Queen's University, the University of Toronto, the University of Manitoba, and the University of Alberta, as well as the medical school of Western University (now the University of Western Ontario) and the Universities of Saskatchewan and British Columbia. The Rockefeller Foundation chose to aid six select Canadian medical schools.1 The three schools that I examine in detail received more than half of the allotted gift of U.S.$5 million. I chose the medical schools at Toronto, McGill, and Dalhousie for three reasons. First, Toronto and McGill were each originally earmarked to receive $1 million - the single largest portion of the gift. Second, the schools represent three unique case studies in their approach to raising the requisite matching funds, in their support for

4

Introduction

full-time clinical teaching, and in their distribution of the funds. Even though Toronto, McGill, and Dalhousie represented different geographical regions, they each set out with a common ideology - to teach medicine using the latest in laboratory and clinical techniques and to build a post-graduate medical program and specialties so that Canada could train and teach first-rate medical professors. Third, Toronto, McGill, and Dalhousie represent three types of schools: Toronto was a "state" school, responsible for offering a solid liberal arts education to the people of Ontario, even though the provincial government often under-funded it. Toronto's medical school was, in 1919, still reeling from its troubled history as a relatively new professional faculty made up of various remnants of local proprietary schools forced to amalgamate with the university faculty because of skyrocketing laboratory costs. McGill was the nation's medical school, with more than eighty-five years' experience in medical instruction, well-respected throughout North America and well-supported by private, Montreal money. Dalhousie was the Maritimes' school, the only Canadian medical school east of Montreal, resurrected from its previous incarnation as Halifax Medical College. This medical school bore the responsibility for training all the region's physicians while trying not to drain all of Dalhousie's operating budget in a single year. There has been little written on the Canadian and American gifts that helped define a pedagogical and professional identity,2 except for passing references in institutional histories3 and biographies, like those of University of Toronto President Sir Robert Falconer4 and of Duncan Graham,5 the first full-time chair of clinical medicine in the Commonwealth. The triumphs and tensions caused first by the need to woo donor dollars and then to effect change form part of the history of the medical schools in Toronto, Montreal, and Halifax.6 Finally, this work adds to that of Canadian scholars Bliss,7 Gingras,8 Li,9 and McRae10 on the growth of Canadian research. By examining the reforms that underscored the laboratory revolution preceding research, my work offers additional insight into the maturation of the research ideal in Canada. O U T L I N E OF THIS STUDY

I believe that the Rockefeller Foundation gift of $5 million announced in December 1919 to aid Canadian medical education had a significant effect on reforming medical teaching in Canada. Although the ideas that this money supported had existed for as much as forty years, putting these reforms into practice took considerable capital

A Tale of Three Cities

5

investment. Not only did the Rockefeller Foundation's gift encourage substantial matching gifts from both government and private sources, it also offered medical schools a greater opportunity to reevaluate their curriculum, infrastructure, and faculty requirements and their applicant pool. Modern 'scientific medicine' required laboratories, equipment, and clinical teaching facilities. Without these, Canada was at risk of falling far behind Britain, Continental Europe, and the United States in medical education. The Rockefeller money also represented a way to pay for the continuing scientization of medicine as either Foundation money or subsequent matching funds paid for the expansion of laboratory space, equipment, and full-time instructors. Chapter i offers a brief overview of the history of medical education in Canada, so that the reader might better understand the unique educational niches occupied by the medical schools in Toronto, Montreal, and Halifax leading up to and at the time of the Rockefeller gift. Chapter 2 focuses on the history of private philanthropy as it affected North American universities from the i88os to the 19105.1J We can learn lessons from the way in which the Foundation offered to help Canadian schools. Like the Flexner Report, these reforms affected all U.S. and Canadian medical teaching facilities, but analyses of how the Canadian schools changed have been minimal. I compare, in chapter 2, Canadian use of Rockefeller Foundation dollars to U.S. applications. Chapter 3 tells the story of how the University of Toronto's medical school wooed the Foundation for its million-dollar gift and examines the stir that the changes wrought with this and another private gift of $500,000. Because, to this point, the provincial government largely funded it, Toronto is a unique case study of the tension between teachers and those who control the purse strings. Within the existing body of research on medical education at Toronto, chronologically my work fits between the work of McRae12 and Li/3 and that of Gidney and Millar14 and McKillop.15 Chapter 4 details the McGill case. Like Toronto, McGill was originally to receive $1 million from the Rockefeller Foundation, the largest gifts to a Canadian medical school. And like he did Toronto, Flexner lauded McGill in his 1910 report. But here the similarities end. McGill had no appreciable provincial government support. It did, however, have a history of considerable private support, particularly from wealthy Montreal anglophones. Hence, there was no corresponding provincial interest in how McGill spent the original gift or the matching funds. Although McGill has the oldest, continuously operating medical school in Canada, the history of medical education

6

Introduction

at McGill has been the subject of only one major monograph to date, other than as chapters in institutional histories.16 Chapter 5 documents the case of Dalhousie University. Medical education in Halifax has been the topic of three articles.17 The best is Penney's bleak description of Dalhousie's medical faculty predecessor, the private Halifax Medical College.18 Penney's article makes the Rockefeller gift to Dalhousie all the more extraordinary: the Foundation's guiding principle for gifts was to aid the best schools, a form of educational 'natural selection.' Dalhousie was certainly not the best medical faculty in 1919 - but it was the only Canadian option east of McGill and received $500,000 from the Foundation. Finally, chapter 6 examines the longer-term impact of the $5-million gift on Canadian medical education. This work describes people and personal connections, debts owed or perceived, and the final phase in the scientization of medical teaching that placed medicine squarely within the Canadian university. As in any tale with many characters with different interests, there are scandals, successes and failures, heroes and villains. But one thing is indisputable - medical teaching would never be the same in Canada, largely because of changes expedited as a result of the Rockefeller gift of 1919.

1

Ripe for Change: Medical Education in Flux

The Rockefeller Foundation's gift of $5 million in 1919 marked a turning point in Canadian medical education. It represented a "way" to reform, to catch up finally to the "will" that had existed since the late nineteenth century. Ludmerer expresses a similar sentiment with regard to the Harvard medical school. He argues that Harvard had a distinct advantage in trying to reform teaching because it was adept at raising funds. The school raised $3 million in its drive of 1901 and hence had a head start on other schools in implementing the new scientific and research medicine ideal. Ludmerer acknowledges dedicated faculties elsewhere aware of what needed doing, but lacking resources to carry out their plans. By the time Abraham Flexner published his evaluation of all 155 U.S. and Canadian schools in 1910, Ludmerer says, more than thirty were running deficits in an attempt to offer better training. "Everywhere in the nation," he writes, "lack of money became the limiting factor in how far the reform of medical education could proceed."1 The impact of philanthropic gifts to select medical schools was magnified by matching funds2 and the promotion of research and the scientization of medicine. To understand the impact of the Foundation's gift on Canadian medical education, it is useful to examine first the funding of Canadian medical schools in the decades before the Great War. It involves as much the history of higher education and the making of the profession of medicine in Canada as it does the politics and demographics of professional education.3 Medical schools operated on the fees

8

Ripe for Change

collected from their students. Until 1905, none of the University of Toronto, McGill University, or Halifax Medical College received substantial provincial support. After 1905, when James Whitney's Conservatives came to power in Ontario, the University of Toronto's medical program began to receive grants, but McGill and Halifax continued to rely on fees and private endowments. For example, Donald Smith, Lord Strathcona, gave McGill an endowment of $150,000 for chairs in pathology and hygiene and a general medical faculty endowment fund. William Macdonald, on his death in 1917, bequeathed $500,000 to the Faculty of Medicine at McGill.4 Furthermore, the Flexner Report5 had little effect in Canada, and a number of American historians6 have noted that, as Gidney and Millar observed, "the history of medical education in nineteenthcentury Ontario, and especially in Toronto, is not that of the United States writ small."7 For example, as precarious as was the position of Halifax Medical College, it was not as insecure as many smaller U.S. proprietary schools, many of which closed about the time of Flexner's report.8 As Flexner noted in his first chapter, up to about 1890 many American medical schools affiliated with universities became caught up "in the wave of commercial exploitation which swept the entire profession so far as medical education is concerned. For years they managed their own affairs, disposing of professorships by common agreement, segregating and dividing fees, along proprietary lines. In general, these indiscriminate and irresponsible conditions continued at their worst until well into the eighties. To this day, it is as easy to establish a medical school as a business college, though the inducement and tendency to do so have greatly weakened."9 This grave situation does not, however, describe the Canadian schools of the period. For schools such as McGill and Dalhousie, which received little to no provincial funding, conditions were never consistently as poor as at the worst American schools. Weisz says that McGill stood out from other Canadian medical schools as early as the mid-nineteenth century. None could compare to it; Ontario's were proprietary schools, loosely affiliated to a university at best and without adequate hospital teaching facilities. In contrast, McGill offered a university medical education that was comparable to that found in Boston, New York, or Philadelphia. This changed only in 1887, when the University of Toronto Medical School opened, thereby ending McGill's monopoly10 To explain the eager anticipation of the Foundation gift of 1919, this chapter examines the early years of medical education in Canada; the

Medical Education in Flux

9

emergence of scientific medicine; and the laboratory revolution and the full-time system. The resulting funding challenges facing Canadian medical schools of the 19005 and 19105 grew out of the scientization of medical teaching that began in the 18705. THE EARLY YEARS: POPULATION AND POLITICS

Funding medical education in British North America was not a critical issue in the early nineteenth century. Most physicians studied in Continental Europe or Britain, where training centred on apprenticeship. Others served as apprentices or received their practical training through the British army or Royal Navy, as had been the practice in the eighteenth century.11 There were, however, two pressing issues. The first was a combination of the country's size and its small population. The second was a sense of the need for a professional identity coupled with a desire to oust competitors - non-traditional medical practitioners such as homeopaths, Thomsonians (also known as botanies), and eclectics, as well as American practitioners. Low population density in most areas meant that physicians keenly felt competition for services in the first half of the century. Ludmerer writes that the Thomsonian movement discouraged reforms in early medical schools such as Harvard. Because Thomsonians believed that the principles of medicine were simple enough for any man to understand, Harvard, which was a proprietary school, was slow to change. The Harvard medical program seemed adequate partly because medical knowledge remained relatively limited. It was only in 1870, with the introduction to the United States and Canada of the European advances in clinical training and laboratory experimental medicine and research, that Harvard Medical School took up major teaching reforms.12 Because of economic necessity, most physicians, civilian or military, lived and practised in the populated towns and cities in British North America.13 As Canniff notes in his history of the medical profession of Upper Canada, by 1815 there were only thirty-six or forty medical men "possessing some qualification."14 He cites Robert Gourlay's 1817 survey of several townships. Gourlay asked settlers how many medical practitioners there were in their township. For example, for a population in four districts of 26,977,ne found twenty medics. But medicine was a difficult way to earn a living in a land where distances between settlements could be great15 and payment difficult to collect: '"While I was in Canada/ Gourlay writes, 'men of education, talent, and experience, came from home to settle there, but

10

Ripe for Change

it would not do, and many of them have left the Province. A country surgeon at home had hard work of it. What may he be supposed to have where the population does not amount to seven bodies to the square mile (?) and where fees must be received per the barrel, or the bushel; perhaps in lumber/"16 There was no medical school in the Canadas, university-based or private, until 1824, when the Montreal Medical Institution opened. Upper Canada17 had no medical school until 1832. Although formal medical education was limited until the 18305 and 18405, the existing medical profession showed early signs of restricting those who might legally practise. In Upper Canada, one such attempt at licensure occurred in iy92.18 As MacNab outlines, subsequent attempts "to regulate the practice of physic in this Province" took place throughout the early nineteenth century - as much to keep politically dangerous American practitioners out of Canada as to discourage quackery. Most legislative acts proved too difficult to administer. There was the question of the profession's division between newly trained physicians and those senior members of the profession, trained under a different model years earlier, who did not meet the formal training requirements set out in the new guidelines. There were also logistical challenges in requiring that those who applied for a licence to practise would have to pass an examination. Physicians with established practices needed to take tests like young students, which insulted their egos and their professional integrity. Furthermore, as MacNab points out, "the problems of a scattered population and an inadequate supply of qualified doctors still existed."19 As for the shift from apprenticeship to classroom learning, which occurred in the first half of the nineteenth century, classroom instruction preceded clinical instruction in the ward of a teaching hospital. There, a form of group apprenticeship took place, as senior medical students shadowed a clinical instructor on hospital rounds. As Gidney and Millar point out, students wanted to train in the larger hospitals, where they might have access to patients on the wards as well as in the dissecting room. New methods of diagnosis and surgical advances made greater exposure to a variety of cases indispensable. As a consequence, physicians and hospital trustees saw economic rewards in offering students courses in anatomy and other subjects. They organized classes and soon entire schools of medicine.20 As a result, Gidney and Millar explain that a "new pedagogy" combined small-group instruction with large class lectures, and hospital work with classroom learning.21 Throughout the first half of the nineteenth century, British North

Medical Education in Flux

11

American doctors worked towards establishing a professional identity. Contributing to this were government-supported licensing efforts, creation of medical schools, and establishment of provincial associations. The Medico-Chirurgical Society of Upper Canada was among the earliest, formed in York (now Toronto) in 1833, ten years before King's College in Toronto set up its medical faculty. Soon there was interest in a national medical association; in 1847, two years after discussions began, the forerunner of the Canadian Medical Association was formed. Other foundings included the Medical Society of Nova Scotia (1854) and the Prince Edward Island Medical Association (1855). Six provinces followed decades later: New Brunswick (1880); British Columbia (1900); Saskatchewan (1905); Alberta (1906); Manitoba (1908); and (before it joined Confederation) Newfoundland (i924).22 These bodies represented physicians' concerted efforts to present themselves as professionals. All the associations became divisions of the Canadian Medical Association, the national organization as we know it today being set up in 1867. As Gidney and Millar explain, physicians, lawyers, and clergymen were still striving to establish their collective identity as the century wore on. Integral to their strategies were education, examination and licensing, and peer censure. Nineteenth-century medical practice is rife with wars between the traditional, or allopathic physicians and those on the fringes - namely osteopaths, chiropractors, homeopaths, and eclectics. As physicians gained greater professional autonomy, they pushed other groups further to the fringes. In Ontario, for example, an act of 1869 established the College of Physicians and Surgeons of Ontario and gave it the power to administer licensing examinations to would-be practioners and to administer medical education, including curriculum and matriculation standards for entry into medical schools.23 It could maintain control of entrants* by setting school admission standards and by regulating professionals via licensing and disciplinary committees. In the first decades of formal, "school-based" medical education, funding education was not difficult. Instructors shared their expertise with a small class of students. Lectures and lecture-demonstrations were the predominant methods used to convey knowledge, followed by an apprenticeship period with one of the instructors in the hospital. Furthermore, a longstanding criticism was overemphasis of lectures and consequent dearth of clinical hours. Although students spent considerable time in the dissection room taking practical anatomy, laboratory instruction and clinical training required more attention. As early as 1890, a Special Committee of

12

Ripe for Change

the General Council of Medical Education and Registration (Ontario) gathered together. Its assignment was to compare the Ontario medical schools' curricula to those of leading British, Continental European, and other Canadian schools. The committee reported inadequate practical training, with too much effort going to lectures. The recommendations led to new curriculum requirements for Ontario schools in 1891 and subsequent halving of lecture hours in each course - from one hundred to fifty hours - and addition of a fifth, practical year to the four-year medical course. As MacNab notes, schools had added a fourth year to the original three-year course in 1880 and a ten-week summer academic term in 1889 and had tried to decrease applications in 1890 by raising matriculation standards and making the course longer. There was concern about overcrowding the profession in Ontario, but Canadian matriculation standards did not change in 1891. The five-year course was officially adopted, first by McGill in 1907/08. The University of Toronto followed the next year, and Dalhousie in 1911/12.24 Hanaway and Cruess observe that in the second session of the Montreal Medical Institution (1824-25), twenty-five students attended lectures on Materia Medica and Dietetics; Practice of Physic; Chymistry (sic) and Pharmacy; Anatomy, Physiology and Surgery; Midwifery and Diseases of Women and Children; and Botany, with "visiting hours at the Montreal General Hospital," in the Edinburgh tradition. That tradition encouraged teaching at the bedside of patients. The history of this pedagogical method goes back to Giovanni Battista Da Monte (Montanus) of Padua (1498-1552). Montanus believed that students could learn only by supplementing their theoretical lessons with bedside observation of patients. His ideas on ward teaching travelled first to Ley den and in the eighteenth century to the Edinburgh University School of Medicine, which added anatomy and physiology to the curriculum. The Edinburgh influence was so strong that Hanaway and Cruess write, "McGill medicine was, in essence, a clone of Edinburgh in the New World."25 Outside the wards, instruction took place "almost exclusively" by lecture, and students spent from four to seven hours each day listening to lectures. McGill was, however, renowned for its teaching of practical anatomy. Cadavers were readily available for instruction, and this feature attracted many students from eastern Canada and the United States. Well into the 18703, dissections for students of the brain, chest, pelvis, and abdomen were rare because surgeons hardly ever oper-

Medical Education in Flux

*3

ated on these areas, for fear of patients' certain death from infection.26 Although many students enrolled for one or two years, few actually finished the McGill course and qualified for a licence to practise.27 In terms of financing, students paid, in 1832, three pounds (Halifax currency) for a term's ticket for each course, except for anatomy and chemistry, each of which cost three pounds, fifteen shillings. The course lasted five years: students had to attend lectures for three years and then received bedside training in the hospital for two years.28 The total enrolment at McGill remained about twenty-five students even into the early 18405. The costs of primarily lecturebased instruction therefore were minimal. Although McGill was teaching physiology as far back as 1849, the chair of physiology from 1849 until 1872, William Fraser, arrived with minimal laboratory experience. In fact, as instructor of physiology, histology, and pathology, subjects known collectively as the Institutes of Medicine - he brought only a didactic tradition and textbook knowledge. By end of his tenure, schools in Europe offered laboratories and pieces of equipment such as kymographs (developed by German physiologist Carl Ludwig) for experimental physiology, and schools in Edinburgh and London used microscopes, but Fraser continued only to lecture. Eraser's successor was Joseph Morley Drake (1872-74), who gave way to William Osier (i874~84).29 Revenues from student fees sustained first the private school and then the medical faculty at McGill. But by 1841, the school had financial problems. Although up to five hundred pounds in aid came from the new Province of Canada, it did not prove enough, and only moving to the new, rent-free McGill University buildings in 1845 alleviated the financial pressure. The new space included two lecture rooms and an anatomy dissection room that lacked adequate light, heat, and ventilation.30 Thus, the school was facing financial difficulties long before science-based reforms. Although the chronology is easy to document for the McGill school, it is not so simple for other institutions. There is no easy way to list all Canadian medical schools in chronological order of establishment. Early Canadian medical education involved private schools' specific relationships to nearby universities and licensing bodies as much as university-based medical teaching as we know it today. We can list many of the medical faculties (see Table 1.1), in order, but with more than one date of founding. Many nineteenthcentury faculties emerged as private schools, so the first date is the school's year of founding, and the second, the year it joined the University with which it is associated today.

M

Ripe for Change

Table 1.1 Canadian medical schools / faculties, with dates of founding(s), 1824-1970

Proprietary school Montreal Medical Institution Rolph/Duncombe (St Thomas) John Rolph (private classes) King's College Montreal School of Medicine and Surgery

University/ university affiliation

Established/ joined university

McGill

1824/1829 1824 (closed 1826) 1832 (closed 1837)* 1843 (closed 1853)

King's College Victoria College (Cobourg) Laval

Trinity Queen's Toronto School of Medicine Halifax Medical College Bishop's (Lennoxville) Trinity

Manitoba Medical College Women's College (Toronto)

Dalhousie McGill Trinity College Western Ontario Manitoba Alberta Montreal Saskatchewan Ottawa British Columbia Sherbrooke McMaster Memorial Calgary

1843 (closed 1874) 1848 1851 (closed 1855) 1854 1856/1870 (Victoria)/ 1887 (Toronto) 1867/1911 1871/1905 1871 refounded/ 1904 (Toronto) 1881/1913 1883/1918 1883/1905 1921 1923 1926 1945 1950 1961 1967 1969 1970

Sources: Various; some dates differ by a year or two, depending on the source. *MacDermot, One Hundred Years of Medicine in Canada, 96, says that Rolph began teaching again in 1843 "and laid the foundations of what became the Toronto School of Medicine."

The predecessors of some Canadian university medical faculties, such as Toronto's, included more than one private school. In Toronto this was partly the result of denominational universities which later federated. At various times throughout the nineteenth century, Trinity University (Anglican), Victoria University (Methodist), and King's College (eventually non-denominational) each had its own medical school, and there were proprietary schools such as the Toronto School of Medicine run by John Rolph. This situation influenced the raising of funds to support the new, scientific medicine. With no longstanding, unified base of alumni from which to draw

Medical Education in Flux

15

gifts, the University of Toronto became anxious about funding and was ready to meet whatever conditions donors might stipulate in its bid to become a "world-class" medical teaching and research facility. SCIENTIFIC MEDICINE

There are those historians, such as John Harley Warner31 and J.T.H. Connor,32 who argue that medical sects not only represented economic competition, but also helped traditional physicians to unite and forge a common professional identity, grounded in systematic training and professional licensing. While competition for patients was low, physicians uttered few cries for stringent, school-based training or examinations. But as Gidney and Millar point out, "while the regulars had always routinely condemned the dangers of quackery, it is only around mid-century that the chorus of complaints rises to a crescendo."33 Physicians competed not only with other traditional physicians, but also with botanies, eclectics, and homeopaths. Howell notes how, in Nova Scotia in the i86os and 18705, some practitioners experimented with unorthodox remedies in an effort to have medicine appear to do more. Conservative physicians, or the medical elite as Howell calls them, fought back by supporting medical colleges, developing hospitals, forming societies to discuss germ theory, and struggling for legislation - the Anatomy Act of i869-34 Although their efforts were not in vain, Howell writes that it would take decades before arguments within Nova Scotia's medical elite ended. Even in 1880, they could not agree on germ therapy and Listerism. Howell tells of one physician, Edward Farrell, who came to accept the principle of antiseptic management and surgical cleanliness but continued to practice bloodletting. Only the efforts of men such as Dr A.W.H. Lindsay and Dr John Stewart (who had studied under Lister), spreading the word at medical society meetings, convinced colleagues about the germ theory. By the mid-i88os, this scientific theory, which helped explain disease transmission, dominated the profession.35 As a result of increased scientific rigour demanded, the number of practitioners licensed to practice decreased.36 This scientization of traditional medicine37 helped to differentiate modern medicine from that of the "irregulars." The cost of equipment helped vanquish private medical schools in Toronto, for example. Although it was relatively easy to procure parttime clinical instructors - many Toronto-area physicians enjoyed the prestige of teaching in a medical school - student fees in late century

i6

Ripe for Change

Figure 1.1 Tuition fees for medical programs at Toronto, McGill, and Halifax Medical College / Dalhousie, 1894-1925

Source: Calendars of the University of Toronto, McGill University, and Dalhousie University for 1894/95,1904/05,1914/15, and 1924/25.

could not cover microscopes and laboratory equipment for chemistry and physiology experiments. Not having equipment for the emerging laboratory loosened schools' competitive grip on students. This, coupled with growing interest in the science of medicine brought back by graduates studying in Germany, led to the general feeling that Canadian medical schools were falling behind. For those institutions with university links, the situation was only marginally better. Dissection specimens were still a challenge to procure in the necessary numbers, and facilities that were adequate in the 18505 were overcrowded by the iSpos.38 For post-i890 expansion, see Figures 1.1 (fees) and 1.2 (enrolment).39 Serious economic challenges hindered scientization of the medical curriculum. Financing the change played a role in Queen's lagging behind McGill and Toronto in medical education. Queen's Principal George Munro Grant (1877-1902) allegedly viewed the medical course as "peripheral to the essential purpose" of the university. As late as 1886, he was writing, "I attach little importance to the Medical School. Our medical students are a wonderful, hard-working lot, but the mass of medical students will go and ought to go to Montreal and

Medical Education in Flux

*7

Figure 1.2 Enrolment in medical programs at Toronto, McGill, and Halifax Medical College / Dalhousie, 1890-1920

Source: Calendars of the University of Toronto, McGill University, and Dalhousie University for 1890/91,1899/1900,1904/05,1909/10,1914/15, and 1919/20.

Toronto."40 In 1892, however, Grant advanced $750 to Dr A.P. Knight for new laboratory equipment. Knight, professor of animal biology and physiology, had asked for that amount after touring Continental Europe and Britain in the summer of 1892 to determine what materials Queen's needed to bring its labs up to date.41 The sum represented three-quarters of Knight's annual professorial salary.42 Laboratory medicine was costly. Schools needed microscopes and experimental devices for physiology tests, laboratory space, and experienced instructors. In return for this investment, the traditional medical profession could boast that only its members had rigorous training in scientific investigation. Latour argues that acceptance of laboratory methods by the profession was gradual. Clinicians were suspicious of new methods that took them away from the patient's bedside. The bacteriologists' approach in attacking and preventing disease was, they thought, "too biological" and "never took the individual sick person as a unity," as the clinician did.43 Resistance was also economic. Doctors feared being shut out of the new medicine, one that used vaccinations to prevent disease, thereby robbing them of potential patients. As Latour says, "The conflict between health and wealth became for each physician a matter of how to earn a living

18

Ripe for Change

while treating people ... with such problems the physician could have nothing more than a polite but distant interest in the acrobatics of microbes in laboratories."44 One factor that finally won them over was that scientization would narrow competition, shutting out charlatans and lengthening the medical course: "By extending the period of medical study, the sciences would limit the number of colleagues."45 Money pressed private medical schools to affiliate with universities. Throughout the nineteenth century, governments in Canada funded post-secondary education in the arts46 but saw professional training as separate. Medical schools derived income almost exclusively from student fees. Unfortunately the advent of the research ideal and laboratory medicine was forcing up the cost of laboratory equipment and facilities. It had been considerably cheaper to lecture to an entire class than to equip laboratories, which explains in part why the early proprietary efforts fared quite well earlier in the century. None the less, the proprietary schools launched a successful initiative in the i88os towards "extending the range of clinical instruction, in adding laboratory work in physiology and pathology, and in seeing that all students received more practical instruction in basic and surgical anatomy."47 By Gidney and Millar's account, in the i88os the Toronto School of Medicine and Trinity Medical College had combined annual revenues of about $40,000 from fees from more than five hundred students. In turn, the Toronto School's courses grew to include botany, chemistry, normal histology, medical psychology, pathology, toxicology, and zoology.48 When enterprising physician educators such as Rolph of the Toronto School and Walter Bayne Geikie of Trinity modernized their facilities in the i88os, they faced a formidable challenge. Toronto, unlike Montreal, still had more than one medical school. Ultimately, the story in Toronto had one clear winner. Although Trinity had operated, since 1853, solely as a privately funded medical school, by the i88os Geikie could see that the same was not true of the Toronto School of Medicine. When the latter became a professional faculty of the University of Toronto in 1887, it appealed to the province for aid to this new addition to the provincial university. Soon the faculty obtained the newest building on campus - the new biology building, erected in 1888 and expanded in 1890. This facility included dissection rooms.49 Geikie's cries of favouritism fell on deaf ears at the legislature. Although Trinity Medical College avoided federation until 1903/1904, its fate was sealed. The city's last independent medical school could not compete with the more modern, better-funded and

Medical Education in Flux

19

-equipped, provincially supported medical faculty. Dependent on fees, Trinity would have priced itself out of the medical education marketplace to keep its training methods and facilities up to date. When the university absorbed it, an era in medical education ended. As McKillop comments, Geikie was not "an anachronistic old curmudgeon intent on holding onto his personal academic fiefdom" but a "self-imposed champion of the older, humanistic notion of the medical 'arts.'"50 Geikie was lost in the new age of the research ideal. He saw the biological sciences as complementary to medicine, but not as fundamental to its teaching. By 1887, the province disagreed and showed its support for research by offering money for new facilities to encourage research and laboratory teaching. Hence, McKillop notes, "the proprietary schools met their fate not because they had failed but because they were seen to represent a different kind of medicine and medicine man."51 The Toronto situation was somewhat unusual, since Trinity Medical College survived without full affiliation with the university until 1903/04. This was almost twenty-five years after the research ideal began to gain momentum. Halifax Medical College, incorporated in 1875, was reabsorbed into Dalhousie University in i885-52 Halifax Medical College reopened as a proprietary school in 1887, and, even though students took some pre-medical science courses at Dalhousie, the college remained the site of medical education until 1911. This was the case even though its facilities were far below standard and the research ideal found a poor home in crowded, poorly lit, dank quarters. In becoming Dalhousie's medical faculty, medical education finally stood a chance of thriving in Halifax, especially since it would be the only Canadian medical school east of McGill until Memorial University opened its medical faculty in 1969 in St John's. Although affiliation with a university seemed the solution, funding research remained a challenge. Medicine at McGill, for example, enjoyed the longest association as a professional faculty of a university. Unlike Toronto, it had minimal competition. McGill also had on staff one of the most respected instructors - Osier - at a time when medical teaching was changing. Among Osier's legion of admirers was Frederick Taylor Gates, philanthropic adviser to John D. Rockefeller. It has become legend that Gates, after reading Osier's 1892 text, The Principles and Practice of Medicine, persuaded Rockefeller to focus millions on improving medical education for the benefit of humankind. As Hanaway and Cruess describe it, Osier wanted a properly equipped laboratory, where students could "learn by doing" after he saw this in practice at Harvard in

20

Ripe for Change

the mid-iSyos. Symbolically, McGill refitted a lecture room as the first physiology laboratory in Quebec: "In addition to the special table, benches, sinks, and the eleven microscopes, there were microtomes, warming stages, hemocytometers and hemochronometers, a spectroscope, a kymograph, batteries, induction apparatus, animal head and body holders ..."53 Unfortunately, Hanaway and Cruess do not mention how McGill funded this transformation. In moving towards the research ideal, however, traditional medicine was distancing itself quickly from the "irregulars" and setting up a niche in medical training that would be difficult for the sectarians to fund and follow. As early as 1879, lecture hours at McGill decreased as laboratory time increased. This also created a new role for research-oriented junior scholars as laboratory demonstrators. Hanaway and Cruess attribute Montreal's improvement of medical education to the enthusiasm of McGill's medical faculty. In turn, the public responded to the exciting changes with financial support. These changes included the growing body of work going on in laboratories to combat tuberculosis, tetanus, and diphtheria. The public could now see "that medicine had a future in the university setting"54 and began to support medical education in earnest. Lord Strathcona gave $50,000 to McGill's medical faculty in 1882; the faculty matched this figure in 1883, and the public and medical alumni established a solid foundation of support that set the tone for the needs of the school in 1919. Hanaway and Cruess state, "The high standards Abraham Flexner found on his visit to Montreal in 1909 were the direct result of the scientific reorientation which had started in the 18705."55 A large part of this success involved McGill's ability to finance the shift towards the scientific or research ideal. Unlike the situation that Flexner would find at Queen's in 1909, McGill's scientization was aptly and ably funded. This would play out in 1920 when the Foundation chose McGill and Toronto as "peaks to be made higher"56 and excluded Queen's from receiving any part of the $5-million gift, despite the pleas of its faculty. THE LABORATORY

REVOLUTION

AND THE FULL-TIME SYSTEM

If the research ideal as applied to the pre-clinical sciences was the first major pedagogical change in modern medical education, then the "full-time system" of clinical teaching was the second. As revolutionary as turning lecture rooms into laboratories seemed in the 18705

Medical Education in Flux

21

and i88os, so did employing only full-time instructors in the 19105 and 19205. Full-time clinical education was a natural outgrowth of the scientization of medicine. Full-time instructors of the pre-medical subjects such as biology, chemistry, and physics were already in place in the latter half of the nineteenth century. For example, John William Dawson taught zoology and botany to McGill University medical students as well as serving as principal from 1855 to 1893. Dawson advocated the laboratory's use as a teaching tool, as did Robert Palmer Howard, McGill's professor of medicine 1860-89 and dean of the medical school 1882-89. Howard graduated from McGill medicine in 1848 and travelled to Europe to further his education. He was revered by his student Osier and was instrumental in hiring Osier on the latter's return from studying in London, Berlin, and Vienna. This is just another example of how so many of the men who helped scientize the curriculum had learned from their studies in Europe. From the mid-iSyos to the mid-i88os, during what Hanaway and Cruess call a period of "progress and enlightenment," all four men hired to teach at McGill had spent considerable time studying in Europe. In addition to Osier, there were Gilbert Prout Gird wood, professor first of practical chemistry (1872) and then of chemistry, who had studied in London; Francis Duller, lecturer (from 1877) and then chair of ophthalmology and otology (from 1883), who followed three years in Germany with four in London; and Francis John Shephard, first demonstrator of anatomy (1875-83) and then chair of anatomy (from 1883) who studied in Europe and then returned to McGill with innovative teaching methods, including full, systematic dissection of cadavers, laboratory examinations, and a growing emphasis on the relations of anatomy to physiological and biochemical sciences.57 Laboratory work in the second tier of medically related sciences such as anatomy, histology, pathology, and physiology, began to appear in U.S. and Canadian schools. Flexner lamented, "An utterly mistaken notion prevails as to the extent to which animal experimentation is practised in this country [the United States]. Only a very small minority of our medical schools use animals at all; as a matter of fact, ordinary medical teaching suffers seriously from the failure to employ them."58 Flexner held up the laboratory, particularly for physiology, as "of immense educational importance to the prospective physician. Physiology is, in a sense, the central discipline of the medical school." He added that "the best schools" devote some 450 hours of instruction to physiology.59

22

Ripe for Change

Reform of physiology teaching has a long history on which many scholars have commented, among them Mazumdar, Kremer, and Warner. Mazumdar argues that the physiology taught in earlynineteenth-century London took two forms: one, as part of clinical surgery, taught by hospital surgeons, based on "the holistic physiology of sympathy," and the other, as taught by surgeonanatomists, as a way to justify and outline the anatomy being demonstrated. As Mazumdar succinctly states, "In the hospital, it explained the condition of the patient; in the school, the anatomy of the cadaver."60 From 1825 to 1835, the tradition of anatomical physiology began to fade away, partly, Mazumdar argues, because of the establishment of the University of London. The new university competed for students with the anatomy schools run by surgeon-anatomists and won. Soon standards rose, new subjects came in, and local physiology instructors without formal university training disappeared. The medical profession began to experience a rise in status even as private anatomy schools began to close their doors.61 There are parallels to the proprietary schools in Toronto and Halifax, which eased only with university affiliation. Kremer, in discussing the building of the first physiology institutes in Prussia, from 1836 to 1846, offers another model for the teaching of physiology. Long before the establishment of Ludwig's institute in 1869, physiology was an independent subject, though still related to anatomy. In Prussia, studies of all forms of physiology, including chemical, physical, and anatomical/microscopical methods, took place within a framework of teaching practical skills to medical students.62 Unlike the anatomy schools that Mazumdar evaluates, Kremer says that the Prussian institutes faced little real competition from university laboratories in teaching physiology. They found their niche and offered entrepreneurial faculty members the opportunity to pursue research, which university laboratories did not.63 They succeeded, Kremer argues, because medical faculties supported the idea of independent institutes and already, by 1843, recognized a need for physiological research using experiment and observation. In fact, many Prussian anatomist/physiologists were supplementing their lectures with experiments and visual materials by the i84os.64 Warner acknowledges the effect that "the intellectual excitement of the experience" of studying in Germany had on visiting American students. They formed allegiances to German laboratory methods, which they transported home, along with the idea that

Medical Education in Flux

23

the laboratory replaced "speculation with fact, impressions with exact method, superstition with positive knowledge."65 Warner cites the "mystification" of medical knowledge as a necessary element in changing the American attitude towards knowledge and towards the medical profession in general. Medical knowledge became special, which set it apart from that of the lay community. Gone was the Thomsonian ideal that medical principles should be simple enough for anyone to understand. This shift brought with it a rise in status for the profession, with corresponding pecuniary rewards and an increase in authority and clinical power. The United States was ready, Warner argues, for the reforms advocated by Flexner.66 Warner says elsewhere that, as physiology matured in the 19005, professors teaching it to medical students related it less to clinical application. Their own research reflected growing specialization, and "two cultures emerged within the field, and within medicine generally: the scientific and the clinical." Hence, physiology underwent what Warner calls a change in status from an important subject in the medical curriculum to the "epitome of medical science," the subject among all the basic medical sciences relevant to the training of physicians.67 Armed with German training, the reform-minded educators knew diseases from the laboratory, not from case histories. U.S. and Canadian physicians had substantial exposure to German laboratory research methods. Hudson states that 15,000 American students travelled to Germany and Austria to study between 1870 and 1914. They benefited from the early work of Virchow, who set up the first pathological institute in Berlin in 1856 and the study of bacteriology later.68 With the introduction of laboratory science to medicine in much of the world came the challenge of maintaining scientific rigour - a tool first in diagnostics and then in clinical research and a way to further professionalism. The lab introduced the ideas of replication and peer evaluation. Scientific truth was attainable, but only after replication of results to the satisfaction of the professional community at large. As Latour notes, physicians accepted the scientization of medicine or risked staying behind, with no more professional respect than the charlatans and quacks whom they wished to eradicate. The benefits of bacteriology and laboratory medicine may have seemed anathema to physicians at first - treating microbes made no use of their marketable skills as clinicians, they believed. Beginning in the 18905, as one practitioner noted, "This physician is ready to admire science only in order to crush the charlatans ... At the cost of a little labora-

24

Ripe for Change

tory equipment, they gained the means of diagnosing and treating diphtheria, a terrible childhood disease."69 Berliner credits Ludwig's physiology lab in Leipzig with inspiring the full-time plan and Franklin P. Mall, an American anatomist, with importing it to North America. Mall spent a year with Ludwig in the mid-i88os. When he returned to the United States, he became professor of anatomy, first at the University of Chicago and then at Johns Hopkins University. Rothstein writes that German medical research took place in government-supported institutes. Although informal training may have occurred, the professors and researchers in these European institutes did not hold faculty appointments and had no formal teaching duties.70 Gates, chief adviser to John D. Rockefeller and a member of his General Education Board, saw merit in a full-time clinical faculty and soon was looking for a place to start one. The Rockefeller Institute opened in New York City in 1901. Berliner notes that its charter required the full-time plan: "No person on the salaried staff of the Institute should receive pay for any outside practice, that the Institute should itself send no bills for service to any patients within or without its walls, or accept any remuneration; The penalty for violation of these provisions by the Institute was the forfeiture of the endowment given by Mr. Rockefeller."71 Gates's first application of the ideal originated with a hospital for the Rockefeller Institute. The hospital, which opened in 1910, was the first American institution to apply the full-time clinical system, while Johns Hopkins became the first medical school to do so in 1913. Hudson says that the 15,000 Americans studying in Germany and Austria had three effects. First, it elevated the research ideal. Second, it promoted specialization - as knowledge grew exponentially, students could attempt research problems only of a particular body system and not of general problems. Third, it focused attention on Johns Hopkins, which started full-time clinical teaching, making it the benchmark.72 Eventually, most U.S. and Canadian medical schools would turn to full time in one form or another. The question of when often depended on money. Full-time clinicians, like scientization, would be costly as well as necessary. In Canada, competition existed for personnel as it did in the push for well-equipped laboratories. The only difference lay perhaps in scope: in the i88os, there was still some inter-city competition among remaining proprietary schools. Of course, competition from American schools existed then, but by 1910 it was even stronger. Flexner's 1910 evaluation of all 155 medical schools in Canada and the United States only enhanced the reputation of Johns Hopkins as the ideal

Table 1.2 Income from fees and teaching ratios at Toronto, McGill, and Halifax Medical College, 1909

Institution University of Toronto Faculty of Medicine McGill Faculty of Medicine Halifax Medical College (Dalhousie University)

Annual income from fees ($)

No. of students

No. of professors

No. of other instructors

Student fees per student

Professor -student ratio

All instructors and professorsstudent ratio

64,500 43,750 5,000

592 328 63

27 19 16

41 80 17

$108.95 $133.38 $79.36

1:22 1:17

1:9 1:3 1:2

1:4

Source: Flexner, Medical Education (1910), 320-1. Notes: The smallest medical, and the least expensive to attend, was Halifax Medical College. It was also the most poorly equipped in everything but its teaching staff. Though it is significantly smaller in enrolment and in fees-based operating budget, its overall instructor-student ratio was closer to McGill's. Larger classes at Toronto raised the student-teacher ratio there to triple McGill's. In professor-student ratio, Halifax was highest, at 1:4, with the other two schools much lower. Enrolment was a crucial factor. Toronto had close to 600 students, almost twice as many as McGill. As the provincial university, it perhaps felt obliged to serve Ontarians. Standards were higher at McGill: many American students attending McGill planned to write U.S. licensing examinations. Flexner notes that additional operating income differed radically for these medical schools. While Toronto's received an undisclosed amount "from general university funds," McGill's obtained a share of general university funds and had a sizeable endowment of $350,000, and Halifax Medical College had a provincial grant of $1,200 per year.

Ripe for Change

26

Table 1.3 Selected U.S. and Canadian medical schools, ranked by average fees, 1909

Rank

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Institution

Harvard, Massachusetts College of Physicians and Surgeons (Columbia), New York Johns Hopkins, Baltimore University of Pennsylvania University and Bellevue Hospital Medical College, New York Jefferson Medical College, Pennsylvania Northwestern University, Illinois Rush Medical College, University of Chicago American School of Osteopathy, Missouri College of Physicians and Surgeons, Illinois Tulane University of Louisiana McGill University University of Louisville, Kentucky University of Toronto Halifax Medical College, Dalhousie University

Total annual fees ($)

Average student fees ($)

Student enrolment

253

285

72,037

242 204 192

312 297 546

75,500 60,542 104,612

186 174 171

408 591 522

76,115 102,995 89,076

169

488 560

82,452 89,600

155 est. 154 133 125 109

517 439 328 600 592

80,155 67,500 43,750 75,125 64,500

79

63

5,000

160 est.

Source: Flexner, Medical Education (1910), Appendix, 329-35. Notes: While Toronto ranked second only to Louisville in enrolment, it had total annual fees of $64,500, ranking twelfth, ahead of only Johns Hopkins, McGill, and Halifax/Dalhousie. As Flexner does not itemize any operating grants or gifts, I use fees as a baseline for comparison. An education at Johns Hopkins cost twice as much as one at Toronto, and almost 50 per cent more than one at McGill. Halifax Medical College looks to be an anomaly here. I have included it to show that and to emphasize how unusual its rescue was. If not for its relative geographical isolation, it probably would have closed.

institution. Flexner visited eight medical schools in Canada in this order: Laval University Medical Department (Montreal); McGill University Medical Faculty; University of Toronto Faculty of Medicine/Manitoba Medical College; Halifax Medical College; Laval University Medical Department (Quebec City); Medical Department of Queen's University; and Western University Medical Department. Toronto had the most students (592), with McGill a distant second (328) and Halifax Medical College last (63) - see Table 1.2. Although Toronto led in number of professors (twenty-seven, to McGill's nine-

Medical Education in Flux

2

7

teen and Halifax's sixteen), McGill was far and away the leader in "other instructors" or part-time teachers, with eighty to Toronto's forty-one and Halifax's seventeen. In an Appendix, Flexner offers a summary of these details in chart form for all the Canadian and U.S. schools. Toronto had the second largest enrolment of all the medical schools; only the University of Louisville's Medical Department had more students, with six hundred - see Table 1.3. That department also employed forty professors and fifty "other instructors." McGill ranked eighteenth in student enrolment.73 Administrators of Canadian medical school were aware of American competition - for students as well as for instructors - and for operating dollars to supplement student fees. Since the Rockefeller philanthropies did not hide their bias towards full time, schools wishing to receive their money would have to employ that system. Canada watched with interest the U.S. debates over the pedagogical pros and cons of full time.74 Although supporters argued that clinical instruction would benefit from a full-time faculty's devotion to teaching and university-based research, opponents, including Osier, said that a physician with no private practice "would lose touch with the real practice of medicine and be a poor example for medical students."75 But how to fund the full-time system in Canada? Historically, the medical schools had employed a core of full-time instructors, particularly in the pre-medical sciences, but those who offered their professional expertise part time, particularly in clinical medicine, received only a small stipend. They did not do it for the money - they had private practices, some of which were lucrative indeed. They sought the prestige of university affiliation and hospital admitting privileges. These part-time, or "other instructors" (Flexner's term) far outnumbered full-timers, particularly in Montreal. On the financial side, Brown argues that student fees were the first source of funding for pedagogical change in the United States. In 1910, only 19 per cent of all medical school fees were more than $150 a year; by 1925, 85 per cent charged more. But the market's desire to pay set a limit. The schools could not increase their fees beyond students' willingness to pay them.76 To supplement fees, schools became dependent on philanthropic endowments. By 1927, endowments became the second-largest source of support, behind student fees, and represented the difference, as Brown says, "between making it as a class A school or not making it at all."77 It was now necessary to be a solid, scientific school because students were seeking a 'scientific medical education,' to get the requisite medical training to pass the

Table 1.4 Presidents and deans of medicine at Toronto, McGill, and Dalhousie University of Toronto President

Dean

John McCaul* (1848-53)

McGill University Principal

Dalhousie University Dean

President

Dean

James Ross (1863-85)

A.P. Reid (1867-75)

J.W. Dawson (1855-93)

George W. Campbell (1870s) Sir Daniel Wilson (1880-92)

W.T Aikins (1887-93)

Robert Palmer Howard (1882-89)

James Loudon (1892-1906)

Uzziel Ogden (1893-96)

Robert Craik (1889-1902)

R.A. Reeve (1896-1908) Sir Robert Falconer (1907-32)

William Peterson (1895-1919)

C.K. Clarke (1908-21)

Rufus S. Black (1875-?)+ John Forrest (1885-1911)

Thomas Roddick (1901-08) Francis Shepherd (1909-14)

Alexander Primrose (1921-32)

Auckland Geddes (1919-1920)

H.S. Birkett (1914-21)+.

J.G. Fitzgerald (1932-36)

Sir Arthur Currie (1920-33)

Charles F. Martin (1923-36)

A. Stanley MacKenzie (1911-31)

The province renamed King's College the University of Toronto in 1850 and made it a non-denominational institution. tThe College's turbulent period; in 1911, Dalhousie reabsorbed it as its medical faculty, t A.D. Blackader was acting dean, 1915-18.

Colonel John Stewart (1919-32) H.G. Grant (1932-54)

Medical Education in Flux

29

licensing examinations. Though more expensive, it was the only method of teaching for the future. Canadian medical education differed in many ways from its U.S. counterpart, yet there were few barriers to Canadian graduates seeking U.S. post-graduate training or practice. Some Canadian university presidents and medical school deans (see Table 1.4) saw this as a virtual epidemic. As American medical colleges strengthened their faculties and new colleges opened, they were luring Canadian graduates to permanent positions. The First World War slowed but did not stop this phenomenon, and the exodus of many bright young Canadian physicians spurred full-time professorial appointments at Canadian medical schools. There were two goals in advocating full-time teaching. One was to strengthen the basic sciences - physiology and later bacteriology and biochemistry - the foundation for the first years of medical school. For medical graduates who excelled in lab research, there was little incentive to abandon a medical practice, with its prestige and seemingly unlimited income, for a fixed income as a professor with little time to practise. The other goal was to initiate full-time clinical teaching. Although the full-time system had its supporters early in the century, it took twenty years to become standard. Of course, war helped delay implementation. So did lack of money, both for top-notch facilities and equipment and for professorial salaries. Prescient medical educators and administrators realized that schools keen to be among the best in medical education would have to increase not only entrance requirements and standards of education, but also the quality and quantity of lab facilities and equipment and of teaching staff - from basic medical sciences to clinical teaching. These additions would later extend to post-graduate and doctoral studies for Canadian physicians interested in teaching and research. It was funding that set the pace for the reforms. As Ludmerer said, "few schools had the capital resources to implement their ideals adequately."78 For many people, it probably seemed as though progress had reached a plateau, given the equipment and knowledge base of the day. Perhaps this explains the views of American cardiovascular researcher Carl J. Wiggers. Wiggers trained as a physician at the University of Michigan and spent from 1918 to 1953 teaching physiology at Western Reserve University in Cleveland, Ohio. In 1960, he wrote: "When in 1903,1 began to look for a research problem in the field of circulation, I could not cull from the literature any significant problem that either remained unsolved or seemed solvable

30

Ripe for Change

by available tools; the cream seemed to have been skimmed off in the nineteenth century."79 Strengthening basic sciences and initiating full-time clinical teaching were expensive goals, particularly for Canadian medical schools. The Rockefeller Foundation announcement of 1919 came at just the right time.

2

Rockefeller Aid: Which "Peaks to Make Higher"? Philanthropy is a serious and difficult business. The Rockefeller Foundation is not a general philanthropic agency. It tries to attack problems which are fundamental and important; it tries to be patient and persistent, realizing that long-term results are usually more significant than immediate ones; it tries to avoid contributions that merely replace other support. Partly because the world itself changes and partly because the Foundation has learned something through long experience, the Foundation program has changed during the years. In the first decade the Foundation made many large contributions for building and endowment; in the last two decades contributions have usually been made for current support. In the early years, Foundation programs covered rather broad fields; latterly, the Foundation has shown an increasing tendency to concentrate. As Mr. Rockefeller, Junior once said, 'you can't split a boulder unless you keep hammering on one line.'1 The story of the Rockefeller Foundation's involvement in U.S. and Canadian medical education has been the subject of publications, of varying degrees of depth and from different perspectives, by past presidents and board members of the Foundation2 and by historians3. One of the favourite areas of support was medical research and medical education, at first only in the United States. These endeavours have been well-documented. The millions given to American medical colleges between 1914 and 1960, via the Rockefeller General Education Board, included: Vanderbilt University (in Nashville, Tennessee), $17.5 million; University of Chicago, $14.5 million; Johns Hopkins University, $11.1 million; Meharry University (in Tennessee), $8.7 million; Cornell University (in Ithaca, New York), $8.2 million; Washington University at St Louis, $7.3 million; Yale University, $6.9 million; the University of Rochester, $5.8 million; and Tulane University (in New Orleans), $3.4 million. The entire amount pledged to all of

32

Rockefeller Aid

Canada via the Rockefeller Foundation totalled less than the amount that it gave to Rochester's medical school and represented just 6 per cent of the $83.3 million total for the above-listed nine colleges; yet its effect was significant.4 How did Rockefeller become a major benefactor of medical education in Canada? This chapter looks at the Rockefeller Foundation's growing interest and connections in Canada, its selection of Canadian medical schools to assist, and the influence of its gift. The Rockefeller Foundation received its charter under the laws of the state of New York on 14 May 1913, and John D. Rockefeller, Jr, served as first president. It was the third organization set up by John D. Rockefeller, Sr, following the Rockefeller Institute for Medical Research (i9Oi)5 and the General Education Board (1903). The mandate of the Foundation was general: "to promote the well-being of mankind throughout the world," and during its first years it distributed more than $232 million6 to organizations and causes around the world, particularly as financial aid to those suffering as a consequence of the Great War. As Foundation President George Vincent wrote to the trustees in 1924, "As was natural at the outset before Foundation policy had taken form, many miscellaneous gifts were made for objects admirable in themselves but falling outside the fields in which work is now being carried on. During the critical years 1914 to 1918 the Foundation responded to the demands of the situation. "7 But this meant that John D. Rockefeller, Jr's, "boulder" would never be split because the Foundation was hammering all over the rock (as noted in this chapter's opening paragraph), not along any particular line. The end of the war and the appointment of Vincent as president - he succeeded John D., Jr - marked a turn towards setting that line. Central to the analysis is an evaluation of the evolution of projects supported by the Rockefeller Foundation and the philosophy behind and personal ties between Foundation officers and influential Canadian educators and politicians that precipitated the gift to select medical schools in Canada.8 Medical education, in embracing basic science and the laboratory, had become a far more expensive endeavour. As Ludmerer says, "the financial requirements of modern medical training had become awesome."9 Fortunately, the means to aid medical education existed, particularly via philanthropy: in 1914, there were 4,500 millionaires in the United States, and by 1926, n,ooo.10 Major philanthropic gifts swept educational ideals into a new era. Although there was not the same need or desire to "organize modern medical schools across the land" in Canada as there was in the United States, the effect of the major benefactions was significant.11

Which "Peaks to Make Higher"?

33

Although Abraham Flexner often receives credit for creating full-time medical education, Ludmerer disagrees: "The full-time system in clinical departments arose because clinical science had become a true scientific activity, not because anyone had arbitrarily decreed that such a system should exist."12 Ludmerer explains the challenges of implementing the system. People who supported full-time study had to overcome not only the status quo upheld by conservative groups in the profession but also the tension among faculty members within the universities. The full-time clinical faculty instructor was to earn $10,000 per year - "twice as much as full professors in the basic science departments were making, but considerably less than the $25,000 or $30,000 the top consultants in practice were earning."13 Berliner examines the shift from individual philanthropic gifts to organized foundation-based giving and also philanthropy's role in reforming U.S. medical education. He finds philanthropic foundations, including the Rockefeller Foundation, the General Education Board, and the Carnegie Foundation responsible for major reforms in medical education and research carried out about 1900.l8 Brown offers a more self-serving motive for the generosity. He argues that the full-time system was a way for corporate philanthropy to gain control over medical education and medical care. The goal was to set up a system wherein society's needs, defined by the corporate class, would triumph over the medical profession's interests; in turn, this would be the first large-scale attempt to rationalize American medical care.15 I agree that full time had a powerful effect in Canadian medical schools as well, particularly in changing the teaching of medicine and attitudes towards the teaching of clinical medicine. For example, the system began at the University of Toronto as 'geographic full time/ allowing for some time each day for private consultation. "Geographic full time," by definition, was more flexible than "full time." This "Harvard Plan," allowed full-time clinical professors to keep a small percentage of their time for independent consultations.16 Furthermore, Graham, the new full-time chair of medicine, instituted an organizational system that anticipated future needs, with junior researchers progressing up a departmental hierarchy and receiving pay as they trained. This raised the status of clinical researchers and gave them more time to train and perfect their skills before moving on to positions at other teaching facilities. Unlike Johns Hopkins, which found it difficult to recruit and keep a successful physician as a full-time clinical instructor, Toronto's first choice was not a clinician but a young bacteriologist, who kept the position for twenty-eight years. As a non-clinical, medical scientist, Graham did not mind

34

Rockefeller Aid

earning $10,000 per year and did not have to give up two to three times that amount in patients' fees to take up the position. Although philanthropy applied to medical education existed before the First World War, not all schools were as fortunate as Harvard University, which had benefactors such as J.P. Morgan and Arabella Huntington, who gave $1,135,000 and $250,000, respectively.17 Harvard Medical School ran two successful fund-raising drives for its medical school, in 1874 and 1901, long before the Rockefeller Foundation existed - a fact that dispels the myth that large-scale philanthropy began only after I9i8.18 Historians such as Ludmerer acknowledge Flexner's role in expressing the state of medical education in the United States and Canada and in pushing the full-time system as the ideal. Most scholars, however, no longer agree that educational reform began with Flexner's report or that full time was his idea. The move towards fulltime clinical faculty began, Atwater notes, with a decrease in the number of schools (down from a high of 162 in the United States in 1906 to less than one hundred in 1920), an increase in the per-student income of medical schools, the introduction of the clinical clerkship, and better educational preparation for entrants to medical school. "The proposed changes did, in fact, come. In part they were the results of forces already in motion when Flexner appeared on the scene."19 Flexner and his financial backers helped accelerate the reform, and I believe that Flexner himself was a product of the very changes that he advocated. I would argue that, even though the Foundation's large-scale investment lasted only five years and $5 million was a small amount in its overall scheme of giving, it was a large sum relative to Canadian funding, public and private, and to medical school expenditures. Each U.S. $1 million in 1920 is worth approximately $9 million today.20 Furthermore, the influence and lessons learned in Canada from initiatives encouraged by the Foundation, such as the push for full-time clinical teaching, helped reshape the teaching of medicine. The Rockefeller Foundation continued to invest in other medical projects in Canada, on a more regional and project-specific basis. Efforts after 1925 concentrated on public health initiatives, a full-time school of nursing associated with the University of Toronto, the Montreal Neurological Institute at University, and individual fellowships to Canadian researchers. After thirty years with the Rockefeller Foundation, Alan Gregg, director of the Medical Sciences Division of the Foundation, hailed McGill's Neurological Institute as the ideal recipient. "If I was asked to name a single grant that the Medical Sciences Division of the Foundation has made since 1931, that I consider ideal

Which "Peaks to Make Higher"?

35

in purpose, in performance, in local response and in national and international influence ... I would say without a moment's hesitation the grant to the Neurological Institute of McGill University."21 Full-time clinical education was a major goal from the start, for example, in Toronto. In practice, it meant a sort of hybrid. This "geographic full-time" was still more full time than the previous system of many part-time appointments, which bestowed annual honoraria ranging from $50 to $1,000 on physicians who worked mostly in private practice. These honoraria ended in 1920, and clinical medicine went under a single chair of clinical medicine, Duncan Graham. He received an annual salary of $10,000 to oversee the Department of Medicine and had to devote full days, or eight hours each day, to clinical teaching and administration. He had the equivalent of two hours per day for private consultation, hence he was not entirely "full time." THE ROCKEFELLER FOUNDATION AND CANADA

The idea of giving to a church, a charity, or an individual less fortunate is by no means a new notion. During the nineteenth century, however, there was a select group of U.S. individuals whose wealth grew so quickly, and who believed so strongly in sharing that wealth, that the idea of systematic or "scientific' giving emerged. Two of the earliest foundations established in the United States were the Peabody Fund (1869) and the John F. Slater Fund (1882), both set up to educate African Americans. As Zurcher notes, philanthropic foundations are largely a twentieth-century phenomenon in the United States and Canada. He argues that the proliferation of U.S. charitable foundations resulted from four factors: the creation of great fortunes; generous tax exemptions for donations; the maturing of the American economy; and a continuing tradition of voluntarism.22 It was only after the Civil War that being a millionaire justified the notion of a businessman as wealthy as Rockefeller hiring a full-time administrator such as Gates to evaluate how best to spread his wealth. Zurcher defines the years from about 1900 to the mid-i93os as the "heroic period of American foundations,"23 a time when the philanthropists were at their most creative in giving, and he credits Rockefeller with, among other things, revolutionizing medical education.24 At the same time, Andrew Carnegie sought to use his millions to benefit humankind, but there was a tension between setting restrictions that foundation administrators had to follow and leaving the guidelines for spending open-ended. This was the difference, as Hall

36

Rockefeller Aid

notes, between "retail giving" and "wholesale philanthropy" wholesale philanthropy had professionals, such as Gates, whose job it was to decide how best to administer millions of dollars. Hall points out that Carnegie and Rockefeller began their philanthropic giving by "parceling out their fortunes" - to specific types of institutions, such as churches, libraries, and universities. Carnegie, for example, gave libraries and organs for churches to countless U.S. and Canadian cities, including Toronto.25 By relinquishing the burden of assessing each individual request, yet retaining some say and influence on a plan of giving, Rockefeller learned from Carnegie and his predecessors in philanthropy and expanded the scope of giving. We can define a foundation as a "nongovernmental, nonprofit organization, having a principal fund of its own, managed by its own trustees or directors, and established to maintain or aid social, educational, charitable, religious or other activities serving the common welfare."26 The Russell Sage Foundation, established in 1907, had an endowment of $15 million, and the Carnegie Corporation of New York was set up in 1911. But being first was not the issue for Rockefeller - being efficient in benefiting humankind was his goal. By 1913, he wanted to broaden the geographical scope of his giving outside the United States and found that American laws would not allow that within the charters of existing organizations. Although there is a growing body of scholarly study on philanthropy, most of it deals with American donors and recipients.27 There is little on Canadian groups or institutions receiving major gifts or establishing foundations. The sheer magnitude of Rockefeller money dedicated to philanthropy is staggering. In the first five years of the Foundation's existence, Rockefeller gave $182 million.28 By December 1919, he had donated another $50 million to the Foundation. Hence, although the "best" Canadian medical schools shared a substantial sum of $5 million, this was just a fraction of the $232 million that Rockefeller gave to the Foundation between 1913 and 1919. In his 1952 history of the Foundation, Raymond Fosdick gives the following figures, "at the market price of the day on which each was made," for Rockefeller's gifts: Foundation, $182,851,480.90; General Education Board, $129,209,167.10; Laura Spelman Rockefeller Memorial (established in his wife's memory in 1918), $73,985,313.77; and Rockefeller Institute for Medical Research, $6o,673,4O945.29 By 1940, the Foundation had an endowment value of $145,068,365.56. By the end of 1940, it had paid out that year more than $8.5 million in grants and was as the top-ranked U.S. foundation, representing more than 21 per cent of grants reported for that year - more than double those of the

Which "Peaks to Make Higher"?

37

General Education Board and even of the Carnegie Corporation of New York.3° The Foundation's charter facilitated, and influential Rockefeller friends encouraged, extension of support to improve medical education in Canada. Rockefeller was also touched by Canadian losses in the war that had just ended. On 18 December 1919, Rockefeller Sr wrote to the Foundation: "My attention has been called to the needs of some of the medical schools in Canada, but as the activities of the General Education Board are by its charter limited to the United States, I understand that gift may not be used for Canadian schools. The Canadian people are our near neighbors. They are closely bound to us by ties of race, language and international friendship; and they have without stint sacrificed themselves, their youth and their resources, to the end that democracy might be saved and extended. For these reasons, if your Board should see fit to use any part of this new gift in promoting medical education in Canada, such action would meet with my cordial approval."31 Who brought Canadian needs to his attention? His family had myriad ties with a number of influential Canadians, as well as to the country itself. Many of the Canadian connections assisted in deciding which medical schools were to receive funds. The first mention that I have found of general financial assistance for Canadian education was from Rockefeller friend Dr C.A. Eaton. A summary of applications for Foundation aid from colleges outside the jurisdiction of the General Education Board noted that "special consideration was given in 1917 to an application from a group of twelve educational institutions in western Canada, the foundations of which had been so weakened by the war that several of the colleges seemed likely to collapse. ... The matter was first brought to the attention of Mr. Rockefeller, Jr. by Dr. C.A. Eaton who had been the pastor of Mr. Rockefeller Sr. in Cleveland some years before."32 The mention did bring Canada's education system and wartime sacrifice to Rockefeller's attention. Ultimately, no aid went for this specific request: there were "questions of Provincial policy with regard to education, which, in any event, would make the Foundation hesitate to intervene," wrote Foundation President George Vincent. "It is the policy of the General Education Board and The Rockefeller Foundation carefully to avoid any action which might be interpreted as an attempt to dictate or unduly influence public educational policies." The Cleveland connection goes back to the mid-nineteenth century. The Rockefellers moved there in 1853, when Rockefeller was fourteen years old, and the city gained from his philanthropic giving as early

38

Rockefeller Aid

as i856.33 The Erie Street Baptist Church, which was renamed Euclid Avenue Baptist Church, also received Rockefeller support. Eaton's Cleveland ties go deeper - Rev. Dr Charles Aubrey Eaton, pastor at Euclid Avenue, was uncle to financier Cyrus S. Eaton of Pugwash fame. In fact, Cyrus Eaton, who was born in Pugwash, Nova Scotia, met Rockefeller while visiting his pastor uncle in Cleveland and soon went to work for him. Rockefeller helped finance Cyrus Eaton's 1907 business venture, and years later Cyrus followed his example in supporting Dalhousie University in Halifax, Nova Scotia. The Rockefellers were also aware of another Canadian Eaton, unrelated to the Nova Scotians, as the Foundation prepared to send millions to Canadian medical schools. Timothy Eaton, founder of the Canadian retail department store empire, was, like Rockefeller, a man who believed strongly in philanthropy. A staunch Methodist, Eaton advocated tithing long before he made his millions and kept up the tradition as his wealth grew. His son, John Craig, also thought medical education and research worthy of support. Hence, in 1919, the Rockefeller Foundation noted with great interest an agreement whereby the University of Toronto medical school was to receive a half-million dollars from the T. Eaton Co. Limited - $25,000 per year for twenty years. This "Eaton Endowment" supported a fulltime chair in clinical medicine, the first such position in the Commonwealth.34 Two other well-known Canadians also encouraged Rockefeller to support Canadian medical education. The first was clinician Sir William Osier. Although Osier, dying in 1919, would never see the maturation of Canadian medical education, he lobbied early and hard for Rockefeller support. Osier himself received $15,000 over the period October 1914-26 May 1915 and served on the Foundation's War Relief Commission, headquartered in Oxford, England.35 From Oxford, Osier sent a plea to Dean General Herbert S. Birkett to maintain McGill Medical School's pre-eminence. In a letter dated 29 August 1919, Osier called for "sympathetic and active co-operation of University and Hospitals," which required more personnel and a restructuring of the reporting relationships between the school and "two of the best equipped hospitals on the Continent (Montreal General and Royal Victoria)."36 Money was necessary, and Osier suggested "an appeal to the public," while adding: "Possibly the Rockefeller Board might help, but this is a citizen's affair which should appeal to all who are anxious to see Montreal keep in first rank as a medical centre."37 Osier's position as the most celebrated clinician of his time was not his only calling card with the Foundation. He was also one of the four original staff members of Johns Hopkins Medical School, the bench-

Which "Peaks to Make Higher"?

39

mark against which people measured all other U.S. and Canadian schools.38 Abraham Flexner helped to promote Johns Hopkins as the model, and the Foundation acknowledged its prominence. Flexner, in his 1910 report, describes its laboratory facilities as "in every respect unexcelled," with the clinical facilities of the hospital and dispensary providing "practically ideal opportunities" and the medical staff and clinical faculty identically ideal.39 Osier wanted only the same status for his alma mater in Montreal. The other public figure who kept Canada in the minds of the Rockefellers and the Foundation was William Lyon Mackenzie King. King became leader of the federal Liberal Party in 1919 and Canada's longest-serving prime minister - 1921-25,1926-30, and 1935-48. The King connection, as William Spaulding observes,40 grew from King's role as adviser and ally to John D. Rockefeller, Jr, during the labour-management crisis associated with the "Ludlow Massacre" in Ludlow, Colorado, in 1914. The massacre involved the burning of a miners' camp by the state's National Guard. Many of the miners were on strike and worked for the Rockefeller-controlled Colorado Fuel and Iron Company. Sadly, two women and eleven children died while trying to hide in the day-long stand-off between the Colorado militia and the miners on 20 April 1914. After the tragedy, the fighting escalated. Rallies took place across the United States, and John D., Jr, was even "the target of unsuccessful bomb attempts."41 King met father and son on 6 June 1914 and within a week had an invitation to join their Foundation to study challenges in industrial relations. This was the beginning of a lifelong friendship between John D. Rockefeller, Jr., and King. King coached John D., Jr, through the (U.S.) Commission on Industrial Relations hearings on the Colorado mines problem42 and travelled with him to meet with the miners and seek their support for a new industrial-relations plan. With King's help, Rockefeller turned a crisis into a public-relations and business triumph. When it was all over, King remained with the Foundation in New York until 1919, when he returned to Ottawa as the leader of the Canadian federal Liberal Party. Harr and Johnson outline the success that King enjoyed while working for John D., Jr, both professionally and personally.43 In 1918, while at the Foundation, King published Industry and Humanity, which further enhanced his reputation. King also enjoyed a flourishing consulting career, counting Bethlehem Steel, General Electric, and International Harvester among his clients, and Andrew Carnegie offered him a lucrative position to head up all the Carnegie philanthropic organizations. On a personal level, John D., Jr, and his wife introduced King to an eligible single woman, "Miss X," but, despite King's advances, the romance did not lead to marriage. King's return

40

Rockefeller Aid

to Ottawa, though disheartening to Rockefeller, meant that the Foundation had an influential ally and trusted adviser in matters concerning the millions to go towards Canadian medical education beginning in 1920. The degree to which the Foundation sought King's advice emerges in the pages that follow. At the same time that Foundation executives were soliciting King's opinions, they were also consulting a cousin of the Foundation's new President. In 1917, John D. Rockefeller, Jr, stepped down as the Foundation's first president and became chair of its board. Replacing him as president on i May 1917 was the president of the University of Minnesota, George Edgar Vincent. Vincent, a renowned administrator, orator, and member of the General Education Board since 1914, was also related to the eminent Massey family of Toronto. Vincent's aunt married Chester Massey, second son of Hart Massey, who had made a fortune manufacturing farm equipment with the MasseyHarris Company. Chester was father of Hollywood actor Raymond Massey and of Vincent Massey, Canada's first native-born governor general (sovereign's representative, de facto head of state). King and Vincent Massey had political connections as well. In 1926, Massey went to Washington, DC, as first Canadian minister to the United States. And from 1930 to 1935, as King did in his period with the Rockefeller Foundation before 1914, Massey "travelled," returning only after King won the federal election in 1935 and soon offered Massey the post of high commissioner in London. It was to his first cousin Vincent Massey that the president of the Rockefeller Foundation would turn for trusted advice on how best to disperse funds. This advice went both ways. In her biography of the Massey family, Gillen tells how it was George E. Vincent who advised Vincent Massey in 1918 to set up the Massey Foundation to avoid "undiscriminating distribution of the estate's assets too rapidly." Vincent, using the Rockefeller Foundation as a model, suggested that the Masseys create a "continuing benefaction." A federal charter set up the Massey Foundation, with Chester Massey serving as chair until his death in 1926, at which time his elder son, Vincent, took over. Where the much wealthier Rockefeller Foundation concentrated on medical science and education, the Massey Foundation is best known during this period for Vincent's Hart House (opened 1919), an athletic, cultural, recreational, social, and spiritual centre for students at the University of Toronto.44 Finally, the Rockefellers were no strangers to Canada on a personal level. After their wedding ceremony in Cleveland in 1864, John D., Sr, and his bride, Laura Celestia Spelman, took a trip to Niagara Falls, Montreal, and Quebec, before returning to Cleveland via New Eng-

Which "Peaks to Make Higher"?

41

land and New York.45 The ties to King and to Canada remained strong enough for King to send John D., Jr, in 1935, a "photostat" of the register page from the St Lawrence Hall Hotel in Montreal, as signed by John Dv Sr, while on his honeymoon trip.46 CHOOSING CANADIAN 'PEAKS TO MAKE HIGHER'

The stage was ready for philanthropic dollars to flow into Canada even before 1919. Flexner's 1910 report included an analysis of all Canadian medical schools.47 As Gidney and Millar point out, the situation was not as dismal as that of the United States: "It never paralleled the excesses of the American experience, where free trade in medicine reigned more or less supreme and where the multiplication of small schools and short courses gave medical education itself a bad name."48 The impact of Flexner's report was, therefore, far less striking in Canada. Flexner wrote in his report: "In Canada conditions have never become so badly demoralized as in the United States. There the best features of English clinical teaching had never been wholly forgotten. Convalescence from a relatively mild overindulgence in commercial medical schools set in earlier and is more nearly completed."49 Among the scholars who argue that reforms were long under way are Hudson,50 Jonas,5a and Ludmerer.52 Jonas writes that reforms started in mid-nineteenth century. Not only was the report not as influential as many have claimed, he says, but the "Flexnarian" model medical school bears few similarities to what Flexner recommended.53 The Foundation announced a gift on 25 December 1919. Its press release included a quotation from John D. Rockefeller, Sr, about his "attention [having] been called to the needs of some of the medical schools in Canada" and ended with his reiteration of Canadian war sacrifices. Vincent noted, "In order to carry out Mr. Rockefeller's suggestion concerning Canadian Medical Schools, the Trustees of the Foundation will be asked by the officers to set aside approximately $5,000,000 for the improvement and development of the leading medical schools of the Dominion. From this sum appropriation will be made by the Foundation to medical schools on conditions that they raise additional funds from other sources. It is hoped that $5,000,000 ... will give a distinct impetus to the development of medical education in Canada."54 Whenever possible, Vincent and Richard M. Pearce, director of the Foundation's new Division of Medical Education, sought the advice of influential Canadians, among them Vincent Massey, King, and medical educator A.B. Macallum.55 Foundation executives knew that

42

Rockefeller Aid

interested schools had to have a plan and raise matching funds as well. As Ludmerer points out, there were willing donors for medical school reform a full generation earlier.56 Harvard Medical School received $200,000 in 1874 and $3 million in 1901. Other examples are the gifts of Donald Smith (Lord Strathcona) and Sir William MacDonald to McGill. The one difference, Ludmerer argues, is that early recipients set the agenda for reform. Donors gave passively. As the foundations grew, benefactors developed "the potential to manipulate medical schools by virtue of the criteria they used to apportion their gifts."57 This point would come back to haunt the Rockefeller Foundation and the Batons after the University of Toronto medical faculty implemented the full-time system in 1920. Vincent and Pearce often met or corresponded with confidants to check on the political and academic climate. These solicitations began almost immediately, in December 1919. Five days after announcement of the Canadian gift, George Vincent wrote Vincent Massey for "counsel and co-operation." "Before we can deal with any one medical school in Canada, we shall of course have to work out a Dominion-wide policy." Not all schools would receive the same amount - or even support at all. "Instead of distributing what funds we have available to all the medical centers in Canada, we shall try to select a few strategic institutions." Vincent explained the Foundation's general policy of asking for matching financial support. He did not specify whether Canadian schools were to raise them privately or from "governmental sources." He understood the difficulties in giving so much money in another country and yet not appearing to dictate how to teach medicine while none the less attaching conditions. "For an outside agency to come in and assume standardizing functions might well be resented," Vincent wrote. "We need, therefore, so far as possible to throw the responsibility upon a group of Canadians. What I hope you will do is to suggest a method of procedure."58 Massey replied that "the responsibility of allocating funds, must, subject to the general policy which you lay down, be delegated to a group of Canadians."59 Massey also saw this as an advantage. Not only did it not look as though the Foundation was interfering in another country's education, but it also lessened the ultimate dependence on the Foundation that might result from taking such a sizeable gift. Massey explained: "This will relieve the Rockefeller Foundation of inevitable criticism from sectional interests, and will throw the onus of making difficult decisions on a local body."60 Massey listed as worthy of assistance the only "really important Medical Schools in Canada": McGill, Toronto, Manitoba ("about which I don't know much"), and "possibly" Queen's. Though not a medical man

Which "Peaks to Make Higher"?

43

himself, Massey filled his letters with advice and, even though he did furnish names for a Canadian advisory committee, made clear his concerns for potential political pitfalls.61 On 5 January 1920, before Vincent and Pearce began their own inspection of Canadian schools, Vincent wrote to King in Ottawa: "it is a delicate matter for us to deal with the medical education situation as a Dominion policy," and the only way to "be of real service" was "to select certain medical schools that are strategically located and give reasonable assurance of future usefulness." Vincent asked King two questions. First, did King think that there should be a formal advisory group, or was meeting personally with "outstanding individuals" the better course? Second, would King supply "names of individuals who would be recognized throughout Canada as men who have the welfare of the whole Dominion at heart?" Vincent conceded that the list might be short, and possibly no individuals "would be regarded as wholly detached from local and institutional influence."62 King's reply was swift. He advised against a formal advisory group and suggested instead a preliminary survey of Canadian medical schools. "If you yourself," King wrote, "or someone specially designated by the Foundation, could personally see and confer with the Presidents of the leading universities, and the Deans of their respective Faculties of Medicine, and at the same time meet informally and talk with a few outstanding persons whose names you might receive from different sources, that, I believe would be the most prudent way of beginning."63 This was what Vincent and Pearce chose to do. King continued to correspond with Vincent throughout January 1920. He alerted him to Canadian newspaper reports that the Foundation had chosen an advisory board to help it disburse medical education funds. The article named five Toronto men, all members of the governing Unionist Party, recently defeated in the Ontario election. King, new leader of the federal Liberals, warned that such a report would lead Canadians to expect control of the Foundation endowment by a "small Unionist group in Toronto ... and as such [it] is certain to occasion some feelings of disappointment, if not prejudice as well."64 The following day, he offered names for individual consultation, among them Vincent Massey. King excluded himself as "actively engaged in politics and [having] no special knowledge of matters pertaining to medical education and research."65 King's advice was timely and accurate. In fact, the newspaper accounts were just the tip of the iceberg. The source of Vincent's woe was an interview with student delegates Roy McLeod and Marshall D. McPherson, both representing Western University at a Student

44

Rockefeller Aid

Volunteer Convention in Des Moines, Iowa, in January 1920. The delegates reported that Vincent had confirmed a Canadian committee, and four Toronto newspapers and the New York Herald and New York Tribune reported the gift. On 16 January, Vincent issued a formal denial of the rumoured committee. "Many inquiries are reaching the offices of the Rockefeller Foundation with respect to the policy to be adopted in connection with the aid to Canadian medical education." He went on to state, "The Foundation is not likely to appoint in any formal or official way a special committee for administering the gift to Canada," although its representatives would delay final decisions until "after conference with a large number of prominent Canadians representing all the significant institutional and geographical interests in the Dominion."66 Finally, one of the individuals to whom King referred Vincent was Toronto medical professor Macallum.67 Macallum chaired the Honorary Advisory Council for Scientific and Industrial Research in Canada, and King suggested that the Foundation delegation speak to Macallum in Ottawa.68 These exchanges with Macallum would become one of the most interesting documented correspondences and would keep Vincent informed of political and departmental intrigues that seemed to threaten progress in medical education at Toronto and at McGill. On a later visit to Canada, Pearce met with Macallum. Macallum suggested using fear of losing the annual grant - the money was not, in policy, to go to a school in one lump sum - as pressure to maintain fund-raising and pedagogical progress. Macallum also proposed that investing the balance of funds in Canadian government bonds at 5^ per cent "to show that the balance is actually being held for Canada," and not to give it outright on endowment. Even though he, Macallum, was in the running for the chair of physiological chemistry at McGill, he told Pearce that he would love to go to China on a Foundation appointment, even for just a year. He had just finished a decade as chair of biochemistry at McGill.69 By 25 February 1920, Foundation executives had a plan to evaluate schools, which Vincent presented to the board. Vincent advocated clear communication of the gift's intent and care to "confer with a large number of Canadians representing various geographical and institutional interests in the Dominion." After a preliminary visit to the "chief medical centers," a Dominion-wide policy was to be formulated. Choosing "peaks to make higher" would "involve delicate situations in which political, racial, and possibly ecclesiastical considerations will be involved. It is extremely important to avoid, so far as possible, complications which will impair the good will which this

Which "Peaks to Make Higher"?

45

gift is designed to promote. At the same time educational principles must not be sacrificed/'70 Vincent concluded that use of the money would emerge case-bycase, and he named progress in building and equipment, hospital and clinical facilities, methods, and personnel as parts of a general development program. "Every effort will be made to avoid any appearance of domination or of desire to impose a pre-conceived and inflexible scheme," Vincent said. Recipients must only seek other sources for additional, if not matching, sums.71 Just as Flexner had a decade earlier, Vincent and Pearce made a tour of Canadian medical schools. They spent March 1920 visiting Winnipeg, Toronto, Montreal, Quebec City and Halifax. Their first stop was Winnipeg, on 6 March. After visiting the University of Manitoba medical school and general hospital, they also met with governors of the university and Manitoba's minister of education. University of Alberta President Henry Marshall Tory also travelled to Winnipeg for a conference with Vincent and Pearce. When a university, such as Alberta, Western University of Ontario, or Queen's (Kingston), did not receive a visit, its deans would call on the Foundation delegates at a city on their itinerary. Vincent and Pearce spent six months visiting and revisiting schools. In their summary, they noted such details as, "The morning [9 March 1920 in Toronto] was spent with the medical faculty of the University of Toronto discussing a plan which had been prepared, typewritten and bound, pointing out the improvements desired and representing a program of development to cover the next ten years."72 When the Toronto medical faculty heard that the Foundation planned to spread its wealth in Canada, it held a series of meetings that asked each department head to document its current operating budget and present an annotated "wish list" for additional personnel and equipment. Without such a document, it feared, it might suffer the same fate as (U.S.) Western Reserve University's medical school, which took Foundation support for granted and "lost" available money by not drawing up a plan. As Appleget wrote, long-term results were "more significant than immediate ones." Toronto's medical faculty redrafted its document more than twenty times before the March 1920 visit. Sixteen departments participated, and the committee, chaired by Dean Alexander Primrose and including Professor Duncan Graham, met twenty times, as recorded in minutes, for an average of three hours each time.73 The delegation noted Sir John Eaton's support for full-time clinical teaching. Given the Eaton Endowment of $500,000, the province's promised support worth $300,000 for a new anatomy building,

46

Rockefeller Aid

$200,000 allegedly forthcoming from the new provincial government, and the faculty's ten-year plan, Toronto seemed worthy of Foundation investment. As Pearce wrote, "With the gradual development of the ten year program outlined by the faculty this school will be second to none in North America/'74 To be sure, Vincent and Pearce did not set out on their Canadian tours without favourites. Although they would not dismiss any school without visiting it, they did report that Queen's and Western, for example, were "doubtful propositions ... The chief argument for their continuance is that they serve definite centers of population."75 Vincent Massey remained a valued source of opinion. For example, on 10 March 1920, Massey told his cousin and Pearce in Toronto that Queen's graduates had "a good deal of influence" throughout Canada and suggested aid for Queen's. He expressed a "pessimistic view of French-Canadian education," telling them that support for a French school should be considered, since "French-Canadian doctors ... must be trained and that they will not resort to English Protestant institutions," such as McGill.76 When Vincent and Pearce visited with Mackenzie King in Ottawa the next day, King agreed that "something should be done for a French Catholic medical center," not on political grounds but "because the large population needs medical men."77 He illustrated this statement in a table which showed that, in 1918, Quebec had more than twice the area of every province but Ontario, but had only 1,984 physicians to serve more than two million people.78 The delegation and King made a fifteen minute 'formal call' on the governor general, the Duke of Devonshire, who served as a governor of the Royal Victoria Hospital in Montreal. From April until August 1920 the duo paid visits to Halifax, Toronto, Montreal, Kingston, London, Quebec City, Winnipeg, Saskatoon, Edmonton, Calgary, Vancouver, and Ottawa. The Foundation wanted to be as thorough as possible in determining the needs of an entire country and how select medical schools could best meet these needs and projected future requirements. THE I N F L U E N C E OF THE R O C K E F E L L E R GIFT

The money allotted to aid Canadian medical education came from a transfer from John D. Rockefeller, Sr, to the Foundation of four sets of securities: 366,517 shares of Anglo-American Oil Company, Limited; 49,000 common shares of Standard Oil Company of New Jersey; 10,000 preferred shares of Standard Oil Company of New Jersey; and 35,000 common shares of Virginia-Carolina Chemical Company.79 In a final gesture of goodwill, Vincent told John D., Jr, that, since

Which "Peaks to Make Higher"?

47

the Canadian dollar was at a discount of 12 to 15 per cent against the U.S. dollar, the initial $5 million would purchase $5.5 million in Canadian currency. In his letter of 6 April 1920 Vincent suggested that if trustees invested this sum in Canadian Dominion bonds, as Macallum had suggested, "such a purchase of Canadian Government securities for this purpose [of endowing Canadian medical schools] would be regarded as a friendly act."80 John D., Jr's, office replied on 14 May 1920 that Canadian medical schools would receive the aid as dividends from Standard Oil Company of New Jersey 7 per cent preferred stock, paid in "New York funds." At that time, they could take advantage of the greater buying power of the U.S. dollar. Vincent and Pearce concluded their report, "The most satisfactory school is the University of Toronto with McGill a close second. These have very definite programs for improvement and should be helped to the greatest possible extent financially. Winnipeg comes next in order and with the rapidly developing school at Alberta should be assisted in order to take care of the western provinces. Halifax, isolated as it is, but doing its best under adverse circumstances should be aided in order to take care of the eastern end of the Dominion."81 The Council on Medical Education had assessed the Canadian schools and rated only Toronto and McGill Class A. These schools also had by far the largest enrolment. In 1918/19, Toronto had 619 men and seventy-nine women enrolled in a five-year program, while McGill had 463 men and eight women in a five-year program. The Montreal School of Medicine and Surgery had 241 students, all men. The same order held for number of faculty members.82 The summary advised more detailed study before a decision on support for French-language schools and reserved judgment on "real need" for any other medical schools in Ontario, namely Kingston and London. This echoes Flexner's judgment of 1910. As for Queen's, Flexner wrote that its future "depends on its ability to develop halfway between Toronto and Montreal, despite comparative inaccessibility," and Western was among the medical schools with "no present function."72 It took less than six months to release the first funds in the Canadian gift - $500,000 to Dalhousie, on 26 May 1920. The Foundation was aware that the Carnegie Corporation had "practically promised" an equal amount to Dalhousie in the autumn of 1920. This was, as minutes of the Rockefeller Foundation's board recorded on 26 May 1920, in addition to local support. Hence, this "B-rated school" became the first Canadian medical faculty to receive Rockefeller money from John D., Sr's, gift.

48

Rockefeller Aid

On 9 September 1920 the board authorized gifts to McGill and Toronto ($1 million each) and to the University of Manitoba ($500,000). Medical faculties at the University of Alberta and the Universite de Montreal each received $25,000 from income from the remaining $2 million. The Foundation reserved the option of future aid to Canadian medical education with this surplus. It left out Queen's and Western, which were "in the same [geographical] area with Toronto" and lacking "adequate clinical and other facilities."84 Thus the Rockefeller Foundation grants gave the pre-eminent and a few struggling but isolated medical schools a spur to specific educational reforms. These institutions tested modified "geographical fulltime" clinical instruction. They erected buildings, and if not with Rockefeller funds, then with private matching donations or provincial gifts. Rockefeller money gave them the leverage to obtain government and private money to support medical education and research. It would have been difficult for Canada's leading medical schools to compete with U.S. counterparts for space, instructors, and lab facilities and equipment, and they would have remained dependent on students' fees, as in the nineteenth and early twentieth centuries. Proof of this continuing practice appears in Flexner's 1910 report, which noted the amount and source of financial "resources available for maintenance." Of the eight Canadian schools that he visited, only two had any government or endowment money. These monies - fees, government grants, and endowments - went to everything from buildings and equipment to professorial salaries and maintenance of the faculty. Williams describes how foundations seek out what needs doing and yet is overlooked, unpopular, or too controversial.85 They also, he argues, should start projects that local governments can later continue permanently on their own.86 Applying this rationale to aiding Canadian medical education via the requirement of matching funds, the Rockefeller Foundation kick-started reform, which other private and public money maintained. In medical education reform, the Foundation found a cause that people were overlooking. Despite years of advocacy for reform, there had been scant financial aid, and minimal reform. The Rockefeller Foundation stopped choosing "peaks" in the 19205. The money for Canada assisted a few medical schools in harnessing the new scientific medicine and, along with matching grants, helped them keep up the momentum long after they had spent the grant money. By 1925, the Foundation had moved on to find new projects to support.

3 Turmoil in Toronto: The Provincial University

In 1919, the Rockefeller Foundation's gift of U.S.$i million to the University of Toronto followed Sir John Craig Eaton's endowment of $500,000. Both benefactors intended to aid the transition to and implementation of full-time clinical education. This chapter examines the university's situation in 1919 and its shift to full time; the two major gifts; and the ensuing controversy and provincial inquiry. The final pages look at a U.S. example and the longer-term significance of the Rockefeller and Eaton gifts to Toronto. TORONTO IN 1919AND FULL T I M E

The 19005 and 19105 saw reforms at the University of Toronto. Among these changes, Trinity Medical College affiliated with the University's Faculty of Medicine in 1903/04, making the faculty the city's only remaining medical school1 and control and management of the university shifted from the provincial government to an independent board of governors in 1906. William Osier, then at Johns Hopkins University, gave the inaugural address to the new combined Faculty on i October 1903. New laboratories for pathology and physiology opened that same day. The added space was essential: amalgamation of the Toronto and Trinity faculties increased the number of medical students in the city from 494 in 1902/03 to 721 in 1903/04. The University's inaugural board, selected by the Ontario government, included Joseph Flavelle (a major benefactor of Toronto General Hospital); Chester Massey (Vincent's father and George

50

Turmoil in Toronto

Vincent's uncle); Sir E.B. Osier (older brother of clinician Sir William Osier); and E.G. Whitney (brother of Conservative Premier James Whitney). These transitions went hand in hand with increased funding from the province's new Conservative government. It may seem ironic that the province was offering more money to the university while preparing to relinquish control over it. Ayre views it more as Premier Whitney's controlled weaning of the institution from legislative authority.2 It was Whitney who had called for a royal commission in 1906 to look at reorganization of the university that would set up a cabinet-appointed board and an arm's-length connection to the legislature. Ayre argues that "although the 1906 legislation greatly increased the University's income through the provision of an annual grant based on a percentage of succession duty income, Whitney envisaged that the institution would exist on this money and that there would be little, if any, further demands upon the Government."3 Those duties would grow as the province prospered; by 1914 the government amended the University Act to limit succession duties transferred to $500,000 per year. At that time, Ayre explains, the act of 1906 offered a stellar compromise: "It provided a state connection which justified state support, while at the same time it ensured the University's effective independence from political interference."4 Ayre believes that by creating some distance from the university, the province freed itself from a major burden, passing responsibility on to the university's board of governors and its president, whose powers increased with the act of 1906. The transition was also supported by a recommendation for public support of the faculty rather than reliance on student fees and what Wallace calls "the self-sacrifice of members of the medical profession."5 The relationship between the university and Toronto General Hospital, though formally defined, was not always easy. Robert Falconer met with Flavelle and thirty-nine members of the medical faculty on 10 October 1907 to discuss whether to use the German, laboratory-based model or the British, clinic-centred model. As Connor outlines, the German approach centralized power, while the British decentralized it, using "as many services in each department as might be considered wise."6 A final report in January 1908 called for a compromise: departments in gynaecology, medicine, obstetrics, ophthalmology, and surgery, and a joint department encompassing laryngology, otology, and rhinology. A medical advisory board, made up of heads of services, ran clinical instruction in all public wards of the teaching hospital.7 Connor writes, "In 1908, the Toronto General became, in all but

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name, a university hospital, in which medical education was another of its integral obligations."8 Fittingly, the hospital moved to new buildings in 1912, next to the university campus.9 As early as 1908, the university and the teaching hospital agreed that each head of a clinical department in the Faculty of Medicine had "a service in the hospital," and subsequent appointments "were to be made by the Board of Trustees of the Hospital only on nomination by a joint committee of the Board of Governors of the University and the Board of Trustees of the Hospital."10 New buildings went up for medicine (1902) and pathology (1903) to accommodate the expanding student body and offer improved facilities. Finally Falconer, who took office in 1906, would serve as university president until 1930! The 19005 and 19103 also saw administrative and curriculum changes within the faculty. Dr R.A. Reeve, appointed in 1896, resigned as dean in 1908. His successor was. Dr C.K. Clarke, also professor of psychiatry. When Clarke resigned in 1920, Dr Alexander Primrose, a long-time faculty member, took over." The medical course changed from four years to five years in 1908/09 and to six years in 1919/20, partly in response to the steady expansion of the curriculum to include new laboratory-based subjects such as bacteriology, introduced in 1909/10, and biochemistry, started the following year. At the same time, the university received a number of large private gifts. Among those earmarked for medical teaching and research were the Connaught Anti-toxin Laboratories, including a fifty-eightacre farm in the north end of Toronto (Dufferin and Steeles Avenues), valued at more than $75,000, from university governor Colonel A.E. Gooderham, in 1917; a lab for zymology research, also funded by Gooderham, in 1918-20; and various fellowships for specific studies.12 Finally, the world war deeply influenced the university and the faculty. It affected enrolment, teaching, policy, and endowment patterns. "When war broke out in August, 1914," as Wallace notes, "the members of the University were scattered far and wide."13 During the war, the Faculty of Medicine served its country in many ways. Toronto staff members, alumni and students set up and staffed a stationary hospital, interrupting their instruction. The Number 4 General Hospital was the university's facility and saw service from May 1915 to July 1919 in four sites: Shorncliffe, Salonika, Kalamaria, and Basingstoke.14 The commander was Lieut.-Colonel J.A. Roberts, and the staff consisted of thirty-eight officers, seventy-three nurses, and 206 men, many of them undergraduates. The hospital handled an average of 1,300 patients daily! Among the other hospitals with

52

Turmoil in Toronto

specific university affiliations were: No. 3 General (McGill); No. 6 General (Laval); No. 7 Stationary (Dalhousie); No. 9 Stationary (St Francis Xavier); and No. 10 Stationary (Western); No. 7 General/No. 5 Stationary (Queen's); No. 8 Stationary (Saskatchewan College of Physicians and Surgeons). In all, Canadian troops operated sixteen general hospitals and ten stationary hospitals.15 The military hospital figures in both the details of Duncan Graham's appointment as the Commonwealth's first full-time chair of medicine and as an example of Canadian sacrifice that would inspire John D. Rockefeller, Sr's, aid to Canadian medical education. Captains E.S. Ryerson and W.R. McPhedran16 led the Toronto medical staff and students, consisting of two of the university's nine companies. Ryerson became secretary of the faculty in 1918, after ten years as assistant. Companies, organized by Christmas 1914, were divided by faculty and college. Medicine was in Companies F and G.17 In total, 1,217 University of Toronto staff members, students, and alumni took part in the Army Medical Corps of the Canadian, Imperial, or Allied Forces. Seventy-nine men joined the Naval Medical Service, and many people associated with the medical school, particularly in the early years of training, left school to enlist in other branches of service. Altogether, more than 1,300 participated in the war effort.18 In total, 608 of the university's 5,681 incumbent staff, graduates, and undergraduates on service were killed in action or died on service, and another 884 were wounded.19 Enrolment rose to unprecedented levels when the war ended. The number of registered students almost doubled, from 2,799 1917/18 to 5,237 in 1919/20.20 In medicine alone, in 1918/19, there were 746 men and eighty-two women - the largest total for any of the university's six faculties or five federated colleges.21 The Full-time System In Canada, the University of Toronto was among the earliest medical schools to embrace the full-time system - first, in principle, in the Toronto General Hospital Act, 1911, and then in Graham's appointment. As Ludmerer notes, however, the transition from part time to full time was not easy. Although knowledge of background science and its application to medicine was becoming increasingly important, the salaries of full-time professors were in no way commensurate with clinicians who had equal years' experience.22 Hence, administrators had to hope that the lure of research was enough to make a physician choose a full-time clinical position. Bliss cites the facilities available to Banting, Best, Collip, and Macleod at Toronto as

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a "condition" for the discovery of insulin23 - specifically, the facilities for "major animal research" - and "testimony to the important work done in the preceding fifteen years or so in modernizing the University of Toronto."24 Another question involved how much patient contact would suffice. Osier, for example, thought clinical instructors too far removed from medical practice to be effective.25 Of course, Osier belonged to an earlier generation of physicians; he once said that if he had to perform a physiology experiment, he would not be able to operate the equipment. He remained sceptical of this shift towards science in teaching. Berliner tells of how Osier argued against the full-time system. Osier wrote to Ira Remsen, president of Johns Hopkins, from Oxford, where he was Regius Professor of Medicine. Using the university hospital as a research institution, he wrote, would only "subvert the goals of training practitioners." Restricting full-time clinical instructors to seeing only hospital patients would deny them exposure to varied cases and lessen their clinical skills. Osier also acknowledged professionals' jealousy towards "laboratory men"; he contended that while the latter accused clinicians of being too prosperous, they did not understand the clinical situation. For example, while lab scientists received a fixed salary and worked regular hours, clinicians were on call and available to patients around the clock.26 Initially, "full-time" meant that physicians would control clinical departments in the final two years of a medical program and devote all of their time to teaching, research, and patient care in the associated teaching hospital. If they carried out private consultations as part of their teaching or research, any fees were to go to the university. The unfaltering support of Abraham Flexner and a few key innovators at schools such as Chicago, Johns Hopkins, Vanderbilt, Washington University, and Yale overcame initial difficulties in instituting the full-time system.27 As Rothstein writes, by 1919 the General Education Board was questioning the considerable cost of the full-time plan and began to relax its definition to include "geographic fulltime" appointments.28 By 1925, Rothstein says, the board gave Columbia the choice of strict full time (with salary top-ups from the board), geographic full time, or part-time clinical appointments. Two years later it "relieved those schools who had signed binding agreements with it of their strict full-time obligations.29 Abraham Flexner saw the efforts of the Rockefeller Foundation and other philanthropies as subsidizing the creation of a U.S. national standard in clinical research to keep up with the work being done in Germany.30 A new age of clinical instruction had begun.

54

Turmoil in Toronto TWO MAJOR

GIFTS

The Rockefeller Gift

As we saw above, the announcement regarding the U.S.$5-million gift for aid to Canadian medical education took place on 25 December 1919. The University of Toronto was in the throes of adjusting after the war, re-establishing pedagogical order while integrating almost twice as many students. Although the time was ideal to introduce new ways of teaching, many of these changes were expensive, and provincial support was not enough. In 1919 Toronto decided to follow other U.S. and Canadian universities and appeal to alumni for support. As Cassidy observed in 1919,31 the same principles used by "specialists" to raise thousands of dollars quickly for the war effort could work for education. U.S. and Canadian colleges, he noted, had also set up capital endowment campaigns, some quite ambitious. For example, Harvard University was asking for $15 million; Cornell, $5 million; and Fordham University and Phillips Exeter Academy, for $2 million each. McGill had asked Montrealers for $1 million and within one week collected more than $1.5 million, while Haligonians in less than ten days gave Dalhousie the half-million dollars that it requested for campus buildings. Toronto's Memorial Campaign of 1919 was a challenge. The university had made little effort to keep track of graduates. It was only because undergraduates, staff members, and alumni had served together in military units during the war that any strong alumni ties emerged. In his November 1919 editorial in University of Toronto Monthly, W.N. McQueen picks up on Cassidy's observation of Dalhousie, Harvard, and McGill's success in noting that Toronto's campaign was going steadily but slowly; by 7 November, it had raised $199/799-32 "The University of Toronto," McQueen wrote, "has never known well-organized, united, alumni support. ... The alumni have been widely scattered; until recent years the University has not been a unit in itself." McQueen commented that the post-war situation allowed alumni to "[join] hands in the sacred cause of perpetuating the memory of the University men and women who laid down their lives in the war."33 As the Memorial Campaign continued, news of the Rockefeller gift, soon after the Eaton endowment, spurred the overcrowded yet ambitious Faculty of Medicine. President Falconer spent weeks travelling across Canada and the United States seeking funds from alumni groups. In November 1919 alone, he visited Brantford, Ontario, New York City, Hamilton, Welland, and Montreal. Distin-

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guished alumni, such as Professor W.P. Mustard of Johns Hopkins and Professor R.J. Bonner of Chicago, addressed Toronto alumni during major fund-raising drives. Newspapers and alumni publications followed the campaign. When mention of the Foundation's gift appeared, the editors of University of Toronto Monthly could not cite how much of the money was allocated to Toronto. The two-paragraph news brief did, however, observe that Toronto, for the number of students enrolled, had "fewer instructors than any other medical college of the better grade on the Continent" and speculated that much of the grant would go towards "the advancement of research work."34 For all this speculation, the University of Toronto's administrators did not want to take any chances and lose the money before they received it. Despite the Rockefeller Foundation's unfathomable wealth, it turned away many projects and individuals seeking financial aid. Before Vincent and Pearce travelled to Toronto, they prepared background notes on medical education and public health in Toronto. Some earlier material was available, including the Flexner Report (1910); the Toronto General Hospital Act, 1911; and a detailed financial statement for the Toronto Faculty of Medicine (July 1918). Communication between Toronto and New York long antedated announcement of the gift and visits. For example, Vincent inquired of Dr Alexander McPhedran on 11 December 1919 about an error in the faculty's financial statements, sent 27 November - the budget for thirty "whole time" staff in the Department of Medicine was $10,250, when Medicine had no "whole time" faculty members at all. This figure probably represented the eleven heads of clinical departments, plus any "assistants." The Faculty promptly made the correction.3? There were no full-time clinical instructors in any department, yet the staff numbered 129, with total annual salaries of $36,045. By comparison, there were fifty-six staff members in the departments of anatomy, chemical pathology, pathology and bacteriology, and pharmacy and pharmacology, including nine "whole-time" positions. The total amount paid these people each year was $30,182. This brought the total remuneration for staff to $66,227. Secretarial expenses added $3,500, and "miscellaneous expenses," including $15,215 for "a building," brought the reported total to $94,994. Tuition fees that year for the five-year course, with 600 students enrolled, yielded $82,i55-36 In 1919, in addition to planning to change the five-year program to six years, the faculty saw enrolment explode, needed yet more laboratory space, and began to plan for graduate instruction. Therefore, the 1918 financial report ends with the plea: "It is manifest that there is great need for increased income to make it possible to carry on, not

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Turmoil in Toronto

only the more efficient undergraduate instruction, but also to develop graduate work, a matter of the greatest importance."37 This was in keeping with both Falconer's desire for more graduate work within the university and the expansion of the research ideal that had taken hold in Toronto in the i88os and 18905. As Greenlee notes, Falconer believed that only reform of the Faculty of Medicine and establishment of a "reputable school of graduate studies" would stop the "intellectual drain to the south" and strengthen the "fabric of Canadian culture."38 The resulting report for the Rockefeller Foundation on the University of Toronto's medical school, dated 7 February 1920, outlined the faculty's history, personnel, and courses. In 1918/19 the school had 698 students registered, each paying $150 for the year's tuition in a five-year course; fifty-six post-graduate students; and 216 faculty members.39 Clinical teaching facilities counted upward of 1,500 beds, spread among four downtown institutions: Toronto General Hospital (with "more than 700 beds and a large out-patient department"); the Hospital for Sick Children (250 beds); St Michael's Hospital (400); and Toronto Western Hospital (120). An X-ray facility at Toronto General was "said to be one of the most complete on the continent."40 The teaching hospitals were of particular interest to the Foundation, partly because of their pedagogical and professional role in the fulltime system. The Foundation asked for a copy of the 1911 act for the Toronto General.41 The act had three parts: by-law number 5454, passed 25 April 1910, to provide for the issue of debentures up to $250,000 for a grant to the hospital and to acquire more land; a by-law about the medical staff, passed 25 January 1911; and the act itself generally, respecting the hospital.42 Although little information exists on the act, it features prominently in the Toronto story. It seems as though the legislature passed it partly to give some administrative structure to the new hospital, particularly after the 1906 act that shifted governance of the university from the legislature to the university's board of governors. The university's needs, as outlined in the act, were considerable: $300,000 to help purchase land "fronting on Avenue Street" and build the new hospital and $100,000 to put up adjacent structures for the Departments of Bacteriology, Pathological Chemistry, and Pathology at University and Christopher streets.43 The by-law on the medical staff outlined the most striking conditions: no remuneration to members of the visiting staff; three co-ordinate services in medicine, including dermatology and neurology, and four co-ordinate services in surgery; a single service in each of gynaecology, obstetrics, ophthalmology, and otology, rhinology, and laryn-

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gology; a retirement age of fifty-five in surgery and sixty in medicine, unless otherwise negotiated with the board of trustees; heads in medicine not to take part in general practice and to confine their efforts to consultation outside the hospital. This meant that consultations by the department heads in medicine should take place off hospital property.44 The by-law was specific about both heads of departments and the visiting staff: heads in medicine, for example, were not to "engage in general practice but shall confine their work outside of the Hospital to consultation," while the head of gynecology "may outside engage in Surgery but not in general practice."45 The only exempt head was the current head of surgery, I.H. Cameron (the by-law gave no explanation). Finally, the by-law divided clinical work from the laboratoryor science-based positions: it placed Pathology and Bacteriology as well as Pathological Chemistry, not under an independent head of department, but under unversity professors. Flavelle signed this bylaw as chair, and Miller, as secretary. The medical staff by-law passed almost two months before the 1911 act. What it did was to create heads in a number of clinical specialties while placing research or laboratory positions under members of the university faculty. Even more striking, it provided for a full-time system, with some concessions for consultation, long before the Eaton gift mandated the system. The one major difference was that the later system put in place by Graham in 1920 consolidated the eleven services into two. Medicine and Surgery, and soon, Pediatrics, were the only full-time services under the Eaton initiative. This was probably because the 1911 division of labour was premature: it was unlikely that there was enough work for three heads of medicine and four heads of surgery. Furthermore, organizationally, it would have been a nightmare to ensure that all these department heads were of like mind and working towards a common goal. Methods and techniques differed, providing less co-ordinated training for students. Finally, there is no mention of money paid to the heads of departments in the 1911 act. Given that these officers would be some of the best clinicians, who might expect to earn $25,000 to $30,000 per year,46 it would be very generous of them to give that up to make less than $10,000, plus token fees from consultation. Compare this annual salary range to the $40,000 that Osier allegedly earned in 19O2.47 By 1920, it had become obvious that only higher remuneration would keep excellent men, and so Graham received $10,000 per year and one afternoon a week for his own cases. But maintaining eleven fulltime clinicians was impossible.48

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Turmoil in Toronto

The Eaton Gift Although it represents an entirely separate gift, the 'Eaton Endowment' of 1919 is worth examining for two reasons. First, it was substantial: totalling $5oo,ooo,49 it was half of the amount given by the Rockefeller Foundation and likewise, supported full-time clinical teaching. Second, its terms led to a backlash within the Toronto medical profession that threatened to mire the Rockefeller Foundation in bad press and return the university to strict provincial control. The Foundation was paying out its gift to Toronto in instalments. By the time of the third payment, disgruntled critics of the full-time system were accusing both the Eatons and the Rockefellers of interfering in the running of the medical school, setting its policy, and illegally changing its organization with their push for the full-time system. The Rockefellers were particularly sensitive to this bad press as a consequence of the writings of U.S. journalist Ida M. Tarbell50 and the idea that they were trying to buy into the good graces of the Americans and Canadians with tainted money. Remember that this is part of the reason that the Foundation could not get a U.S. federal charter: some lawmakers in Washington, DC, were suspicious abou use of the philanthropic millions and saw the initiative as just another way for John D. Rockefeller, Sr, to exercise control over the American people with his substantial wealth. The genesis of the idea at Toronto to bring together a major gift, a full-time professorship in medicine, and a general reorganization of the faculty is not clear. Greenlee narrows it down to Falconer or Eaton. He reports that Falconer was negotiating with Eaton as early as the spring of 1918 for a major new endowment. What resulted was a plan of action that accompanied Eaton's gift of $500,000.5* In an effort to be thorough, Vincent and Pearce sought information not only on the clinical teaching relationship between the Toronto General and the university faculty but also on one of the items in the faculty's July 1918 financial statement to the Foundation: using the Eaton Endowment for a new chief in clinical medicine and four fulltime assistants. The Eaton gift was to proceed in twenty annual payments of $25,000, the first on 9 January 1919 and the last on 9 January 1938. Each year $20,000 was to go to Medicine and $5,000 to the chief of paediatrics, who "gives half of his time."52 Although the conditions had no direct link to the Toronto General Hospital Act, 1911, they no doubt built on them. The change from eleven heads of department to two in 1920 was fundamental. Furthermore, the secondary paediatric appointment implies that limited funds and resources could not support a number of the original

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department heads. Instead, one head of Medicine was enough, supplemented by four full-time assistants, so that a core group of laboratory-trained, clinical men would be able to take over the next generation of positions. Certain terms of the Eaton gift are noteworthy. The annual sum of $25,000 was to go to the Department of General Medicine; the head of the sub-department of paediatrics was to "give at least half of his time to such sub-department"; and "The Head of the Department of General Medicine shall recommend to the President for appointment and dismissal all men in his Department whether under salary and giving their whole time to the work in which they are engaged or whether receiving an honorarium and giving part only of their time or whether giving their time without honorarium or salary."53 This last point established and put into practice full-time clinical education. Signing the indenture for the Eaton Endowment, dated 9 January 1919, on behalf of the donors were Sir John Craig Eaton; his wife, Flora McCrae Eaton; the T. Eaton Co. Ltd.; R.Y. Eaton, ist vice president; and J.J. Vaughan, secretary-treasurer. Signing on behalf of the university governors were S.A. Lash, vice chairman and Ferdinand J. Moure, bursar. The document was signed, sealed, and delivered in the presence of A.M. Gall. In their biography of Graham, Kerr and Waugh credit five influential Canadians with establishing this new system of teaching, or what they call the "Flexnerian model of medical education": Sir John and Lady Eaton, Falconer, Joseph Flavelle, and William Goldie. The Batons enjoyed a longstanding philanthropic interest connected to both Sick Children's Hospital and the medical school, and Sir John had served on the university board where his term ended in 1920. Goldie was the Eaton family's physician. In her autobiography, Lady Eaton describes both him and Graham as "our good friends as well as our medical advisers" and notes that it was "with them, some time before," that she and her husband set up the chair of medicine at the university. She describes how, when her husband fell ill with pneumonia in January 1922, Goldie and Graham suggested bringing in a pair of specialists from Johns Hopkins Hospital. Unfortunately, the unnamed specialists could only confirm Goldie's initial diagnosis, and Eaton died at the age of forty-five on 30 March 1922.54 Falconer saw the rejuvenation of the medical school as part of a process of helping the university to achieve greater prestige on a national scale. And Flavelle had become chair of the board of trustees of Toronto General Hospital - the main clinical teaching facility - and oversaw fund-raising for and building of the new 670bed hospital, opened in June 1913 - the largest teaching hospital in

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Canada. Flavelle, like Eaton, served on the university's board, retiring in 1924. Credit for bringing together the idea and the man who could finance the reorganization goes to Goldie. Kerr and Waugh describe him as a "strong advocate" of the full-time clinical system. They attribute Falconer's taking up the cause to Goldie's persuasiveness, although I believe that it would not have been difficult to convince Falconer, given his drive to elevate research and academic ideals. I would argue that Goldie was most important as intermediary: first linking the idea to the leading administrator (Falconer), then introducing both the idea and the president to those who could finance implementation (the Batons), and finally pointing out a suitable candidate (Graham) and facilitating his acceptance. Goldie was active each step of the way and hence appears the mastermind in introducing the full-time system to Toronto.55 In 1918, Goldie was teaching in the medical department of Toronto General Hospital and approached Eaton about an endowment for a full-time "geographic" chair in medicine. The occupant would be fully responsible for defining and organizing medical teaching, with an attending staff, using the Toronto General as the teaching clinic. This was a radical departure from part-time clinical instructors, who maintained their own full-time practices while teaching part time in the hospital. For this, they received honoraria commensurate with departmental standing and seniority, with annual sums ranging from $1,000 for the part-time head of a department to $50 for a junior member.56 Kerr and Waugh outline the circumstances that brought Graham back to his alma mater.57 The search for the best possible candidate, which began in May 1918, was not taken lightly. Nominees included Englishmen Dr Henry H. Dale, director of the Wellcome Physiological Research Laboratory and later director of the National Institute for Medical Research and Nobel laureate, and Dr T.R. Elliott, who instead took a faculty position at University College Hospital in London, England. Kerr and Waugh write that there were no serious American candidates, quoting Goldie: "The outlook for first class men from the U.S. is very poor, though a search will be kept up until the spring [of 1919], at least."58 Alan Brown, who would receive part of the Eaton Endowment as professor of paediatrics put forth Goldie's name. Goldie himself declined.59 Falconer even travelled to England to talk with potential candidates. While Falconer and Goldie were looking at many prospects, the winner would have to transform clinical teaching. Falconer and Goldie agreed that clinical services in medicine should fall under one

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head of department, to serve whole, or full-time - eight continuous hours per day. Falconer met with the Batons on 15 November 1918. Sir John's other major benefactions, which totalled more than $4 million at the time of his death in i922,included: the Surgical Wing at the Toronto General, named for his father the Timothy Eaton Memorial Wing ($365,000); the Methodist National Campaign ($100,000); and the Halifax disaster in 1917 ($66,000). Eaton was an honorary governor and member of the board of trustees of the Toronto General Hospital; member of the board of governors, University of Toronto; and honorary governor and member of the board of trustees, Victoria College. The day after meeting with the Eatons, Falconer wrote to Goldie at No. 4 Canadian General Hospital, then in Basingstoke, England. Graham was chief of the medical division there. Graham had graduated from the University of Toronto medical school in 1905. His post-graduate career included work in bacteriology and pathology in Canada and the United States, two years of post-graduate study in Europe, lecturing in bacteriology in Toronto, and joining the war effort via the Canadian Army Medical Corps (CAMC) as a specialist in internal medicine. By this time, Graham was the unanimous choice of the selection committee, and Falconer pressed Goldie to persuade him to take up the position: "will you talk to [Graham] about it; get his views and try to persuade him to accept... Very probably we shall be able to secure a change in the matter of services and have them under the direction of one man."60 Goldie agreed heartily with the choice, as he did with use of the Eaton gift as a catalyst for change. He acknowledged that the shift to full time would be unsettling, but he replied to Falconer, "It has been a great pleasure to me to know that you have determined to carry out the principle involved in such a radical move, and also that in doing so that you have selected Graham."61 The Eaton Endowment became reality on 9 January 1919, and Falconer suggested that Graham return to Toronto early in 1919 to take up the chair. The Basingstoke hospital would, he surmised, soon disband, but Goldie could replace Graham there until it did. Graham took up his position in Toronto on i July 1919, and less than two weeks later the Advisory Committee on the Department of Medicine met. It defined full- or whole-time work - it agreed that "full-time" meant that "the day [was] to consist of eight continuous hours." It also set aside $5,000 for development of the sub-department of paediatrics and appointed Alan Brown as its head, devoting "half time to this work." The members of this advisory committee were

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Falconer (chair), C.K. Clarke, Goldie, and Graham; the Batons, though not official members of the committee, received reports of its meetings if they did not attend. Although the Batons missed the meeting of July 1919, the minutes specified that any resolutions arrived at during meetings would, for adoption, require approval by the Batons or their representative, Mr Wyly.62 More changes were to follow. In September 1919 Graham put forth recommendations for reorganization within the Department of Medicine that included ending part-time clinical instruction. He did not foresee that such a change would create problems. "With reference to the discontinuing of the present annual honorariums to part-time men," he wrote to Falconer, "I may say that I have discussed this question with the men I have interviewed re: appointments in the Department and explained the reason for advising this. I do not look forward to any particular trouble should this be acted on favourably by you."63 But there was an uproar. By the end of September 1919, "with the stroke of a pen, Graham had revoked the appointments of nearly forty percent of the Department's staff."64 And their outcry would lead to a provincial inquiry that threatened to destroy the Eaton Endowment and the medical faculty and frighten away the publicity-shy Rockefeller Foundation. There was a history of fighting between university administration and physicians in Toronto. In 1908, when new regulations set limits on outside consultations for staff physicians at the Toronto General, laid down mandatory retirement ages, and attempted to reorganize departments, there was a hue and cry from the physicians. Many believed that the university should control staff appointments, and the subject produced debate in the Toronto press.65 Graham established himself as head or physician-in-chief of a previously tripartite clinical department. He also used part of the Eaton Endowment to fund full-time salaries of $2,400 for six young physicians who would devote all their hours to research and clinical training in bacteriology, biochemistry, internal medicine, pathology, and physiology. Graham kept these physicians as full-time researchers and teachers for three or four years and then began to wean them off full time by giving them two hours per day to build up their own practices. Eventually, when they were self-supporting, he cut them loose and hired new, young researchers as full-time clinical fellows. Weisse describes a similar sort of influence. He says that the greatest contribution of American clinician Carl J. Wiggers was his training of new cardiovascular researchers. This new generation of specialists included thirty-seven of his students who went on to become departmental chairs or directors of research institutes.66 This repro-

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ducing of oneself is one of the most striking effects of the full-time system. Norton points out the effect of this phenomenon. He says that clinical teachers create, in their own image, more of themselves: namely, skilled specialists. In outlining his criticisms of British medical education, Norton points out that by 1968 there was only a single professor of general medicine in all of Britain.67 This new system encouraged promising researchers not to move on to a lucrative practice simply because of economic factors. Hence there were full-time clinicians at the top and bottom of the organization. In a 1959 article published in the University of Toronto's Varsity Graduate, the unnamed author wrote, "The combined stress on clinical and chemical knowledge paid off. When Insulin was discovered, Dr. Graham had a team of men specially trained in clinical practice and the chemistry of diabetes to help with the first treatment of human patients. Another team was ready when liver was found to be effective in the care of pernicious anemia. In heart and chest ailments, metabolic disorders and skin diseases, the research groups also played an important part."68 R E P E R C U S S I O N S OF THE GIFTS: THE S P E C I A L C O M M I T T E E OF192 3

In Toronto, the Rockefeller money was a strong incentive in and of itself. University officials used the leverage of the condition of matching funds to campaign for government and private money. But it would be the adoption of the full-time clinical system, in opposition to a strong, conservative core of part-time instructors, that would push the changes made possible by the Eaton and Rockefeller gifts to the brink of infamy.69 When Duncan Graham assumed the Eatonfunded chair of clinical medicine, he quickly began to reorganize the medical school. As A.B. Macallum reported to George Vincent, when Vincent visited Montreal in August 1922, The dismissal of a number of part-time clinical men and the installing of Graham as full-time head of medicine made trouble. Some of the men displaced had been in service overseas and one or two were very popular. A public agitation for the restoration of these men was begun and in one or two cases the University authorities seemed likely to yield.... The medical row led to a general attack on university administration. ... It is possible that [President Robert] Falconer may weather the storm; but in many ways he has been weak and it is not unlikely that he may lose his post. In the long run the University and the Medical School are likely to maintain their status and prestige, but there may be an unfortunate period of agitation and discord.70

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The "agitation and discord" played out in the trade and the general press. For example, it provoked discussion in Canadian Practitioner and Review71 and in Saturday Night. Long before any formal investigation, Canadian Practitioner (April 1920) was reporting on a situation at McGill in which J.M. Elder, a surgeon and war veteran, resigned to protest the hiring of "a German" as professor of pathology. The appointment was "a direct insult to every McGill graduate, to every returned soldier, to every patriotic citizen, and to the community in general." Even worse were the "German methods": "For years it has been feared by many people in Montreal as well as elsewhere that McGill, like Toronto, was growing too fond of Germans and German methods. ... One of McGill's most highly gifted sons is Francis Shepherd/2 who, some years ago expressed his views in the following words: 'In many of our modern hospitals with their laboratories, students are not taught to observe so carefully the evident symptoms of disease, and they are becoming mere mechanics. ... The higher and more intellectual means of drawing conclusions by inductive reasoning are almost neglected."73 The next editorial addressed "German methods" at the University of Toronto. Again, the editor's bias is clear, as he excerpts a speech to the Canadian Medical Association (CMA) in 1912: "The German method of medical education is to tie the medical student to a microscope, as opposed to the English method of cultivating knowledge through the unaided eye. In Germany the aim is to make scientists first, and then doctors, whereas the primary purpose for which students learn science is to become physicians not scientists. For years American medical teaching has been dominated by the German plan of instruction. It is claimed we have been guilty of a fetish worship of laboratories in medical instruction and in medical practice."74 The speaker, Dean Hugh McCallum of Western University, was criticizing the Carnegie Corporation's overemphasis on "the laboratory side of medical instruction." No doubt, this refers to Flexner's preference for schools that featured "German methods." The editorial names fifteen Toronto faculty members, including H.B. Anderson, H.A. Bruce, and Fred Marlowe,75 who opposed "the German methods of teaching medicine." They no doubt could see what was to come - and the end of their part-time clinical appointments. This editorial asks what John T. Fotheringham, who "sacrificed much from a financial standpoint" to serve in the Great War and who wanted to work for his alma mater, could expect from the University of Toronto? The issue of "German methods" would continue to surface sporadically in the Canadian Practitioner during 1920 and 1921. It could be a mere point of elucidation/6 a discussion of governance at

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the University of Toronto, 77 or even a comment on worshipping laboratories in medical teaching and practice. In an ostensible obituary notice for McCallum, in March 1921, the editor again takes aim at German methods. He cites again McCallum's 1912 address to the CMA, claiming that North Americans "have become guilty of a fetish worship of laboratories." He takes up the cause of Fotheringham, who, like McCallum, disdained too much emphasis on lab work. The editor notes appreciation of McCallum's work at Western but forsaking of Fotheringham by Toronto. "This latter," concluded the editor, "may now be considered almost an old story, and, perhaps, the authorities of the University of Toronto think it should be relegated to oblivion. But that will not happen for a long time. A mean act of injustice is not soon forgotten." The lack of initiative on lab facilities and science teaching at Western, which this editorial was lauding, led to its poor evaluation by Flexner in igio.78 The unambiguous .support for the returning soldiers displaced at Toronto continued through the summer of 1921 in the Canadian Practitioner, evoking phrases such as "the gross injustice" to men who had "sacrificed much" and "the maltreatment of these University servants."79 A personal tone to the debate gave way only later to open criticism of the full-time system. An editorial contains excerpts of articles written by three alumni: Angus MacMurchy, president of the Alumni Federation; Lieut.-Colonel T. Gibson, who represented dismissed part-time teachers; and D.B. Gillies, a member of the university's Senate. The editorial points out that Gillies believed that the "whole ruction" came about "because some members of the staff in medicine are out and others are in." The editor agrees that the "personal element" was at the centre of the situation and that only when it is "sufficiently understood" will some resolution be possible.80 Another editorial criticized the curriculum's growing devotion to botany, chemistry, comparative anatomy, and physics. This shift was a result only of "teachers who have never been engaged in active practice" and who wanted more hours in the crowded and expanding curriculum. The editor disliked the six-year program, particularly because the added years went to "purely scientific" courses .8l Furthermore, scientific subjects were not the foundation of a good medical education, and the university was "making a fatal mistake" in dismissing experienced part-time clinical instructors in favour of a full-time professor with assistants. "Any system that pays the head of a department, say $10,000, and his assistants, who may be as competent, or even more competent teachers, nothing, is sure to fail. The final result of such a method is that the only assistants will be young and inexperienced men who wish to learn, and are willing to give up

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a few years without pay, with this end in view. It may be truly said of such under-teachers that there is neither pay, praise, or promotion in store for them. A most experienced teacher quite recently said: 'Thank God, I have nothing to do with the present ruinous system/"82 The editor described the new system as not sane and lamented the classes that would graduate without instruction from experienced teachers and clinicians.83 By January 1922 the debate was in full flower. It was no longer a personal or local issue. With the Rockefeller Foundation's announcement of its gift to Canada, and with examples available of full-time U.S. clinical teaching, it was obvious that the scope of this new pedagogy was growing. In its first issue of 1922, the Canadian Practitioner printed a summary of early Rockefeller-funded efforts at Johns Hopkins. The editor describes full-time positions as a "fad" and hopes that medical schools will soon "return to a sane and rational system of medical teaching."84 A barely veiled hint about interference from the Rockefeller Foundation appears in the excerpted words of Dr J.B. Deaver's presidential address to the American College of Surgeons in October 1921: "It is our profound belief that the system for full-time salaried chairs for the clinical branches which has been forced upon a number of our foremost institutions by powerful influence is not only contrary to the spirit of American institutions, and contrary to the proper working of the human mind, but is sure to result in degeneration of that art which is the true flower of science, and in the deterioration of the instruction of the student how to deal effectively with the problems which he must confront in his chosen life work."85 Deaver was a distinguished surgeon and professor of surgery in Philadelphia. An even more scathing indictment of Rockefeller involvement surfaced as a news item in March 1922.86 Originally published in Medical Record on 21 January 1922, it read: "To the members of the medical profession: The public and professions are being sold out to (i) foundation control of 'full-time' medical education, (2) lay board domination and the 'closed-up' hospital, (3) socialized state medicine, subsidized community health centres, and hospitals under university or political control, (4) legislature dictation of therapy and fees, (5) demoralization of medical standards by the expansion of cults, (6) exploitation of the specialties by lay technicians." Finally, an editorial in April 1922 summarized both points of view. "One in Favour of It" wrote that the non-practising instructor could spend more time reading journals; would never miss a class because of an urgent call to a patient; would be part of an organized and coordinated system that left fewer gaps and seldom duplicated mater-

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ial covered; and would have at his fingertips a wealth of clinical material in the hospital. "One Opposed to It" worried about too much abstract research that would not assist the ailing patient; too much emphasis on mastering the technology of medicine and too little on bedside manner and patient contact; and modern medicine drifting too close to the work of quacks, "untrained pretenders/' and Spiritualism.87 Coverage of the debate reached local newspapers and the national weekly newsmagazine, Saturday Night. On 6 May 1922, Saturday Night ran the story on its front page. The Rockefeller Foundation's was one of the "munificent gifts to be loaded up with conditions which make them liabilities [and] embarrassing conditions. No such handicap was placed on the donation to McGill University." The article blames, not the Foundation or its representatives, but the university's board and "a small and irresponsible clique which has its ear."88 The Drury Inquiry On 25 October 1922, a special committee appointed by the province began its general investigation into university administration at Toronto. It was to discuss the effect of the Eaton and Rockefeller gifts on medical teaching at the provincial university. Premier B.C. Drury chaired the nine-member committee which consisted of Herbert Hartley Dewart, George Howard Ferguson, Frank Howard Greenlaw, Thomas Marshall, Charles McCrea, Joseph McNamara, Charles Fletcher Swayze, and Edgar Watson. These nine members of the legislative assembly represented the Liberals, Conservatives, and Independents in Drury's United Farmers of Ontario (UFO) coalition government. Drury was an independent himself. The committee also represented various ridings: Grenville, Halton, Lincoln, Niagara Falls, Riverdale, St. Catharines, Sudbury, Toronto, and Victoria North. The average age of members was fifty, younger than many of the ousted physicians. Joseph McNamara, only thirty-five, had lost an arm at the Battle of the Somme and may have been more sympathetic to the dismissed veteran physicians. Howard Ferguson would go on to serve as Conservative premier from 1923 to 1930. The relationship between the university and the Toronto General was one of three issues for the inquiry. The other two were general administration of the university, as laid out in the act of 1906, and "the question of the divorcement of the Faculty of Education from Queen's University, Kingston and the establishment of the College of Education at Toronto."89 Fourteen meetings took place between November 1922 and April 1923,9° and forty-three witnesses testified.

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Falconer attended all the meetings, and the relationship between the university and its main teaching hospital was one of the most hotly debated issues. The committee reviewed the Toronto General Hospital Act, 1911, which stipulated that all appointments to the hospital staff, including the number and kind of services, were the prerogative of a Joint Hospital Relationships Committee, made up of four university governors and four trustees. This stood in direct opposition to Graham's making appointments or dismissals single-handed. The committee sought information from many sources to set Graham's reorganization into a wider geographical, pedagogical context. They collected reports on American and British education, including a royal commission's report on Cambridge and Oxford91 and thirteen bulletins. These reports addressed post-secondary education, from correspondence study and university summer schools to university and college salaries and analysis of education in faculties such as engineering, forestry, and medicine.92 One was a report by N.P. Colwell - Medical Education, igiS-iyzo.931 As secretary of the Council on Medical Education of the American Medical Association, he had accompanied Flexner on his 1910 visits. Published by the United States Department of the Interior, Bureau of Education, Colwell's fifteen-page booklet examined a number of issues, including needs in medicine revealed by the First World War, limiting enrolment, and both post-graduate courses for specialists and continuing education for physicians. Colwell also addressed the shift from part-time clinical instructors to full-time teachers. He acknowledged that, since the 18905, "teaching positions in the clinical branches were eagerly sought for and frequently held a high financial value."94 He cited the gradual increase since 1905 of "all-time," or full-time clinical instructors in U.S. medical schools, partly because of grants from the (Rockefeller) General Education Board and the Carnegie Foundation for the Advancement of Teaching. These grants stipulated that chairs of medicine, paediatrics, and surgery would be salaried instructors ineligible to receive fees for private practice. Their sole task was medical teaching. "Four [U.S.] medical schools are now definitely on that basis and two others are now making provision for such teachers," Colwell reported.95 Although this shift to full-time was underway, progress was slow because few individuals had both the requisite medical training and an interest in teaching full time either in the pre-clinical years or as full-time clinical instructors. If salaries were better, more qualified individuals might enter full-time teaching: "With the development of improved methods of clinical teaching there is a growing need of fulltime teachers in the clinical departments also. Some of these would in

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time develop the skill and reputation which would make them eligible later to occupy the full-time professorships in medicine, surgery, and pediatrics which are becoming more and more available."96 The Drury Inquiry also called for material on university education in Ontario, specifically at Toronto. The Eaton and Rockefeller gifts had received mention, for example, in the report of Ontario's Commission on University Finances (1921). This report presented Graham's appointment as a positive one - "already the good results are becoming manifest."97 The Commission had examined finances at Toronto, Queen's, and Western. H.J. Cody chaired the 1921 committee. The other members were A.P Deroche, T.A. Russell, C.R. Somerville, J. Alexander Wallace, and J.S. Willison. They filed their report on 10 February 1921. Three physicians who were vocal in their opposition to Graham's reorganization also appeared before this commission: Drs Anderson, Bruce, and Marlow. Like Colwell's summary of American medical teaching, this commission lamented the lack of teaching staff: "There should be enough instructors to allow time for original investigation. Unless the University leads in original thought, medical science will retrograde, and special research institutes can never exonerate a university from this duty."98 In addition to increasing the teaching staff, the commission suggested improved laboratories and noted that, even though lab facilities in the Hygiene Department were "moderately" equipped, those for anatomy and pharmacology were poor and for clinical departments non-existent. This situation needed rectification if "the student is to get the habit of independent observation and understand the functions of organs and tissues,"99 - a habit that the authors hoped would carry on long after medical school. The Drury Inquiry took up Graham's appointment slowly. Its public hearings began on 16 November 1922, and its first witnesses established some sense of Toronto's governance. The interviewees also touched on the financial responsibilities of the province, municipalities, and private citizens towards the university the Toronto General, and a new psychiatric hospital advocated for Toronto.100 Falconer, who attended all fourteen meetings, was called on to explain his role in decision-making and specifically his power over committees, faculty deans, and other associates. Although Graham's name did not surface in the early days of the inquiry, the committee was already establishing a line of attack for later questioning.101 Committees did much of the decision-making on new appointments, Falconer explained, or at least he sought the advice of a group within the faculty. The president could veto the choices, he admitted, but

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because all decisions were subject to scrutiny, he had to have an excellent reason to choose a minority candidate. Falconer emphasized repeatedly that if he acted against all advice, whether from a formal committee or informal consultations, he risked his own position.102 McCrea asked him: what if an advisory committee supported one candidate, the board of governors concurred, and only the president was behind another candidate? Falconer replied that even the united board could not appoint, despite being in agreement with the advisory committee, a candidate "over the head" of the president. As Falconer explained, "If there were an important appointment, and the Board of Governors agreed, as they understood, with the Advisory Committee, and the one man interested was the President, I do not see what else he could do. The point is, I have to stand the responsibility, or I have to resign."103 In the weeks that followed, Falconer stood almost alone defending Graham's appointment and reorganization of the faculty. Although no one called for Falconer's resignation, many observers believed that this controversy would cut short his tenure as president. After Falconer, Gibson addressed the committee on behalf of a group of alumni. He moved quickly to the president's powers in appointing and dismissing staff. He outlined his observations of English and American practice and suggested that Toronto placed too much responsibility on the president. He couched his statements in a tone of sympathy for a heavily burdened president: "the Royal Commission made a fundamental mistake, not only have they made a mistake in laying down the method of appointment, which cannot help but lead to friction and trouble, but they have imposed on the President of the University a duty which, if he will allow me to say so, is beyond the power of the President of the Toronto University, or of any other human being."104 Then veiled references to reorganization gave way to insults hurled at the full-time system, its supporters, and university administrators who let benefactors dictate how medicine was to be taught at Toronto. After one day of public hearings, Drury had to ask if there were any other individuals who wanted to testify. For a moment, it appeared as though the committee would finish quickly. But over the next few weeks, a steady stream of willing witnesses surfaced, a number of them displaced physicians. During the second full day of hearings, University Bursar Moure addressed salaries, the retiring-allowance contributions made by Carnegie, and benefactions to Toronto and McGill. He pointed out that the university budget went to academic and administrative staff

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(58-60 per cent); maintenance and operating costs (20 per cent); departmental costs, such as laboratory supplies, apparatus, and library books (15 per cent); and interest on capital charges and miscellaneous overhead costs (5 per cent). During 1920/21, there were twenty-six full professors in the Faculty of Arts, fifteen in the Faculty of Medicine, thirteen in University College, ten in Applied Science, and one in Forestry. The university received close to $100,000 in private benefactions in 1921 ($100,000 in "old endowments" went chiefly for paying interest for scholarships).105 Although the highest salary received by a full professor was usually $6,000, the professors of medicine (Duncan Graham) and surgery each received $10,000. Falconer interjected, "It should be remarked that those $10,000 salaries are paid one from the Eaton Fund and one from the Rockefeller Fund."106 Falconer added more on private support, engaging committee members in a debate defending Toronto against private schools such as McGill, Princeton and Yale, which seemed to attract larger donations more easily.107 He observed, "I think the more you can get the people to contribute to the University the better. On the other hand I do not believe a University that depends upon a few rich donors is quite as healthy ... A wealthy man might have undue influence if he paid for the chair. So I took the view, and I still hold to it, that a University is in a sounder position if it rests on the good will of the whole Province rather than depending on a few individuals."108 Even after the second day, the committee focused on hearing from key players on university governance and financial support. Mention occurred of the Eaton and Rockefeller gifts, but relatively little anger at the full-time system and reorganization of the faculty. The public hearings on 12 and 13 December 1922 debated full-time appointments. Anderson, president of the Medical Alumni Association's board, argued for involvement of the university's board and Senate in any departmental appointment.109 Gibson opined that a Senate committee should examine terms of gifts "offered to the University for the endowment of a Chair or the foundation of a scholarship."110 Endowments were as much an academic issue as a financial one: "a gift might very well be offered from a benefactor of the University on conditions which would make it impossible of performance, or if not impossible, inadvisable in the teaching part of the University."111 When pressed for details, Gibson, who was clearly referring to the Eaton Endowment, replied that he would speak later in the inquiry. Instead, Dr A.C. Hendrick, an elected member of the university Senate, registered his disapproval of the manner of Graham's

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appointment. Hendrick acknowledged that joining the faculty effectively meant joining the Toronto General Hospital. Conversely, dismissal from the university meant the same vis-a-vis the hospital. Hendrick criticized the higher salaries received by Graham and Brown and hypothesized that if the province paid $10,000 or $15,000 per person per year, there would be even more full-time instructors. He acknowledged that "it is a very great advantage to certain medical men to receive those appointments [to hospitals]/' since faculty appointments yielded hospital privileges, making the appointee a "competitor."112 Hendrick also criticized the medical curriculum's growing focus on lab work: "'We have got ourselves surrounded with the scientific spirit so much that we will have the opinion, after a while, that we are really very brilliant ... Gentlemen of the Faculty of Medicine, we feel that you are pressing a little too much the scientific side of the studies, so that when our students go out they are not practical men/"113 Hendrick also opposed the six-year curriculum and railed against specialization.114 Sir Thomas White, a former member of both the university's board and its Senate, also addressed the committee on 12 December 1922. White had sat on a committee making organizational changes to the Toronto General a decade earlier. He pointed out that private financial gifts, with their conditions, might restrict university governors and administrators: "I say if a man wants to give $100,000 to the University of Toronto, or a million dollars, I don't care what it is, I would not allow that man to fetter the hands of the Board of Governors of the University by attaching conditions to that gift which might raise dissatisfaction or be contrary to the interests of the University. It is unsound, and I say it is beneath the dignity of the University of Toronto to accept a gift, I don't care how much it is, provided it is fettered by conditions which might cause dissatisfaction in the Faculty, or among the public, or which may be, in any way, detrimental to the educational interest concerned.""5 White added that he was not referring to any specific gifts but had heard "that there have been one or more gifts of that kind." When questioned, White admitted that some qualifications might accompany a gift and that "unconditional gifts" were unlikely. White also told of the situation a decade earlier, when recent graduates complained that senior and even retired members of the "old guard" jealously guarded the part-time clinical positions. Younger men had little chance of breaking into the clique and these valuable positions. White had helped in the subsequent reorganization and felt qualified to comment on the current situation. He defended the

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president's efforts to gather information from as many individuals as he saw fit and then to name appointees unhindered by a "dictatorial" board.116 Dean of Medicine Alexander Primrose then summarized a meeting held 27 November 1922. Among the points discussed were whether appointment and dismissal rested with the president and whether a council-appointed committee should help him choose department heads within the Faculty of Medicine. Primrose reported that both parts of a resolution to those effects passed unanimously."7 The four meetings following the final public hearing on 18 January 1923 were for committee discussion, examination of the materials submitted, and the drafting of the report and bill for the legislature. A number of people dismissed by Graham submitted letters that entered the exhibits file and the committee deliberations. Dr Fred Marlow was one of the many dismissed physicians who opposed the reorganization of clinical teaching. He had good connections professionally, having served as president (1919-20) of the Ontario Medical Association. McKillop explains how, soon after Banting and Best completed their experiments on dogs in 1921, President Falconer began receiving "decidedly unpleasant letters," the first from Marlow. Marlow ended his initial missive to Falconer, "One is forced to believe that there is something radically wrong with the institution somewhere." Complaints followed from others dismissed like him.118 Like many of those who had strong opinions on full-time clinical education, Marlow submitted his letter to the Drury Inquiry, which labelled it Exhibit 19. He summarized his objections as follows: Objections to the full time professor (so-called) in the clinical departments at Toronto University are mainly these: 1. It tends to a degree to commercialize the teaching of medicine. 2. It replaces the preceptor plan of acquiring knowledge by the pedagogic art. 3. It must reduce the staff and eliminate senior teachers of valuable clinical experience who are capable of imparting instruction emanating from knowledge gained by experience. 4. It deprives the students of the great benefit of contact with such men and promotes the "spoon-feeding" system so much in evidence now. 5. It tends to over standardization of teaching and methods as well, thereby tending to obliterate individuality in both the teacher and the student. 6. It eliminates fair competition amongst teachers of medicine in its various branches. 7. It dispels the idea of service which has been handed down from generation to generation in medicine and lowers the ideals set up by our predecessors,

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inasmuch as the greatest pleasure that one gets from teaching in any branch of medicine is the feeling that comes to one when passing on to students the knowledge that one has acquired by actual experience, with the hope that through them, and still further developed by them, it may be the means of relief of suffering humanity, - a service which cannot be paid for in the coin of the nation. 8. It involves vastly increased and unnecessary expenditure to maintain even a decreased staff with higher remuneration, and especially to pay full time professors and assistants. 9. It tends to so much centralization of authority that a true democratic spirit and organization can hardly exist. 10. An ideal autocrat is about as common as the 'dodo' and even if the head of a clinical department were ideal it is obviously wrong to confer upon him autocratic power in respect of his associates and assistants who are all possessed of the same license to practice as himself and some of whom are of equal or more outstanding ability. Although his responsibility may appear great he cannot unburden his most junior assistant of any responsibility when he permits him to operate or even to prescribe a medicine in his hospital service. Outside of organization and administration his responsibility has been wonderfully magnified.119 G.W. Ross, who had voluntarily retired from the faculty at the time of Graham's reorganization, also expressed his dissatisfaction. Ross, who had almost ten years of teaching experience, wrote a twelvepage letter outlining his objections to the "obscure influence" governing medical education. He took exception to the reorganization of the Departments of Medicine, Obstetrics and Gynaecology, and Surgery, each of which, he charged, was an "illegal act," contrary to the governing statute.120 Ross also gave an anecdotal account of the meeting wherein the reorganization was announced. Although there had been earlier talk of reorganization, action did not take place until early 1919: At a meeting held then of a number of teachers in Medicine a gentleman in authority informed us that the plans for re-organization had been completed and that re-organization would proceed forthwith. I pointed out that such senior men as General Fotheringham, Col. Chambers, Col. Rudolf (as well many others less senior who had occupied important posts before proceeding overseas) were absent on military duty and suggested the impropriety of proceeding to re-organization until their return, especially since it might mean re-organizing some of them out of their academic existence. My objection was characterized as "pure sentiment" and the opinion expressed that sentiment must not be permitted to block plans already completed.121

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This letter, edited presumably by Ross, notes the "injustice" of dismissing "at least four eminent physicians";122 in the original copy, instead of saying "at least four eminent physicians," it lists J.T. Fotheringham, Graham Chambers, Colonel Anderson, and Major Thistle. A separate, anonymous memo, dated 25 April 1923 and submitted to the committee, lists, in addition to Fotheringham and Chambers, J.A. Roberts, Andrew Moorhead, John McCollum, and Herbert A. Bruce as others on military duty whose services the faculty had terminated. "It should be noted," the memo continues, "that all of the above were well-tried and efficient teachers and no suggestion had ever been made that they were not competent to carry on. They were summarily dismissed without notice and all except perhaps Dr. Bruce have suffered materially and in prestige."123 Finally, Ross outlined his suspicion of interference by persons in the faculty via the large Eaton and Rockefeller gifts. Ross wrote that the Eaton Endowment was unlike Eaton's typical benefactions. "Sir John was in the habit of determining the worthiness of a cause, then he gave freely and liberally as we all know, but he also was in the habit of leaving to others in whom he had confidence, the filling in of what one might call 'operating details.'" Ross cited Eaton's gift of a new surgical wing at the Toronto General as representative: no conditions attached. As Ross wrote, "he just gave his cheque to cover that estimated cost of the building. That was all."12-4 Ross concluded that Eaton had made his recent gift without condition and that his" "advisors for the time being" had added conditions. The four-page indenture, dated 9 January 1919, lists no obvious "advisors." Falconer, Graham, and other members of the faculty are not among the signatories.125 There was also a storm over the recent appointment of a new head of Surgery, Clarence Starr. As with the reorganization in Medicine, Starr replaced four co-ordinate chiefs with a single service and dismissed longstanding instructors. Ross described this move as the "summary dismissal of at least four efficient Surgeons ... while at the same time ... surgeons, although of excellent reputation, were retained who were beyond the statutory age limit." Ross blamed partly the Rockefeller Foundation: its gift, he said, allowed for this change.126 Public opinion sat squarely with the dismissed physicians, at least in the media. Following the public hearings of the Drury Inquiry, Saturday Night lauded those dismissed by Graham, "who was essentially a laboratory man. Since the crying need of Canada is for more general practitioners and not for laboratory men and specialists, the

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danger of this experiment are apparent to the layman." The article criticized the full-time system: "During the course of the enquiry the absurd argument was put forward that the day of the practical diagnostician was done, and the day of the laboratory man had arrived as though the hard-working physician in the rural sections of Ontario could afford to wait for laboratory tests with a dying man or woman on his hands/'127 An annual salary of $10,000 "for what is really a part-time service" was far too high in comparison with the highest salary paid to a professor in any other department and with the highest stipend paid ($1,000) to clinical professionals teaching part time under the old system. The article went on to condemn the system for promoting mediocrity: "The system will necessarily prevent the University getting the best men in the surgical field, for no man of outstanding ability will subordinate himself, and give up initiative and independence to supply a cog in such a Czar-like machine. The effect on the University as a whole, of these experiments, injustices and anomalies in its greatest, more expensive departments, is necessarily deplorable. So long as the University was employing men of eminence in private practice for part-time work, the latter could afford for the sake of professional pride in the institution and a sense of public service to accept moderate remuneration."128 Committee Report and Repercussions

Having reviewed more than one thousand pages of testimony and letters, the committee issued a twenty-page report, with eighteen recommendations and a draft bill, in May 1923. In addition to addressing the university's relation to the hospital, scientific research, and composition of the medical faculty, the report outlined hospital reorganization. It concluded that the reorganizations in the Departments of Medicine and of Surgery, "whereby a 'full-time' Professor was placed in charge of each of these services was detrimental to the best interests of the public and the medical profession, and violated the law contained in the schedules to the Toronto General Hospital".129 It noted the role played by the Eaton Endowment in encouraging, even mandating, the reorganization in Medicine and the Rockefeller gift's role in the reorganization in Surgery. With regard to the Foundation gift, it criticized the "conditions regarding salaries and the limitation of students, which, although having little bearing on the reorganization in Surgery, are, in the opinion of the Committee, highly undesirable."130 There was no mistaking the report's tone of derision and resent-

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ment towards both major donors for their perceived interference in the running of the medical faculty. The committee had originally included a recommendation - "That private endowments with conditions attached be not accepted in the future" - but omitted it from the final draft. It also dropped the following recommendation: "That the introduction of the Full-time professorship system was not advisable."131 In total, five recommendations addressed the teaching of medicine: 7. That generous provision be made for the furtherance of the efforts of those engaged in Scientific Research. 8. That the composition of the Council of the Faculty of Medicine be revised, so as to enable lecturers and instructors in the clinical departments to vote after serving as assessors for three years, and restricting the franchise in the primary (non-clinical) departments to full professors only. 16. Re Toronto General Hospital. (a) That the re-organizations in Medicine, Surgery and Gynaecology (1919 and 1920) be referred back to the proper authorities for reconsideration. (b) That the method of removal of certain doctors from the staff was unfortunate. (c) That a new agreement regarding Hospital appointments be entered into by the University and the Hospital. 17. That hospitals receiving Government aid guarantee against the practice of "fee-splitting" by doctors practicing therein. 18. That an effort be made to devise a means whereby doctors not on the University staff may have access to the public wards of the Hospital.132

The recommendation to support scientific research is interesting. No doubt it occurred because of the prestige that the discovery of insulin brought to the university and Canada. The province showed its commitment to scientific research when it passed the Banting and Best Medical Research Act in May 1923 to give $10,000 per year to support scientific research.133 The fall-out from the provincial investigation into the changes made by Graham affected the Rockefeller Foundation and its dealings with future gifts and requests for intercession. For example, the new fulltime dean of medicine at McGill, C.F. Martin, sent a telegram on 30 May 1923, asking Pearce to visit Montreal. Pearce telegrammed the next day: "It is impossible, and I consider it inadvisable for me to visit Montreal at present."134 Pearce in his diary acknowledged that, despite the problem of appointments in the teaching hospitals, "R.F. could not interfere in local problems" and "recent discussions at

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Toronto make it inadvisable that R.F. should take a direct interest in the present McGill problem." The "local problem" in Montreal receives analysis in chapter 4 and relates to the appointments of Drs Gray and Archibald. Pearce none the less states that if "McGill wishes to consider full-time arrangement in connection with Medicine and Surgery or some arrangement approaching full-time, the R.F. would consider carefully and thoughtfully any proposition that might be made to it." Despite the negative publicity in Ontario, the Foundation still sought the full-time system for Canadian schools to which it was offering aid.135 Macallum informed Foundation executives about the unfolding situation. He had a unique vantage point. An alumnus of Toronto and Johns Hopkins, he had returned to Toronto in 1887 to teach physiology and then biochemistry before going to McGill as professor of biochemistry, 1920-29, so he had intimate knowledge of both of Canada's premier medical schools.136 Acknowledged as an advocate and pioneer of scientific medicine in Canada, he chaired the National Research Council of Canada during its early years. "You will recall," he wrote to Pearce in January 1923, "that the Rockefeller gift of one million dollars was made the basis of charges against the University, and especially the Medical Faculty, the charges involving dictation of the policy of the University - a State Institution - by the Rockefeller Foundation."137 This insinuation of interference was exactly what the Foundation and Vincent had fought so hard to avoid. Macallum continued that he had managed to get such references to the Rockefeller Foundation stricken from the printed record, but that the battle continued. The attempt to restrict all clinical teaching at Toronto to fulltime instructors had led to the Drury Inquiry. That body recommended setting university governance, including the medical school, back to the situation before 1906 - namely, direct control by the province. Only the provincial election of 25 June 1923 and a change of government, from Drury's UFO to Ferguson's Conservatives, kep the medical school and the university free of government control. On 3 May 1923, Drury ordered printing and distribution of his committee's reports. Five days later the lieutenant-governor dissolved the legislature in anticipation of an election. In a brief, frontpage article in Saturday Night on 12 May 1923, the author questions the two-month delay in presenting the report and bill. This led to the report and bill's being "shelved on the ground that it was too late to discuss it." The article faulted Drury, who, despite showing early support for reform, "subsequently developed 'cold feet,'" but the author held out hope that "the incoming administration, whatever its political complexion, will make it one of its first duties next session

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to implement a similar or perhaps a more far-reaching bill." Of course, nothing more ever happened under Ferguson, who had signed the original 1923 bill. When he became premier, Ferguson himself took on the education portfolio.138 Perhaps longstanding lack of support from the province allowed major philanthropies to sweep in and set policy. But, even with the support of Whitney's Conservatives (in office 1905-14), these grants could not keep up with the university's growth. Hence any other source of funding was more than welcome. Any conditions seemed perhaps a small price for the capital for expansion, particularly if like-minded individuals leading the way vetted the conditions. There is also the issue of medicine's becoming a state-supported and serving profession. Both the Eaton and the Rockefeller benefactions represented gifts to a state school at Toronto. The General Education Board, in its early gifts to American medical schools, vowed not to support state institutions, because these already had funding. Much of the rhetoric of the period, with regard to Toronto, spoke of training physicians to serve the people: if the people's money went to the provincial university, then its graduates should serve the people.139 This idea was the subject of a 1920 editorial in the Canadian Medical Association Journal.^0 The author, commenting on an article by Professor Fraser Harris of Dalhousie, wrote about a movement to make physicians "servants of the state in a public department similar in status and practice to the civil service." Harris pointed out logically that, since preventive medicine in the form of public health was already a government department, why not make curative medicine one as well? "The author pictures a time when all medical instruction will be given by state aided universities and when on graduating, each student would automatically enter the state medical service (SMS) and choose whether he would serve the state in the practice of medicine, or of surgery, or of obstetrics, or as a pathologist, or bacteriologist or hygienist or some other "specialist" or expert ... and it is contended that all medical men should give up the wearisome, unorganized competition of private practice and become the valued (and pensioned) officers of the noblest state service that can be conceived of."1*1 Harris believed that medical researchers would have a role in this plan. He acknowledged that researchers receive poor remuneration for their expertise. This breed of physician "has an aptitude for research [but] finds himself unable to support himself unless he accepts a teaching post which may demand too much of his time and may be very poorly paid."142 Harris would have researchers on par with practising physicians as officers in the state medical service. In

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return for their support of this model, the people, especially the poor, would receive physicians of the highest skill, and all methods of treatment and diagnosis would be available to the entire population. Harris's model highlights both the class-based, social hierarchy in health care and the inequity in pay between researchers and clinicians. It seemed as though the perceived autocratic way in which the Eatons and Rockefellers "dictated" to the provincial university angered the Drury Inquiry. Drury ran a coalition government, which saw itself as guardian of an independent, state institution, charged with educating people for tomorrow's Ontario. The philanthropists were wealthy and seemed to be buying influence, as the Rockefellers had apparently done in the United States. The two sides inevitably clashed on this issue, particularly as it involved such charged elements as returning war veterans and changes to the status quo. Nor did inconsistencies help, such as retaining some instructors who were past retirement age while dismissing others who were younger. A U.S. FIGHT FOR FULL-TIME MEDICINE

Toronto's brush with losing ground on the full-time initiative was not the only such case in North America. As Cangi writes, the University of Cincinnati College of Medicine saw a similar backlash in 1921. That year, George Heuer, a protege of William Stewart Halsted's at Johns Hopkins, arrived at Cincinnati to take up a Foundation-sponsored full-time post in surgery.143 Heuer's post was not the first fulltime clinical appointment at Cincinnati. In 1917, Roger S. Morris took over the first full-time chair of medicine, and, in 1920, Kenneth Blackfan (like Heuer, from Johns Hopkins) became the full-time professor of paediatrics. Unlike Heuer, neither Morris nor Blackfan faced the wrath of their peers in the Cincinnati medical establishment, and both maintained private practices in addition to their "full-time" clinical teaching duties.144 Like Graham had in Medicine and Surgery at Toronto, Heuer soon reorganized his department. Cangi writes, "It is worth noting, that only four Cincinnati surgeons survived his scrutiny including J. Louis Ransohoff, Frank Fee, Dudley Palmer and J.A. Caldwell. The rest Heuer dismissed."145 She acknowledges that Heuer upgraded the curriculum, also a goal at Toronto. For their efforts, Heuer and Graham, as well as the supporting philanthropists, received severe criticism. For example, soon after he arrived, members of the Cincinnati College of Surgeons attacked Heuer. At a dinner in Heuer's honour, the toastmaster and professor

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of gynaecology, Charles Bonifield, warned against "gifts of gold" from philanthropists, which threatened schools' freedom and independence.146 In editorials in the Journal of Medicine, Bonifield had railed against colleagues who fought for Carnegie and Rockefeller gifts, seeking to woo full-time medicine and research. Bonifield was also editor of the Journal of the Cincinnati Academy of Medicine ,147 Like many in Toronto, Bonifield felt that the medical school existed to train practitioners, not scientific researchers. "Schoolmen professors" had no place in colleges that existed to educate private practitioners, he said.148 Samuel P. Kramer, a former professor of clinical surgery at the faculty, took the college of medicine to court in 1924. He alleged that the General Hospital had illegally set aside one ward for Heuer's private use. "This situation had developed, Kramer charged, because Christian R. Holmes [dean of the medical school, who died in 1919] had traded the school's independence for money from the Carnegie Foundation and the General Education Board," Cangi explains.149 The Supreme Court of Ohio agreed with the critics, and Heuer and his supporters had to find another full-time "research ward". Using connections and the financial support of prominent local families, they opened the Christian R. Holmes Hospital of the University of Cincinnati in May 1929. The new facility featured forty-two private beds and a surgical suite. Despite the venom and the early setbacks, Heuer and the full-time system flourished in Cincinnati.150 CONCLUSION: THE ROCKEFELLER GIFT AND TORONTO The Rockefeller Foundation gift not only changed teaching, but also illuminated the state of the profession and encouraged self-analysis and reflection. One of the most tangible influences was a condition of gift: a commitment to matching funds from government and/or the public. One million dollars was a substantial amount to raise. Toronto medicine had little steady alumni support, because of the separate histories of its component schools. The Eaton Endowment had no condition of matching support. The Foundation gift forced Toronto alumni to "pull together." In terms of publicity and increased prestige, the discovery of insulin did the most to establish the merit of scientific medicine and medical research. It is ironic that Fred Banting had little laboratory or scientific research background and was a physician trained in the old style to practise. The Foundation benefaction also increased the prestige of the

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Toronto Faculty of Medicine, but its direct influence on other private donors is less marked than was the McGill gift. Toronto medical teaching had a more checkered history and could not rival McGill's in alumni and private support. From 1919 to 1921, McGill received more than $12 million in private gifts, while Toronto recorded none.151 Despite the 1923 commission, Toronto did have provincial support. For example, the university received $527,400 in provincial and municipal grants in 1919/20, compared to McGill's $ioi,o68.152 Finally, the gift, and its matching funds, helped certain "longstanding" ideas become realities in Toronto: greater scientization of medicine; establishing the "research ideal" in Canada; setting up a pedagogical mechanism for continuing education for medical graduates; and offering post-graduate degrees that began to slow the "brain drain" to the United States by training instructors and paying them a competitive salary to be full-time instructors in Canada. After Graham's appointment was secure, scientific medicine had an assured place at Toronto. The scientization of medicine had a long history in Toronto and involved laboratory work, clinical teaching, and eventually research careers. McRae credits Ramsay Wright and Macallum153 for the strong tradition, dating back to 1880. They nurtured the trend to the point where, when money became available, the status of science within the medical school could increase yet again. By 1920, there had been laboratory work in the premedical sciences at Toronto for more than forty years, and students received solid lab training. The German tradition, which educators had learned about in the 18705, had become a successful import, and now was an integral part of a U.S. or Canadian medical education, partly because, as Ludmerer and Hudson have pointed out, so many reformers had studied in Germany during the height of the laboratory revolution.154 While the younger generation of reformers, after 1870, had a direct link to lab methods through the German tradition, the older physicians inclined to the clinical tradition of their French and English instructors. There was a professional tension between the two groups. The clinicians mistrusted the laboratory and the role of the basic sciences in medicine. Ludmerer cites a professor of pathological anatomy "so uninformed ... of the advances in medical science that in 1870 he confessed his inability to use the microscope."155 In exchange for their investment in science, and particularly in laboratories, physicians gained new authority. 156 The lab, as Warner says, was a force for elitism; it produced a privileged body of knowledge available to only a few. In this way, medicine remained a mys-

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tery. The result was the growth of specialties and the fractioning of the profession, as researchers spent more time in the laboratory and clinicians had to determine how much time they could spare for the lab. If the lab was at the centre of the first phase of scientization, a second phase was that of clinical teaching. Again, some educators with foresight had made inroads. But the cost was immense. It would take philanthropic gifts to support a radical shift such as full-time clinical scholars, and there was no way to make this change gradual. In the face of great resistance, the full-time system would triumph, but not without problems. The problems would lead the Rockefeller Foundation in 1919 to scale back its full-time expectations of grant recipients. Geographic full-time teaching became the norm, and the earlier "threats" of losing grant money for inadequate implementation gave way to a hands-off, non-interfering policy. Once the commitment and resources were in place, the shift to fulltime took place. Whole departments, filled with part-time clinical instructors, disappeared in favour of fewer full-time teachers. Administrators deemed it beneficial if the physician could learn from the laboratory as well as from the patient and to recognize relationships between symptoms and disease. To do this required a dedication that rivalled that of the scientist. As Flexner wrote, "The laboratory men are heroes - men of ideals who have stood up to their jobs for the sheer love of science!"157 It also required the financial support to take men away from their lucrative practices and entice them to teach full time on a competitive salary. The third and final product of this scientization and full-time clinical teaching was research careers. Now that there was full-time teaching, and that the discovery of insulin had realized the benefits of full-time research, there was no turning back. Li credits the pioneering work of Wright and Macallum at Toronto with setting the stage for an entire Canadian medical research industry. This came to pass in three distinct stages. The first involved Wright and Macallum's efforts to establish honours-stream programs in biochemistry and physiology in the 19005 and 19105. The second phase, following the war, was represented by the generation of J.B. Collip, a biochemist from McGill, who expected research to be part of a physician's career as a healthcare professional. The third, from the 19205 on, was the creation of a social identity for these researchers, with their own professional organizations such as the National Research Council (NRC) and publications. In the original model proposed by Gingras, the phases are the emergence of research practice; the institutionalization of research, which "reproduced" the next generation

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of researchers; and the creation of a social identity through scientific societies and journals.158 On 8 May 1923, the Ontario government put the research ideal on a firm footing. That day, the legislature passed the Banting and Best Medical Research Act, 1923. Introduced by Drury on 27 April 1923, it appropriated $10,000 per year for medical research: "it is believed that prosecuting the research will result in perfecting a remedy for the cure of that disease, and it is desirable and expedient in the public interest to provide by legislative grant for the continuation and prosecution of kindred researches."159 Despite the repercussions of the radical changes imposed by Graham immediately following the Eaton gift, the appointment of a fulltime chair in clinical medicine led to significant pedagogical and organizational changes. These included: a reorganization of the Toronto General Hospital that resulted in more efficient teaching; systematic post-graduate training; an emphasis on laboratory research, coupled with clinical practice; and, for the first time in Canada, fair remuneration, in the form of salaries paid to full-time, university-based junior researchers in internal medicine.

4 Building on Strengths at McGill: The Nation's University

The situation at McGill University's medical school in Montreal in 1919 was not the same as Toronto's. Although McGill, like Toronto, was to receive U.S.$i million of the $5 million allotted to Canadian medical education by the Rockefeller Foundation, it matched, spent, and viewed the gift very differently from Toronto. McGill was not Quebec's "provincial university" - in fact, it billed itself as the "nation's university."1 Even William Macdonald, one of McGill's greatest benefactors, thought the university a national institution. This view of McGill gained substance from its affiliation, as a sort of senior or finishing institution, to a number of smaller Canadian schools. For example, after two years of study in the engineering/ applied science faculties at any of Acadia University, Mount Allison University, Royal Military College, St Francis Xavier College, or the University of Alberta, students would move on to McGill for their third year. This was also true for Alberta's medical program; students who had completed three years in Edmonton could then travel to McGill for fourth year. Internationally, McGill had similar arrangements regarding arts and applied sciences with Cambridge and Oxford Universities and the University of Dublin.2 Of Canada's seven medical schools in 1919, McGill's had the most solid international reputation: unlike Dalhousie (formerly Halifax Medical College) and even Toronto, it had had no prolonged periods without instruction. The two medical schools west of Toronto - at Western and Manitoba - affiliated with a university only in 1913 and 1918, respectively. Finally, Queen's medical school had a tumultuous past,

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particularly in funding and acceptance of female students, and Laval's offered its instruction in French. As at Toronto, the Rockefeller gift of $1 million to McGill was significant on many levels. First, there was the influence of the name; even people unaware of the Foundation's history or of its interest in aiding medical research and education knew about the family's wealth. Almost everyone welcomed any philanthropic investment that the family or its Foundation wished to make in Canada. It was worthwhile to mention the name when seeking additional government or private funding: if the Rockefellers could assist Canadian schools, so could Canadians themselves! Second, the Foundation required that Canadian governments or private donors match its gift. Hence, whatever it gave would at least double. Third, the Foundation's gift and its influence were not only timely but also necessary for the survival of a modern medical school. If McGill's had to rely on student fees, it could not retain its solid reputation. In 1919, sessional instruction brought in $66,456.78. Salaries alone totalled $52,815.95, and light, heat, and power, $20,477.76. Revenue from endowments and bequests amounted to only $58,256.51. Total expenditures were $112,136.89, plus $4,626.40 in hospital and society fees.3 The Rockefeller million was equivalent to almost sixteen years' worth of student fees. This chapter looks first at the McGill medical school's long history, including its strong community support and war record. It then examines the Rockefeller Foundation's crucial role in transforming clinical instruction at McGill. It finally considers the aftermath: the Foundation's other gifts to McGill and a battle in the mid-i92os over appointment of clinical instructors. M C G I L L M E D I C A L S C H O O L : A LONG R E C O R D

Community and Support McGill has the longest history of medical teaching in Canada. The independent school, set up by four Scottish physicians in 1823, became the Faculty of Medicine at McGill University in 1824 - almost two decades before King's College, Toronto, founded its Faculty of Medicine (1843). McGill was the lone option for English-language medical training in Montreal, a point duly noted in the seventeenpage "Supplementary Report to the Rockefeller Foundation from the Medical Faculty of McGill University" (submitted 11 May 1920). The report added: "over 4/5 of the population in our province being

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French, this Faculty can depend on less than one-fifth of the community for sympathy and financial support."4 By the time of the Rockefeller gift, McGill had been graduating physicians for close to a century. By contrast, medical teaching in Toronto had unified only in 1903/04, when Trinity Medical College amalgamated with the University of Toronto medical faculty. Montreal had had constancy in English-language medical education at McGill, while in Toronto various private and college-affiliated medical schools had opened, closed, and even reopened. When Toronto and McGill asked alumni to match the Foundation gift, those in Montreal had a far easier time, given a mature, unified history. Despite the minority anglophone presence in Quebec, support for McGill and medicine was considerable and consistent. McGill also had a long history of sizeable local gifts, and the medical faculty benefited as much as other university departments. Three of the most significant donors were Donald A. Smith, William Macdonald, and J.H.R. Molson. Molson, of Molson's Brewery Limited, gave money to expand the medical buildings in 1895. The new facilities included a lecture hall for 450, a large chemistry laboratory, and, as Frost notes, "provision for physiology, pharmacology, histology, and a dissecting room." A faculty that, by 1898, included more than 400 students in a four-year course, needed all this.5 Smith, chancellor of the university from 1914, was a prominent Montreal businessman. In addition to serving as a governor of the Hudson's Bay Company and president of the Bank of Montreal, he was also a principal shareholder in the Canadian Pacific Railway and a member of Parliament for Montreal West. Finally, Smith in 1897 became a baron Lord Strathcona and Mount Royal. Among the projects that he endowed at McGill were the "Donalda" program for women's education (this would, by 1924, total $1,202,500); the building with his cousin George Stephen of Royal Victoria Hospital; a medical faculty endowment fund ($50,000); chairs in each of pathology and hygiene (totalling $100,000); and gifts for additional resources in 1898 ($100,000). This las gift went for urgent building extensions.6 Frost shows that, fortunately for medical education in Montreal, in 1888 Smith's only child, Margaret, married the son of Robert Palmer Howard, dean of medicine 1882-89, which only increased Smith's interest in medical education.7 Smith also persuaded William Peterson to become principal of McGill (1895-1919). During Peterson's principalship, science and professional fields such as medicine prospered and total endowments grew from almost $1 million to more than $12 million.8

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McGill's other major patron was William Macdonald. Among his benefactions in science were $700,000 towards erection of the Chemistry and Mining Building (1898) and endowment of two professorships in chemistry and a chair of mining and metallurgy. Macdonald also supported the Faculty of Applied Science and departments of agriculture, architecture, botany, and geology with gifts in excess of $8oo,ooo.9 In fact, as Frost notes, during the 18905 and 19005, "Macdonald almost single-handedly financed and maintained the science departments of McGill University on a scale which gave them firstclass potential throughout the world."10 But what of medicine? When he died in 1917, the benefactor and chancellor bequeathed $500,000 to the faculty. Estimates put Macdonald's total benefactions to McGill, excluding bequests, at close to $11 million.11 Toronto had nothing like this! Only Vanderbilt University's medical program had a larger endowment, receiving $17.5 million over the same period from the (Rockefeller) General Education Board.12 Toronto and McGill differed also in the amount of provincial support. While Toronto had sporadic support until 1900, McGill received even less. For example, by 1911, Frost notes, while Toronto was receiving $750,000 in annual grants, McGill's statutory grants totalled $3,000. McGill had a legacy of relying on wealthy private donors. By 1911, however, the Quebec government was willing to support institutions such as the ecole des etudes commerciales, ecoles polytechniques, and even Laval University far more substantially than McGill.13 Anglophone Montrealers became accustomed to supporting McGill and, when called on, particularly in 1911 and 1920, responded generously and in record time. As McGill biochemistry professor A.B. Macallum wrote in 1922 to Pearce, "McGill has to depend wholly upon a constituency in which the French-Canadian element plays no part."14 Macallum went on to tell Pearce that financial support from the province was not likely, particularly since it had just given $100,000 to the Universite de Montreal for the Radium Institute for the treatment of cancer. Like Toronto, McGill absorbed a smaller medical school. In 1905 it took over the rival medical faculty of Bishop's University in Lennoxville. Although Bishop's was in another town, its medical faculty was in Montreal.15 The following year, Principal Peterson also took the initiative to establish McGill University College of British Columbia, and he served as its first principal. Although this satellite college merged with the new University of British Columbia in 1915, the legacy remained. Many students from western Canada travelled

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to McGill, first to complete the third and fourth years of their general programs and often to enter McGill's medical school. The University of Alberta would not have a full program in medicine until the mid19208, and the University of British Columbia not until 1950. The closest geographical option for BC medical students would have been Manitoba Medical College, established in 1883.l6 Not only did McGill's new Medical Building offer space for the growing student body, but more and more medical students were choosing McGill "for the new laboratories and equipment that the broadening conception of medicine demanded."17 Clinical instruction took place at Montreal General Hospital (opened in 1822), Royal Victoria Hospital (1893), Montreal Children's Hospital (1904), and later the Montreal Neurological Hospital and Institute (1934).l8 As for financial management, Frost points out that as recently as 1895 the 'corporate body' of medical professors had continued to manage its own affairs.19 It was not until 1905 that the faculty relinquished financial autonomy to become entirely a constituent part of McGill, governed by and contributing to the university. In 1905 the faculty suggested extending its course from four to five years. Frost writes that the estimated cost of this change was about $10,000 annually in operational expenditures, so Smith gave $5O,ooo.20 War

Effort

When McGill heard of the Rockefeller Foundation's decision to aid Canadian medical education, announced 25 December 1919, the timing could not have been better. For so many years, McGill medicine and the university had turned to Smith and Macdonald. But by 1919, both men were dead, and even though they left legacies, McGill needed other forms of support. One such source was the Carnegie Foundation for the Advancement of Teaching. Peterson oversaw great growth in McGill and the Faculty of Medicine during his long tenure. As Frost notes, "Within three years of Peterson's arrival, the number of students in the four years of the undergraduate [medical] course had gone beyond the four hundred mark and not only the available space but also the financial resources of the faculty were consequently under severe strain."21 This strain resulted from an ambitious building program, a fire, and the university's taking over the medical faculty in 1905, the same year the medical program expanded from four years to five.22 It was during Peterson's reign that the medical facilities grew substantially and the university found the wherewithal to fund the

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expansion. In 1907, fire destroyed all but one of the annexes of the new Medical Building and, a week later, the Macdonald Engineering Building. Although Macdonald funded the rebuilding of the latter (opened 1909), the new medical facilities would not be available until 1911. McGill paid for the new Strathcona Medical Building, which cost $1 million from insurance funds and $500,000 from Smith.23 Peterson oversaw two major financial campaigns in 1906 and 1911 valuable precedents for fund raising when the Rockefeller Foundation demanded matching funds for its $1 million gift. Peterson's connection with the Carnegie Foundation for the Advancement of Teaching goes back to its beginning. Peterson became one of twenty-five initial trustees when the Foundation, with a $i5-million endowment, started in 1905. During McGill's financial campaign of 1906, its board of governors took advantage of Peterson's connections and "dined and wined Andrew Carnegie"24 in an attempt to entice financial support for McGill. Frost tells how shipping merchant Robert Reford challenged Montrealers to raise $1 million to aid the McGill General Endowment. If they met the challenge, Reford promised he would contribute $50,000. In the campaign of 1911, he donated $100,000 of a total $1.5 million raised in just five days. Although the effort to obtain Carnegie support was unsuccessful, it did generate a spirited campaign aimed at Montrealers. In 1911 Peterson was trying to maintain some of McGill's most crucial resources - namely, many of its "world-class" academics. Frost gives the example of pathology professor J.G. Adami. In 1912, the University of Chicago was courting Adami with a salary of $9,000 per year - almost three times his stipend at McGill. Adami let Peterson know that he would remain at McGill if his salary increased from $3,500 to $5,ooo.25 Adami was not the only professor to approach Peterson with such a request, and some of the money raised in 1906 went to this purpose.26 Peterson's efforts were not in vain. The Carnegie Corporation announced on 25 February 1918 a grant of $1 million for McGill. Like the Rockefeller gift to McGill's medical school, the Carnegie grant recognized McGill's contribution to the war effort. Frost, however, notes that Carnegie Corporation directors had made the gift originally to honour Peterson's years (1905-18) as trustee and then chair of the Carnegie Foundation for the Advancement of Teaching. Peterson had asked that the announcement instead associate the gift with McGill's wartime efforts and sacrifices.27 The university's wartime endeavours were substantial. Frost estimates that 60 per cent of all eligible graduates and 65 per cent of all eligible undergraduates served - in total, more than 3,000 people.28

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John D. Rockefeller, Sr, suggested that the Rockefeller Foundation consider aiding medical education in Canada, partly to recognize Canadian wartime participation. McGill was the first Canadian university to establish an Officers' Training Corps in 1912. Furthermore, the Graduates' Society organized a provisional battalion that drilled on campus and eventually combined with the training corps. By 1914, there was a group of more than 600 men ready to go overseas, and the unit continued to train many more from 1914 to 1918. McGill men served in various companies, including the 7th and loth Siege Batteries, also commanded by people from McGill, and twenty-six officers and 186 men from McGill joined the Tank Battalion, made up almost entirely of Canadian university men.29 As with Toronto, McGill students, alumni, and faculty members staffed their own hospital - No. 3 General Hospital. Officers were either faculty members or graduates of the medical program, and the remaining men were students. The capacity grew from 520 to 2,100 hospital beds, and, to the beginning of 1918, No. 3 treated 100,000 patients, with a mortality rate of half a per cent among nonsurgical cases and 2.5 per cent among the 7,000 surgical cases.30 The commander of the hospital was Colonel H.S. Birkett, who took a leave of absence as professor of otolaryngology and dean of medicine from 1914 to 1921. A.D. Blackader, professor of pharmacology, therapeutics, and paediatrics, served as acting dean during his absence. Birkett returned to McGill in 1918. C.F. Martin became the first full-time dean of medicine in 1923. Birkett's second-incommand overseas was J.M. Elder, assistant professor of surgery, who had resigned from the university to protest the hiring of a German pathology professor. The medical faculty distinguished itself in its level of war participation (849 men, of whom 630 were graduates, enlisted) and, in decorations awarded: 198 of the 791 medals, decorations, and mentions in dispatches accorded McGill students and alumni. Only Applied Science had more enlisted (1,188) and decorated men (352). The medical faculty lost eighteen graduates, nine undergraduates, and four "past students" - relatively few among the university's 363 who die or were killed on service. In total, 3,059 graduates, undergraduates, and past students of McGill enlisted in the Great War. Perhaps the most famous was John McCrae, author of the poem "In Flanders Fields." A graduate of the University of Toronto medical school and a professor at McGill's when he enlisted, McCrae went first to an artillery unit on the Western Front and then to McGill's No. 3 General Hospital. He died, of pneumonia, while on active service in January 1918. Another faculty member, Auckland Geddes, also left Montreal

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to join the war. A professor of anatomy at McGill since 1913, he was the first commander of the Officers' Training Corps. By war's end, Geddes was a hero and had been knighted. McGill chose him to replace Peterson as principal in 1919, but he resigned in 1920 to become British ambassador to Washington. His successor was another war hero, General Sir Arthur Currie. Currie would see the Rockefeller Foundation invest almost $3 million in McGill medical teaching and research, beginning with the $1 million endowment of 1920. Currie died of a stroke in 1933 and, though aware of the Rockefeller gift in neurology, did not live to see the Montreal Neurological Institute built.31 The role of personal contacts and debts to be repaid is subtle yet important in philanthropic giving. The Carnegie gift of $1 million no doubt related more to Peterson's long stint with the Carnegie Corporation. But what he gained in shifting the spotlight from himself to the university's war effort he lost in ill-feeling: other universities too had interrupted their teaching and given up their young men and women. They resented McGill's being singled out for the Carnegie gift. Frost observes that the Carnegie Corporation felt no obligation to provide similar aid to any other Canadian medical school, largely because the most vocal protests came from Toronto, which received considerable government support. The Faculty in 1919

As in Toronto, medicine at McGill enjoyed growing enrolment immediately after the war. By 1919/20, it had more than 500 students. Birkett had returned as dean, and under his guidance the five-year program went to six-years by 1919/2O,32 but with war veterans exempt from the extra year. But increased enrolment pressured both resources and facilities. Although the new medical building was less than a decade old in 1920, the faculty was seeking new space. It prepared a detailed report of revenue and expenditures for 1918/19, which included reports from each department. It sent a copy to the Rockefeller Foundation. The document mirrors Toronto's "wish list" and explains how McGill was to remain a leading medical school. For 1918/19, revenue from fees alone was $66,456.78. All other sources of revenue, including bequests and income from existing endowments, contributed $64,485.51, for total revenue of $130,942.29. Expenditures totalled $116,763.29, of which almost half went to "salaries for instruction," which did not include the Dr. J. Douglas Research Fellowship or Studentship in Pathology or the "Wages of Laboratory Assistants, Boys,

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etc." The revenue includes $58,256.51 in endowment funds in addition to items as small as $123.05 for sale of haemacytometers (sic), $4,202.75 in hospital and society fees, and $996 in fees and a provincial grant to the Department of Pharmacy.33 Medical departments sought a range of items, from individual pieces of equipment to more buildings. The interruption of the war, the increase in post-war enrolment, and extension of the medical program to six years combined to bring about both the evaluation and the Rockefeller gift. Sentiment for McGill's fallen spurred generous giving and acknowledgment of the need for investment to maintain McGill's reputation. When the call went out to match the Foundation's gift, the university raised more than $1 million in less than a week. The city noted that McGill's medical enrolment was increasing, from 2,150 in 1914 to about 3,000 and growing after the war, and disciplines such as medicine aimed to embrace new areas of research and more teaching. The successful methods of previous fund-raising worked again. The campaign employed quasi-military tactics. As they had in 1911, E.W. Beatty, W.M. Birks, and John Ross organized teams and captains for the fund-raising blitz of a single week in November 1920. Principal Currie acted as a sort of commander-inchief and spread the word during a series of speaking engagements and visits to Graduates' Society chapters throughout Canada and the United States.3* In one week, the campaign raised almost $6.5 million. The beneficiaries in medicine were the departments of Pathology, Physiology, and Psychiatry, each cited for improvements by the Rockefeller Foundation. The Quebec government matched the Rockefeller gift. Finally, Osier, perhaps McGill's most famous alumnus and former professor, asked Birkett to expand clinical teaching and research at McGill or risk falling behind the leading U.S. and Canadian schools. In a letter of 28 August 1919 from Oxford, Osier advocated "active co-operation of University and Hospitals"35 towards establishing new methods and organization of clinical boards at each of McGill's two teaching hospitals: "The Principal, the President of each hospital, with two collegiate and two hospital representatives to form each Board, which would be separate and independent and would control the appointments of the Heads of the Clinics."36 Osier envisioned eight to one hundred beds for each medical and surgical clinic, as well as corresponding out-patient departments, "ample clinical laboratory facilities," and separate budgets for each clinic.37 Osier did not, however, advocate full-time clinical teaching. He continued to support both full- and part-time assistants, "with

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Building on Strengths at McGill

salaries ranging from $3,000 to $i,ooo."38 He did suggest that the professors in charge of each clinic would be "whole-time" men, "or if thought wiser, largely so," with annual salaries of $10,000 paid by both the university and the hospital. Osier also saw these appointments being made by the clinical board or by an ad hoc committee that it named to appoint them.39 But even this initiative remained on paper until the Rockefeller announcement of December. Osier concluded, "Possibly the Rockefeller Board might help, but this is a citizen's affair which should appeal to all who are anxious to see Montreal keep in first rank as a medical centre."40 A handwritten note following Osier's signature reads, "In Sept. President of R.V. [Royal Victoria] Hospital answered Osier that finances did not permit of any action at present."41 The heads of the clinical departments at McGill nevertheless met on 24 November 1919 to discuss Osier's suggestions "clause by clause."42 They agreed with "largely full-time men, to be paid an adequate salary," as heads of clinics, with "whole and part-time" assistants "appointed by the clinical Board in consultation with the head of the department concerned." This replaced Osier's suggestion of assistants named by the professor and appointed by the clinical boards.43 The meeting concluded with the "opinion that this scheme of reorganization can not be carried out until the Faculty receives a very large addition to its present endowment."44 THE ROCKEFELLER FOUNDATION AND CLINICAL INSTRUCTION

Richard M. Pearce made a series of visits, sometimes accompanied by Foundation President George E. Vincent, to the Canadian medical schools from 6 March to 14 July 1920. Pearce visited McGill four times in 1920: on 11 March, 11 May, 4 and 5 June, and 8 June. He concluded that McGill was worth the investment of $1 million. His first visit to Montreal followed inspections of the medical schools at Manitoba and Toronto. Manitoba Medical College (1883) nacl just in 1918 become the Faculty of Medicine of the University of Manitoba. It was earmarked to receive $750,000 from the Foundation. Pearce ranked it third behind Toronto and McGill. He noted that it "serves practically the entire territory west of Ontario."45 While in Winnipeg, Pearce met with Henry Marshall Tory, founding president of the University of Alberta (1908). A McGill alumnus (arts, 1890), Tory became first principal of McGill University College of British Columbia in Vancouver in 1906. Although Alberta did offer the first three, pre-clinical years of education, students took their clinical training at Toronto, McGill,

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or Manitoba. Tory explained to Pearce the plan for a full course in Edmonton by 1922, and Pearce was aware of the need for more medical instruction in the expanding west. Vincent accompanied Pearce on a tour of McGill's clinical teaching facilities at Montreal General Hospital and Royal Victoria Hospital, and they dined with Sir H. Vincent Meredith, chair of the board of governors. That same afternoon, Pearce and Vincent inspected the medical buildings at McGill. They spent the evening with the governors of both hospitals and medical school faculty members, and they addressed the group at the Royal Club. After one day's inspection, Pearce concluded: "McGill Medical School ranks with, or perhaps second to, Toronto and is housed in a really magnificent building. If there is any criticism it is that too much space has been given to library and museums with some crowding of essential laboratory departments. The school is about to obtain control of appointments in the Montreal General and Royal Victoria Hospitals and is contemplating a full-time scheme in clinical instruction. It has been doing excellent work on a budget of only $114,000 and should with Toronto be more liberally aided than any other of the Canadian schools."46 Pearce also visited with faculty representatives of the francophone Montreal School of Medicine; the school itself had burned down in the winter of 1919, so he and Vincent toured Notre Dame Hospital and Hotel Dieu. In Quebec City they visited both the Laval medical school and Notre Dame Hospital. Pearce acknowledged that threequarters of Quebec's two million people were francophones unlikely to attend McGill and that French-language medical training was a pressing need, but he did not deem either French-language school worthy of Foundation money. As he noted in his diary: "The most important problem is that of the French Canadian schools at Montreal and Quebec serving a population of two million isolated from practically all English influence with poorly trained physicians and inadequate public health service. Much detailed study will be necessary before a decision in regard to these two French Canadian schools representing the province of Quebec can be reached."47 Despite superficial parallels between Flexner and the Foundation's treatment in the early twentieth century of U.S. black medical colleges and the French schools in Canada, the two situations differed greatly. First, Flexner's (1910) denunciation of the African- American schools devastated them. As Savitt demonstrates, their numbers dropped from ten in 1900 to two, both receiving Rockefeller support, in 1923-48 By 1910, there were seven, but Flexner recommended that only two be supported - Meharry Medical College, founded in 1876

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Building on Strengths at McGill

in Nashville, Tennessee, and Howard University, set up in 1869 in Washington, DC. Between 1914 and 1960, the General Education Board gave $8,673,706.12 to Meharry and $587,759.32 to Howard. Meharry ranked fourth out of twenty-five schools in the total amount given by the board over that forty-six years.49 Savitt acknowledges changes under way even before the Flexner Report of 1910, but adds that the report worsened the situation by consolidating information on black medical schools, by advocating closure of many, and, in reflecting the outlook of the American Medical Association, by revealing negative white attitudes. Furthermore, some historians believe that the conditions imposed on black institutions that accepted financial support were onerous indeed. On philanthropic aid to black hospitals between the world wars, Gamble says that trusts controlled the ten hospitals that in 1939 offered black physicians accredited internships. These philanthropies thereby determined the role and the function of the black hospitals and even upheld a racial hierarchy within the hospital administration.50 In comparison, both of the French-language schools in Quebec survived, despite Flexner's recommendation that one of them close. His 1910 evaluation of the two schools was hardly as scathing as that of a number of the black medical schools. Both Quebec schools were affiliated with local hospitals for teaching purposes. What saved the two francophone schools was that they had enough positive aspects to qualify for Rockefeller support in a "second wave" of giving. They also filled a niche by drawing a disproportionate number of their students from rural areas in and around Montreal and Quebec.51 These French-speaking students planned to return to the "country" to practise. Research and laboratory sciences played less of a role in their education, so reforms could evolve more slowly. Markowitz and Rosner note that the Flexner Report also stressed upgrading of some smaller colleges. There was a geographical agenda in this: in areas with few medical colleges, Flexner argued for financial support using a lower standard of evaluation. For the French-language schools, this was true too, on the levels of culture and language - and geography for the Quebec City school. Flexner recommended saving the Quebec City school, no doubt because there was already a school (anglophone) in Montreal.52 Although many of the leading U.S. schools said that the full-time initiative was indeed helping to increase research, there are indications that it was not happening as quickly as many believed. Rothstein says that this was the case, even at Johns Hopkins University. Johns Hopkins justified its going full time by saying that it was

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responsible for training researchers. But a 1916 study says that, of the 456 graduated there from 1897 to 1906, 80 per cent were practitioners and only 9 per cent researchers. The remaining 11 per cent had changed their profession or died.53 Rothstein concludes that full-time faculty members taught hospital-based medicine that was of little use to the community.54 No doubt, this would have been the viewpoint of many faculty members and students at the French-language schools, so many of whom aimed to become small-town practitioners, so these examples may have increased the Foundation's patience with some of the smaller colleges. Hence, it gave its support to Canadian medical schools in two waves. The first to receive money were McGill, Toronto, and Dalhousie. After further deliberation, the Universite de Montreal was to receive $500,000, although, by 1926, it received only a fraction of that ($151,163). Before Pearce and Vincent's first visit to McGill, that school attempted to unify all elements of clinical instruction, just as Toronto had done. The relationship between biology and medicine differed at the two universities. As McRae notes, where Toronto took a "biological approach" to medicine, with close ties between zoology and medicine and a strong physiological base, McGill emphasized its clinical programs.55 Building on Osier's initiative, Acting Principal Frank D. Adams wrote on 3 March 1920 to Sir H. Vincent Meredith, president and chair of the board of governors, Royal Victoria Hospital. Adams outlined the main points of Osier's proposal vis-a-vis the faculty's relationship with the teaching hospitals. Adams pointed out that the faculty had unanimously adopted Osier's ideas, slightly modified, which now needed the support of the teaching hospitals. Only financial constraints had prevented McGill from putting these amendments into practice. "Now, however, in view of the proposed grant of $5,000,000 from Mr. Rockefeller to the furtherance of Medical education in Canada, provision may be made for financing this part of the scheme, which may thus become capable of realization"56 - full-time apppointments in the clinical departments of medicine, surgery, and gynaecology at both teaching hospitals. Specifically, Osier suggested, and the faculty agreed, that each head should receive $10,000 per year "in order that a man of experience and real ability might be secured." Adams added that Osier had written to John D. Rockefeller, Jr, in August 1919, "pointing out the urgent need for additional provision for clinical teaching and medical research at McGill University, and asking Mr. Rockefeller to provide an endowment for the same."57

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Building on Strengths at McGill

Preparing for Pearce and Vincent, heads of departments at McGill, like their counterparts in Toronto, summarized their equipment and space needs as well as the outlook for teaching and research. Even if the Foundation had not requested these documents, it was an ideal time to evaluate the direction of medical education: the war was over and both Montreal and Toronto chose to add a sixth year, beginning with the incoming class of 1919/20. The departmental "wish lists" form three documents: "Revenue and Expenditures of the Faculty of Medicine for the Year Ending 3oth June, 1919";58 a continuation of the same, beginning with a report from the Department of Biology;59 and a "Supplementary Report to the Rockefeller Foundation from The Medical Faculty of McGill University,"60 submitted 11 May 1920. The departments and authors were: Anatomy (gross anatomy, histology, and embryology), by S.E. Whitnall; Biology, by F.E. Lloyd; Chemistry, by R.F. Ruttan; Clinical Medicine, by KG. Finley and C.F. Martin; Hygiene, by T.A. Starkey; Obstetrics and Gynaecology, by W.W. Chipman; Pathology, by Horst Oertel; Pharmacology and Therapeutics, by A.D. Blackader and J.W. Scane; Physiology, by John Tait; and Surgery and Clinical Surgery, by George E. Armstrong and J. Alexander Hutchison. Common feature^ of each department's evaluation included lengthening the medical course; research; less cramped facilities; qualified and suitably remunerated, full-time instructors; better coordination with related medical science courses; and equipment for teaching and advanced research. Among the departments seeking an extension of their course was Anatomy; Whitnall sought a two-year course "during which the body will be dissected twice by each student,"61 covering the body in a broad way in first year and the same material in greater detail during the second. Clinical Medicine requested more bedside, group teaching and "the extension of the present clinical laboratory work both in the University courses and in the hospitals."62 In Physiology, Tait planned to introduce "a new type of practical course" to include experiments on simple tissues as well as "frog work," followed in second year by mammalian experiments. Tait outlines a long history (from 1886 to 1911) of neglect by "a conspicuously inactive incumbent" (unnamed). The department's subsequent chair left after just two years because of illness, and his successor died after teaching only six weeks in 1914. The war then interrupted, and it was not until September 1919 that Tait took over. He inherited a department with "no tradition of physiological research," and one sorely out of date, and with little equipment: "two solitary microscopes

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serve for demonstration of departmental microscopic preparations. The same two microscopes have to do duty for research/' Tait wrote. The only assets were "a good workshop and good operating rooms ... many individual pieces of research apparatus ... some valuable sets of teaching apparatus ... class accommodation and facilities [were] good, [and] ... a handy and convenient animal house."63 Finally, Chipman advocated a trimester system for Obstetrics and Gynaecology, "for only in this way can a student devote himself to day and night attendance" - all the more important, since, Chipman reported, half of the maternity cases happen at night.64 This was a common complaint among instructors and would feature in the development of obstetrics. Flexner had reserved his harshest criticism for obstetrics. Few students ever viewed or presided over live deliveries - cases "always come at night when you can't get students."65 Related to course extension were full-time professorships or additional teachers. Among departments advocating an adequately paid full-time staff were Clinical Medicine and Pathology. In his call for reorganization of Pathology, department head Oertel wrote: during the last ten years the changes in all biological sciences including pathology have been so profound and have brought about such fundamental alterations in our knowledge, that the older systems and methods of research and teaching are antiquated and need thorough re-organization in the light of modern biological conceptions. As an illustration it may only be revealed that the advances in the knowledge of physical chemistry have had such profound influence on biology and therefore also on pathology, that even within the last few years revolutionary changes in our knowledge of pathological phenomena have occurred. Different ideas and modified methods of study and teaching must therefore prevail in the future.66

Oertel staunchly defended full-time instruction - "men without practice, without divided interests, and responsible only to the Pathological Department." Such men would need good pay, he concluded, "under the present condition of the academic market."67 Oertel listed salary ranges for specific positions: professors, $5,ooo-$7,ooo per year; assistant professors, $3,ooo-$4,ooo; instructors, $2,ooo-$2,5oo; research fellows, $i,5OO-$2,ooo; and technicians, $6oo-$i,ooo. Oertel totalled the salaries, using the lower figure in the ranges, at $25,000. Salaries would make up most of the cost of modernizing Pathology between $32,000 and $35,000. Oertel's position was not unusual. As a pathologist, he did not see patients. His specialty meant considerable time in the laboratory,

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Building on Strengths at McGill

with no fees from patients. In this way, his specialty was like that of the institute-based bacteriologists and biochemists and all the fulltime, salaried pre-clinical instructors. The German, governmentbased research institutes served as a model for the Rockefeller Institute in 1901. Oertel was among those whose plea for a "scientific spirit" or "research ideal" led to full-time instructors. When Johns Hopkins announced the full-time system in 1913, battle lines were drawn - in favour of the system was the Johns Hopkins pre-clinical faculty. As Berliner notes, the laboratory scientists resented clinical physicians' high consulting fees and saw full-time as a way to level the playing field. Clinicians could earn up to $40,000 annually, while pre-clinical salaries ranged from $5,000 to $10,000, with no outside consultations.68 Against the plan were the well-paid consultants who served as part-time clinical faculty members and alumni who resented, as they had in Toronto, the end of part time. They viewed the full-time plan as reducing their reputations, decreasing their incomes, and eroding professional potential for worldly success. It was because Johns Hopkins needed the money that the Rockefeller Foundation could push the full time through, Berliner says. But the Foundation did not want to seem to be forcing an unwanted policy on the school.69 Finley and Martin, professors of clinical medicine at McGill, were unusual in advocating full-time appointments, in the forms of a professor of medicine and also a chief of clinic in each of the two teaching hospitals, "whose main duty would be to encourage and participate in the research problems arising out of the clinical services".70 At the time they wrote the report, the chief of Clinical Medicine had "duties" in only one of the two teaching hospitals. Martin would become dean of the faculty in 1923. I believe that they supported full-time clinical instructors for two reasons. First, McGill had had a strong tradition of clinical training since Osier's time. Naturally, a school such as McGill would be among the first to experiment with full-time. Second, the fact that the total paid to all instructors for 1918/19 was $52,815.95 meant that full-time pay, made possible by the Rockefeller gift, would more than double pay to instructors.71 Hence, I see economic as well as pedagogical reasons for Finley and Martin's support of full-time clinical teachers. Among the most vocal for funds to pay full-time instructors were the professors in Surgery and Clinical Surgery (combined), Armstrong and Hutchison. They believed that more experience in both the laboratory and the hospital wards was necessary: "We need the cooperation of a number of men with ideas and scientific inclinations

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as full-time men in the clinical departments of medicine and surgery. This lack, occasioned by lack of funds, has materially retarded our advance in knowledge in building up a new constructive surgery, as well as in other departments of preventive and curative medicine."72 Their one-page report noted that students in their third, fourth, and fifth years spent time in either Royal Victoria or Montreal General Hospital for half the session and then moved to the other hospital. There were also suggestions for entirely new professorships. Examples include Finley and Martin's of one for clinical therapeutics, "associated in some way with the Chair of Medicine," to develop experimental medicine, pharmacology, and therapeutics. They went on to suggest a professor of biological chemistry, who would, in addition to lecturing and research, "oversee the work of the hospital laboratories and act as a consultant to them." Ruttan urged "the immediate establishment" of an entirely new department, called Biological or Physiological Chemistry, headed by an MD/PhD. This full-time instructor would develop a "research school in Physiological Chemistry" and metabolism work in the teaching hospitals.73 Although other departments, such as Biology, Hygiene, and Pharmacology and Therapeutics also wanted full-time instructors,74 one department vehemently opposed the idea: Obstetrics and Gynaecology. Chipman detailed a specific plan of amendments and summarized fourth- and fifth-year studies via a combination of "didactic teaching," or lectures, and clinical instruction from one professor, two associate professors, and five "Junior Staff." Clinical instruction in obstetrics took place at the Montreal Maternity Hospital, including associated ante- and post-natal clinics, to which the students had access. Chipman notes that during 1918/19, fifth-year students helped deliver 538 babies via its "outdoor clinics."75 Gynaecology clinical teaching occurred in the Royal Victoria, with thirty teaching beds, or the Montreal General, with twenty-four. The only existing resource for research in gynaecology was a single fellowship worth $500 per year. Chipman hoped for another endowment, solely for gynaecological research, worth at least $1,500 per year, with an additional scholarship of the same amount for obstetrics research. Although many of his suggestions echo those of other medical departments at McGill, Chipman vehemently discouraged full-time clinical teaching in gynaecology. He believed that the eight teachers received fair compensation, and he feared that full-time would rob the community of valuable consultants: "It will be observed that the full-time system is here not advocated. ... In this judgment the head of a department should not only be a teacher but a consultant for the

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community in which he lives. From such contact with actual practice his teaching need not suffer, rather should it gain in strength and experience."76 Chipman noted that the eight teachers received a total of $4,200 per year, "divided pro rata among the individual teachers." What Chipman did recommend were well-equipped, hospital-based labs for both obstetric and gynaecology interns (operating expenses for each, including a technician, he estimated at $1,500 per year) and a revised system that would encourage bright and talented obstetricians to further their clinical training. Obstetrics had historically neglected clinical training. Longo outlines how, in the 18905, few U.S. colleges offered any practical lab course in obstetrics. J. Whitridge Williams started the first full-time department in North America at Johns Hopkins in 1919. Full professor of obstetrics there from 1899 on, he advocated lectures, laboratory work, and practical demonstrations. Exercises used mannequins to facilitate some level of proficiency and familiarity so that clinical practice did not annoy patients.77 Longo credits Williams's full-time department with "scientizing" obstetrics by introducing scientific precepts into its teaching and with spreading the influence of academic obstetrics through his students. Longo notes that most medical schools retained separate departments of obstetrics and gynaecology until the mid-twentieth century. They taught obstetrics from "a quasimechanical" standpoint and "gynecology as applied pathology." It is this question of teaching objectives that has slowed the progress of the discipline, Longo says. Should general practitioners learn while undergraduates, how to handle all obstetrical problems? If not, then which should they leave to the specialists? Should the material be technical, or should it focus on the endocrinological and physiological facets of the reproductive process? And at what point should undergraduates learn the physiological fundamentals as they apply clinically? Longo concludes that only since about 1950 have gynaecology and obstetrics reached Williams's ideal of 1899: "a field taught by broadly trained persons who combine a thorough understanding of scientific principles with clinical practice. Teaching in obstetrics and gynecology has thus evolved from a presentation of pelvic anatomy and pathology to an understanding of reproductive medicine in its broadest sense."78 Chipman suggested three items for reform. First, he proposed a trimester system and provision of living quarters for obstetrics students either in the hospital or nearby so that they would not lose time in attending cases. Second, Chipman advocated elevating the position of medical superintendent of the Maternity Hospital. Not only would his teaching duties increase, but also his term of service and

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his salary, up from the 1919 level of $1,000 per year. Third, Chipman suggested making a stronger commitment to the future of the obstetrics specialty by retaining promising and interested interns for one to three years, rather than the existing six-month term. The interns could then take on both advanced routine work and research in a well-equipped clinical lab. All elements of this plan "must be soon undertaken in order to secure the best interests of our Faculty as a teaching school, and to provide for the country at large the modern scientific trained obstetrician and gynecologist."79 Once again, this rhetoric underscores the difference between Toronto, the provincial university, and McGill - the nation's school. Many heads of departments raised the issue of facilities, particularly laboratories, in the McGill report. The large-scale requests included a new pathology unit close to one of the teaching hospitals.80 Proximity to a teaching hospital, as Oertel noted, made it easier to obtain "bodies and other hospital material for teaching and research." Oertel added that "in normal times" (presumably not in wartime) such a unit would cost about $150,000. A new biology building would house Botany, Physiology, and Zoology, and perhaps, as Chemistry Professor Ruttan suggested, "ample provision in such a building for Biological Chemistry as an independent department with its own laboratories if the Faculty intends to hold its own with other large medical schools of the Continent."81 Whitnall, head of Anatomy, pushed for a large teaching lab designed for microscopy work in histology and embryology and for a dissection room and research rooms for applied anatomy and operative surgery. Other departments also requested more space - mostly labs. Clinical Medicine saw "an urgent need of a psychiatric clinic." Hygiene sought "an increase of 25% of space in the Museum," so that the whole class might attend each demonstration, Obstetrics and Gynecology wanted "a well-equipped clinical laboratory" in the Maternity Hospital for obstetrics interns, as well as lab facilities for gynaecology interns in either Montreal General or Royal Victoria hospitals, "under the control and supervision of the Department of Pathology and Bacteriology," and Surgery and Clinical Surgery "need greatly increased laboratory space and equipment for teaching and research." Finally, some departments requested specific equipment, either upgrades or new acquisitions. Starkey asked for $3,ooo-$5,ooo worth of teaching exhibits, most of them custom built for hygiene classes costs of supplies and materials had doubled since the war ended, and salaries of teaching and laboratory staff had risen.82 Tait reported Physiology's need for equipment to bring it into the twentieth century. Its was the bleakest picture - hence the longest, itemized list,

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which included a blood-gas pump, centrifuges, a respiration pump, and electricity demonstration material such as induction coils.83 With such material in hand, Foundation representatives continued their visits. The review process culminated on 17 November 1920, when Edwin R. Embree, the Foundation's secretary, sent a telegram to Principal Currie: "We authorize announcement in any way you desire of pledge by Rockefeller Foundation of one million dollars to endow McGill medical school with understanding that funds for buildings approximating nine hundred thousand dollars are raised from other sources."84 In a telegram sent the following day, Currie acknowledged the condition and added that the financial campaign had not only matched the million-dollar gift but far surpassed it: by 19 November, the fund had just over $4.6 million, not including the Foundation's $1 million.8? T R A N S F O R M I N G M E D I C I N E AT M C G I L L

Despite the Foundation's stipulation that its grant not simply pay for medical buildings, within five years McGill, like Toronto, had new space for medical teaching and research. By 1922, a new Biology Building housed the departments of Botany, Pharmacology, Physiology, and Zoology and the new discipline of Biochemistry. By 1924, McGill's Pathological Institute, across from Royal Victoria Hospital, was complete. By contrast, Toronto had a new Anatomy Building (1925) and a new Hygiene Building (1926). The McGill money also went towards raising salaries of instructors, laboratory research, and teaching equipment and materials. The school was in high regard throughout Canada and the United States, despite the substantial inadequacies in facilities in many departments just after the war. Although the Rockefeller Foundation often reminded recipients that it did not wish to interfere in day-to-day decision-making, it did set certain conditions, including raising of matching funds. The Rockefeller name and the set conditions often spurred quick action. The school had to submit its plan for spending to the Foundation before the money arrived. Although McGill's fund-raising campaign of 1920 was a resounding success, improvements took time to implement in many disciplines. But the Rockefeller conditions helped the medical faculty expand more quickly: within four years of the first instalment, the new biology and pathology buildings were ready for teaching and research.86 "The medical projects were fairly speedily realized because of the terms of the Rockefeller Foundation grant," Frost notes.87

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The merits of maintaining this "clinical spirit" were still subject to debate in the professional journals in 1923. An editorial in the Canadian Medical Association Journal defends the clinician's skills in the light of "research work" and "scientific" endeavours in the laboratory. "Medicine is still in need of men of great powers of observation in the wards or outpatients' department, who like Sydenham can picture for us the symptoms and course of a disease, in short its natural history. Such men even if they only recognize and make plain a new symptom-complex add much to science and are entitled to the same rewards as the laboratory worker."88 By 1923, with the discovery of insulin, many people heralded science and the laboratory as heroes. Clinicians felt slighted. The editorial quotes from a letter by British surgeon and medical educator Sir Berkeley Moynihan to the Times on 25 July 1923: "Clinical research and the toilsome discoveries of new technical methods are as fully entitled to the term 'scientific' as any of the good work done in our laboratories. The complexities of clinical research are so intricate, and because of the human material upon which they are conducted are so bewildering as perhaps to surpass all forms of laboratory research in difficulty." Moynihan added that the Royal Society consistently ignored clinical investigators in Britain. The president, he wrote, "is a medical man whose life has been spent in the laboratory." Moynihan concluded, "The joint and separate labours of the laboratory worker, and of the clinician are both, perhaps equally, necessary for the future progress of medicine in all its branches. Both are deserving of recognition at the hands of those empowered to confer it; in 'scientific' value, one does not surpass the other." Moynihan had reason for concern: the Canadian Medical Association Journal in November 1923 announced the Banting Medical Research Foundation, "to facilitate good work 'at home/"89 The goal was to support "purely" medical research and research in biochemistry, pharmacology, and physiology. "Surely," the editor wrote, "this is the much desired democratization of Research, such as is found in the Pasteur, Lister and Rockefeller Institutes of other countries." Partly because of Pearce's confidence in McGill's medical education and teaching facilities, the university received the full sum of $1 million, for "general endowment of the Faculty of Medicine" on i December 1920. McGill also received the interest, at a rate of 5 per cent per annum .9° But the gift was not the end of the Foundation's philanthropy to the university. McGill's representatives boldly talked about their desires to Foundation executives. For example, in August 1922, Vincent, Currie, and Macallum inquired after the "unassigned" $2 million for Canadian medical education.91

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McGill received in total $2,879,588 for medical education and research from the Rockefeller Foundation, ending with a follow-up $2,500 for research in pharmacology on i July 1937. This does not include $57,500 in March 1925, specifically for "the study of child life," nor $160,000 for social science research grants, spread over nine years, from 1930 to 1939. The largest single grant was not the $1 million for medicine but the gift of $1,232,652, made on 13 April 1932 "for the development of teaching and research in neurology" in what became the Montreal Neurological Institute, headed up by Dr Wilder Penfield.92 Fight for Control of Appointments

The initial euphoria following the 1919 announcement of the Foundation's gift, and the success and relative ease of fund-raising in 1920, gave way to controversy resolved only in 1925. Despite the wellthought-out vision of the medical heads of departments, tension built up over politics at the teaching hospitals and appointment of a fulltime chair of medicine. Martin, the first full-time dean of medicine had to mediate between the teaching hospitals and the faculty. He was to see both through an era of change, not unlike Graham and Falconer's difficulties over full time in Toronto. First, there was the power struggle between E.W. Archibald and Sir Henry Gray in Surgery. Who was ultimately responsible for clinical appointments: the university or the hospital administration? In March 1923, George E. Armstrong resigned as professor of surgery and head of the Department of Surgery at McGill and chief surgeon at the Royal Victoria Hospital. Even before they formally accepted his resignation, governors of the hospital invited Gray, professor of surgery at Aberdeen, to visit Montreal as Armstrong's replacement. No one at the Faculty of Medicine knew this, and Osier had suggested appointments by a medical board, made up of representatives of both teaching hospitals and the university.93 Martin kept Pearce well-informed of the mess: "It has thrown a monkey wrench into the machinery because were he [Gray] to come, he would naturally expect the Professorship of Surgery in the University, and as the University Authorities have not had a hand in it, they are somewhat disturbed about the whole matter."94 Perhaps the worst part of this situation was that it angered and disappointed Pearce. Martin depended on continued Foundation support, and the squabbles threatened the reputation of medical education in Montreal. Pearce wrote: "The situation with regard to surgery at your

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School is especially distressing, and I fear of considerable moment for the future, for if the university and the Victoria Hospital cannot cooperate, it is a little difficult to know what is to be done about the development of clinical work in Montreal."95 Gray did accept the governors' offer, and Archibald stayed on at McGill as well. Archibald, as professor of surgery, was responsible for teaching in the clinic; Gray, chief of the Surgical Department and chief of the hospital, was teaching "without academic title" in an effort to demonstrate to the hospital's board the merit of closer ties with the university. Gray was not only a bullish administrator, who believed that he had "a right to sanction whatever teaching arrangements Archibald [was] making," but also a horrible teacher. Martin described this surgical teaching as "stinking in the nostrils of every Medical School in America, and in not a few in England."96 Martin's solution for the erroneous appointment of Gray was to make Archibald a full-time professor of surgery and name Gray a professor of clinical surgery. There would also be a full-time professor of medicine. Like Graham in Toronto, Martin believed in full-time clinical chairs. As he wrote to J.C. Meakins at Edinburgh, whom he hoped might take up the medical chair, "I believe in and shall urge the Faculty and the Governors to adopt the policy of full-time clinical chairs on a modified basis, whereby the Professors will be privileged to practise privately in hospital but not outside of the hospital."97 Martin was wooing Meakins with Rockfeller money and the promise of being part of a new wave of medical education at McGill. At first, however, Martin advocated the full-time system only for Royal Victoria Hospital. More than the deans of medicine at either Toronto or Dalhousie, Martin maintained close contact with Pearce. He informed the Foundation about all developments, hiring, and proposed pedagogical changes. He was perhaps young and immature, but he wanted to keep McGill in the forefront of the Foundation's consciousness. He often sought advice from Pearce and reiterated his belief in the fulltime system. Martin carefully worded his letters on this subject. On 17 November 1923, he informed Pearce^ "We would like at the earliest opportunity, i.e., for next Session, to have a full-time Professor of Medicine in the Royal Victoria Hospital, with all the opportunities for developing a modern scientific Medical Department in connection with the University and Hospital."98 The Foundation-supported McGill medical clinic opened in May 1924. The Foundation promised $500,000 for the development of the Department of Medicine. This gift, analogous to the Eaton Endowment at Toronto, was the final step towards modernizing medical

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education in Montreal. The Royal Victoria Hospital promised up to $15,000 per year for the clinic's operation, as well as for space, equipment, and maintenance. As Sir Arthur Currie wrote to Pearce, "I believe a new era has begun in our Medical School and we shall do our best to keep it in the very front rank of medical educational institutions."99

5 Bouncing Back at Dalhousie: A Regional University

If, in the early decades of the twentieth century, the University of Toronto was the provincial university for Ontario, and McGill University a "national" institution, then Dalhousie University was, as located in the provincial capital, the premier regional post-secondary school of the Maritimes. Although there were other universities in the region, Dalhousie stood out on two counts: it was non-denominational, and it was the only Maritimes school to offer training in professions other than religion - medicine, on and off, 1868-75 and again from 1889 on; dentistry from 1908 on; law from 1883 on; and engineering briefly, from 1905 to 1909. Arts and sciences were, however, the staple, and that faculty was by far the largest in student enrolment from 1863 to 1925.1 The Maritimes had many smaller universities and colleges, some of them among Canada's oldest. They included two King's Colleges (one opened in 1789 in Windsor, Nova Scotia, and one in 1787 in Fredericton, New Brunswick - the latter secularized and rechartered in 1854 as the University of New Brunswick); Acadia College (opened in 1839 by the Baptists in Wolfville, Nova Scotia); St Mary's College (granting degrees in 1841, closed in 1881, when the province withdrew all financial support to post-secondary institutions, and reopened in 1902); Mount Allison Wesleyan College (opened as a secondary school for young Methodist men in 1843 in Sackville, New Brunswick); St Francis Xavier College (opened in 1853 in Arichat and then moved to Antigonish, Nova Scotia); St Dunstan's College (founded at Charlottetown, Prince Edward Island, in 1855, granting degrees from 1941 on); St Joseph's College (in Memramcook, New Brunswick, opened in

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1868 and granting degrees from 1888 on; absorbed into the Universite de Moncton in 1963); College Sainte-Anne (in Church Point, Nova Scotia, founded in 1890 and granting degrees from 1903).2 These individual identities ensured differences in government and private support and helped Canada's weakest medical school - Dalhousie - gain part of the Rockefeller Foundation's 1920 gift. Although the Foundation aided Dalhousie primarily because it was the only school east of Montreal, Markowitz and Rosner give another reason. They tell of a professional backlash to the Flexner Report of 1910. In reaction to its scathing reviews of many smaller medical colleges, angry physicians rebelled against the principle of "making the peaks higher." They turned this maxim around, saying, "Better lend strength to the weak than double the strength of the already strong." Therefore, in the ten years between the Flexner Report and Rockefeller's gift, the Rockefeller Foundation deemed Dalhousie good enough to maintain and to aid.3 As Harris writes, "The single bright feature in the history of higher education in the Maritime provinces in the late nineteenth century was the development of Dalhousie University, an institution that existed only on paper in 1861 but which by 1890 occupied a stronger position than any Canadian university except McGill, Queen's, and Toronto."4 Cueto notes that by the late 19405 Foundation officers believed that "making peaks higher" overlooked local conditions in "backward countries." Compared to Toronto and McGill, Dalhousie was a "backward" medical school; if, however, it received some aid, the Foundation could help raise its standards and level of scientific instruction to the point where it could train practitioners well. It might not be the repository of leading-edge research, but it would be a solid addition to medical training in Canada.5 This chapter looks at the history of medical teaching at the university; the Foundation's evaluation of Dalhousie in 1920; and then the effects of its $500,000 gift to the medical school. In 1920 Dalhousie, hit hard by war and the Halifax explosion of 1917 (which, as we see, attracted U.S. philanthropy), was far less prepared for the research ideal and scientization of medicine. Not much had changed since Flexner in 1910 reported thirty-three students at the Halifax Medical College, 90 per cent of them from Nova Scotia,6 compared with Toronto's enrolment of 5927 and McGill's 328.8 DALHOUSIE AND MEDICINE: ON AGAIN, OFF A G A I N

Medical teaching at Dalhousie has a long and tumultuous history. From 1867, when a partial course in medicine started at Dalhousie, to

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1911, when the proprietary Halifax Medical College closed and Dalhousie reintroduced medical instruction in its Faculty of Medicine, medical teaching in Halifax was in constant flux and financial crisis. Valuable secondary sources include volume one of Waite's history of the university9 and articles by Howell, Penney, and Stewart.10 Howell argues that between about 1890 and 1914, Halifax physicians sought to professionalize medicine. In the name of scientific expertise, they claimed a position of authority in public health. They tried to raise the standards of medical training, create a more efficient public health system, and eliminate "unscientific" medical treatment by chasing competitors from an overcrowded market. Uncontested control over medical services would allow them to define "professional medical expertise" within their own monopoly - a phenomenon that would continue throughout the twentieth century.11 Medical teaching in Halifax from 1867 to 1911 was on again, off again, with the medical school often changing its relationship with the university. Prior to 1870/71, the first year that Halifax had a full, four-year medical course, the closest Canadian medical school was McGill. The nearest U.S. medical schools were in Dartmouth, Portland, and Vermont.12 Attending an American school was an option, and before 1900, U.S. study could take less time and be far cheaper. Penney points out that, as American schools multiplied, many accepted students with no previous university education or formal training, "graduating them in a few short months".13 As in Quebec and Ontario, from mid- to late nineteenth century, many American-trained physicians set up practice in the Maritimes. Their training ranged from strictly apprenticeship to largely lecturebased medical school training - at schools ranging from proprietary operations churning out graduates in less than a year to universityaffiliated programs. U.S.-trained people grew from 53 per cent of Halifax-area practitioners between 1827 and 1857 to 76 per cent, when we count those who graduated between 1858 and i874-14 A local medical school, with a full, four-year course could counter the U.S. influx. The Halifax course was not "graded", and so repeated subjects year after year - there was no more advanced curriculum in senior years. Unlike the partisan, sectarian schools in Toronto or the hospital-medical school tensions in McGill, in Halifax a concerted effort brought together the provincial and municipal Governments, the City and Provincial Hospital, prominent doctors, and administrators and professors at Dalhousie. Penney cites these factors in school's smooth foundation: the reestablishment of the City and Provincial Hospital (1867); passage of an Anatomy Act (1870) that legalized dissection; and governance of the school by local practitioners, who "dominated the provincial medical society ... and, after

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1872, the same names are found as executives, members and examiners on the Provincial Medical Board".15 Five men, trained in Canada, England, Ireland, Scotland, and the United States, formed the first Faculty of Medicine at Dalhousie and took the curriculum from partial courses in 1867 to the full, four-year course in 1870/71. WJ. Almon (Glasgow) was head of faculty, or president; Alexander P. Reid (McGill and Edinburgh) was dean. The others were Edward Farrell (College of Physicians and Surgeons [CPS], New York); Alexander G. Hattie (Edinburgh); and Alfred H. Woodill (CPS, New York).16 William Bruce Slayter (London and Dublin) and John Somers (Bellevue) were also at the founding meeting in 1867, dropped out, and returned "within a few years" to teach. The initial idea - to teach only the "primary subjects" - was modest. In fact, a complete medical course involved co-operation with other nearby medical schools. Students attending Dalhousie could follow up their partial courses and complete their training with clinical years at McGill, Harvard, or the CPS in New York. Such an arrange ment also existed in England, where medical students at Oxford and Cambridge went on to London for their clinical training.1? In 1870 Dalhousie developed its own full, four-year course. All instructors, except science professor George Lawson, worked part time, paid directly from student fees. Penney notes that "the average annual yield for a single class would be in the neighbourhood of $100 to $150, of which the professor received 75 percent." Students paid between six and twelve dollars per course, and by 1873 there were twenty-nine in the class. Although this enrolment seems small, especially compared to Toronto and McGill, it was double the original enrolment. The financial situation, coupled with the cramped quarters, troubled faculty members. In 1874, they voted to withdraw from the university and set up an independent, proprietary medical school - a break finalized in November 1875. With a new president, Rufus S. Black - replacing Almon/8 who had resigned early in 1875 as the money was running out - Halifax Medical College started. The new school secured an annual government grant of $800. Although enrolment remained stable at thirty students, paying $1,118 in fees, it later dropped, increasing financial pressure. This could not have happened at a worse time: the costly scientization of medicine, which began in the 18705, swept across Canada and the United States. The expense of increased laboratory-based, scientific medicine reform helped to fell Toronto's Trinity Medical College. Like Halifax Medical College, Trinity paid its instructors entirely from students' fees. As competition heated up in Toronto,

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with students seeking the most modern methods of learning, Trinity found that raising fees to buy equipment and expand facilities priced it out of the market. As Spragge notes, "it was clear that proprietary medical schools could not provide the answer to the need for a satisfactory medical education in an increasingly scientific world. Competition might be stimulating, but a number of medical schools could not, without wasteful expenditure, install the complicated and costly instruments and provide the facilities that were becoming available and were obviously necessary."19 Trinity amalgamated with the University of Toronto medical faculty in 1903/04. While still proprietary, teaching in Halifax was, as Penney describes, "almost entirely by lecture."20 Though aware of the trend towards laboratory medicine led by German-trained physicians who returned to North American universities and practices, the Halifax instructors maintained lectures and the University of Edinburghstyle "grand rounds" for clinical training in medicine and surgery.21 By the i88os, Halifax Medical College could no longer avoid educational reform. Advances by German researchers in understanding disease were making lab-based medicine and greater individual instruction essential. The science of bacteriology became an important part of the medical curriculum. To include all this required longer courses. The Halifax faculty had more basic problems. The old-style, repetitive, ungraded curriculum no longer challenged anyone, and the faculty debated offering a graded curriculum. Enrolment dropped, jeopardizing faculty salaries. Instructors could not agree on whether to rejoin the university and offer only preparatory courses, as the college had from 1867 to 1870. The decision was made for them. In 1885, the Board of Public Charities, which ran the City and Provincial Hospital, chose the less-qualified candidate as the new house surgeon, which led to "The Great Row". Waite observes that the college had been on the verge of closing in 1884/85. Twenty-five regular medical students would have been put out. After the hospital appointment, with no teaching facility available for clinical instruction, the school did close in August 1885.22 McGill's medical faculty took in students not yet finished their courses, at no extra fee, and recognized work already done.23 The college's faculty resigned in protest, as did the rest of the hospital's medical board. It took two years to resolve the issue. In 1887, the province, led by Premier William Stevens Fielding, took over the hospital, renaming it Victoria General. Stewart observes that chance brought the Halifax Medical College a teaching ally in the form of the new hospital. Because the hospital was now provincially

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funded, it took in patients from across Nova Scotia. "From the standpoint of teaching and of epidemiological research, this system of provincial referral is very valuable," Stewart says. Victoria General offered better clinical experience for medical students, as there were no financial barriers to patients.24 When it reopened in 1887, the Halifax Medical College was once again a Dalhousie affiliate. Enrolment was low - for 1887/88, four. Waite explains that the 'Great Row' and financial problems of the mid-i88os had long-term effects. "There was only one graduate in 1890 and two in 1891, so much had the crisis weakened it. Even in 1895 there were only three, though by then total numbers were clearly on the rise."25 The full course was on offer again in 1889, but only in 1893 was a four-year, graded medical course available, with each year seven months long. Clinical facilities at Victoria General expanded: new wings in 1888 and 1889 and a School of Nursing in 1891. Waite notes that the Nursing School was a rousing success, with a two-year waiting list for admission only five years after it opened.26 Furthermore, until Rockefeller and Carnegie gifts were forthcoming, part-time instruction, although it brought prestige, could still not replace physicians' lucrative income from private practice. Reform of medical education, however, demanded more and more of the instructor's time. Full-time instruction seemed obvious but paid too poorly for established practitioners. The tension between paying for costly equipment, space, and salaries and keeping student fees low threatened to tear the college in two. Aware that many students trained locally because it was less expensive, the school had decreased fees substantially in 1894 rather than risk having fees higher than McGill.27 Laboratory facilities, however, remained non-existent, and only after 1897, through a change in charter, higher student fees, and a larger government grant, did Halifax Medical College modernize its facilities and curriculum. The school purchased equipment, including microscopes, for the teaching of histology, pathology, physiology, arid surgery and set up an ophthalmology clinic and pathology museum. In addition, it built a histology, pathology-bacteriology and physiology laboratory to be headed by a full-time instructor.28 But the move towards a full-time faculty did not start until the hiring of a provincial pathologist-bacteriologist in 1901; even he did not devote all his time to teaching or research at the school. Dalhousie was yet another North American medical school long aware of pedagogical reforms that could not afford to improve medical education. The net result was selected improvements. Subjects other than physiology enjoyed a lab component, and by 1902 pathology-bacteriology had "a full 150 hours of instruction."29 The college also length-

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ened the medical course to five years. McGill had done so in 1907/08, and Toronto in 1908/09; the Halifax Medical College made a fiveyear program its goal in 1911. That year the college closed, and Dalhousie reabsorbed it for the final time. Despite ambitious and well-intentioned reforms, the final years of the Halifax Medical College saw declining enrolment, resulting financial problems, and faculty disputes. As Penney describes it, "Morale plummeted. Instructors complained that their teaching incomes had reached the vanishing point, and began to miss lectures ... Too many of the internists were victims of alcohol, and the surgeons of a disrupting emotional immaturity."30 H.B. 'Benge' Atlee was a 1911 graduate who went on to a respected career as a gynaecologist and Dalhousie faculty member. He and his classmates lost 75 per cent of their lectures in medicine because the professor was drunk so often. The gynaecology course was given by "a dear old Victorian who felt it a mortal sin to expose the female perineum to the light of day." Atlee's two deliveries under the professor's tutelage took place under a blanket.31 He commented on unpredictable elements in his medical education, such as physiology "that of Edinburgh, 1892" and "practically a dead loss" - but "a very fine course in anatomy from Dr A.W.H. Lindsay; I doubt if many medical schools on this continent were giving better."32 Ultimately, the faculty was running out of money and enthusiasm; despite valiant efforts, often funded out of their own pockets, they could not keep pace with the costly scientization of medical teaching, and classes were shrinking. Enrolment dropped steadily from an alltime high of 106 in 1900/01 to a low of 42 in 1906/07 before climbing again. It would take until after the war, however, before enrolment at Dalhousie's Faculty of Medicine rose above the level of 1900/01 - 142 in 1919/2O.33 Flexner's scathing 1910 indictment of Canada's last proprietary medical school was the final straw. Conscientious faculty members visited Johns Hopkins and McGill to view the latest scientific apparatuses and teaching methods. They did so proactively and not as a reactive scramble for survival after Flexner's report. Flexner "missed" thirty-one new microscopes, five microtomes, two incubators, and an autoclave, during his inspection of the college. The equipment served a class of sixty in 1909/10. Penney suggests that Flexner had an ulterior motive in his scathing picture: using Johns Hopkins as the laboratory and research-medicine ideal situated non-conforming schools below a minimum standard. Soon the American Medical Association's Council for Medical Education would, like Flexner, give its lowest rating to proprietary

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schools, which trained practitioners, and its highest to universityassociated, research-oriented schools. Penney argues, "His (Flexner's) ideas were a direct reflection of the goals of a group of research-oriented academic careerists, whose incomes and opportunities would rise sharply after his report."34 Many members of the medical faculty at Dalhousie realized that they could no longer delay the scientization of medicine - university affiliation was the only way to a better future and economic stability. Flexner's report blamed the college's poor rating partly on Dalhousie: "it had been giving medical degrees to students trained under wholly inadequate facilities."35 In reaction, the university Senate in March 1910 set up an investigating committee which compared its observations with a corresponding body from the college. As Waite describes it, both committees agreed that the university should take over the college, making it the university's Medical Faculty. The resolution passed unanimously on 9 May36 Despite changes at the college and better facilities37 than many of the weakest American "diploma mills" with which Flexner associated it - on 11 May the college's faculty "resolved to ask Dalhousie to take over the college completely."38 Within one year of Flexner's report, Dalhousie purchased the college, whose assets included a building and teaching equipment, and had arranged representation on the Dalhousie Senate.39 By 1912, the last proprietary Canadian medical school east of Winnipeg had ceased to exist. The Manitoba Medical College, established by local physicians in 1883, in 1918 became the Medical Faculty of the University of Manitoba. When the next wave of Canadian medical schools opened in the 19205, beginning with Alberta's in 1921, they would all affiliate with universities from the start. A few entrepreneurial physician/teachers could no longer afford to run a successful, modern, medical school with lab and research facilities. The end of an era had come. Carnegie and Rockefeller Aid to Nova Scotians

The fact that medical teaching survived in Halifax without interruption after Flexner's harsh appraisal is testimony to a number of factors, not the least of which was location. Flexner visited Halifax with Dr'N.P. Colwell of the American Medical Association. They gave only thirty hours' notice and visited the college, the University, and Victoria Hospital and met with the president and the secretary of the Faculty of Medicine.40 As Atlee put it, "we didn't have a chance. What saved us was geography. We were the only medical school in the east of Canada. There simply had to be a school in this region."41

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Another factor was government support. Unlike Toronto and McGill, Dalhousie enjoyed varying levels of provincial support. Although the province funded the medical school modestly, it gave willingly, even during proprietary operation. Finally, perhaps because of its origins as a preparatory school, the medical school and the university had an established relationship long before 1910/11. Dalhousie had provided space and granted degrees. Through more than forty years, relations between the medical college and the university had been positive more often than not. Professional faculties added prestige to a university. Though founded in 1818 by Lieutenant-Governor the Earl of Dalhousie, the university had often received major gifts from Americans born in Nova Scotia or with ties to the Maritimes. For example, George Munro, one of its greatest benefactors, endowed five chairs of study and provided for a series of bursaries, giving in total close to $400,000. This was substantial, given that "Nova Scotia has few really wealthy men, and no millionaires." By 1900, alumni were reaching an age when they were increasingly able to aid their alma mater. "An appeal in 1902 to the Alumni and friends of the College brought in $50,000 to equip the Engineering Department, and $20,000 for a library."42 Dalhousie's expansion antedated the Halifax explosion of 1917. The university moved to a larger site in 1887, and then to forty-one acres on the city's outskirts. The new Studley Campus was half a kilometre from the older buildings. Soon after the university took over medical instruction in 1911, MacKenzie wrote to ask John D. Rockefeller, Sr, for $100,000 to help with a new arts building. The old Arts Building was to house the medical school. MacKenzie acknowledged (January 1912) that "the munificent fund which you have founded for the help of deserving Colleges, is for the Colleges of the United States only, but I venture to hope that you will consider the individual cases of equally deserving Canadian institutions."43 MacKenzie's idea was that $100,000 from the Foundation would help meet "present pressing needs," and "the stimulating effect on our own people of such generosity on your part, would be such as to bring from them the last dollar that they could afford to contribute."44 MacKenzie stated that alumni and residents of his own "relatively poor constituency" might donate $400,000, and the Foundation gift would top up the figure to the half-million dollars needed. Dalhousie faced the same sort of competition as Toronto's nineteenth-century medical schools: just as Trinity Medical College and the Toronto School of Medicine were competing for students and support in Toronto, so Dalhousie competed fiercely with other Nova

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Bouncing Back at Dalhousie

Scotia colleges for provincial aid. There was considerable rivalry among the many institutions, including King's College, Mount Allison College, and particularly Acadia College, for any provincial support. These rivalries shaped medical education in the Maritimes. Other universities feared that Dalhousie was taking some fraction of the medical school's grant for itself. If Nova Scotia aided no other Maritime colleges, argued representatives of the smaller institutions in 1887, the medical school should not be privy to $800 per year, as had been the case before the suspension of medical teaching after the Great Row.45 At times, it was easier for Dalhousie to seek financial aid from the city or even from philanthropic groups. Appreciation of Dalhousie was growing steadily but slowly, and only in 1911 were gifts from prominent Haligonians beginning to increase: "The hold of the University on the community is steadily growing. As one instance, she has more students than all of the other colleges in the Province put together; as another, the present canvass for funds, though only a month old, has already brought in $75,000 from the business men of the City of Halifax, which evidently at last appreciates Dalhousie, as Montreal has lately shown it appreciates McGill."46 The 19103 brought great change at Dalhousie. The university took on medical teaching, shifted further out of town, and needed new buildings. Its goal was to raise the money to purchase the land, erect buildings, and alleviate congestion, especially in the scientific laboratories and library. Purchase of and improvements on new site New Science Building Equipment for Science Building Endowment for Science Building Macdonald Memorial Library Endowment for Library Endowment of Chairs - Arts and Science Endowment of Chairs - Medicine SUBTOTAL Less Alumni Fund of 1902 for Library SUM TO BE RAISED NOW

$65,000 75,000 25,000 20,000 40,000 20,000 100,000 70,000 $415,000 25,000 $39O,OOO

The university also needed $100,000, which it had to raise, to pay for the new Arts Building. The Medical Faculty would become the main tenant in the old Arts Building ,47 In the year (1910/11) before Dalhousie took over the Halifax

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Medical College, student fees represented only a small percentage of the university's income. The majority of income came from the General Endowment of $410,000 and $5,000 in "Other Gifts," while 80 per cent of the expenses for 1910/11 went to teaching salaries. Eleven professors in Arts and Science received a total of $25,000, and two professors of law, $4,000. Five "lecturers" in Arts and Science shared $300; seven in Law did better, sharing $1,000. The faculties differed widely in enrolment: 328 students in Arts and Science, fifty-two in Law. Hence the average cost of educating a student was $112 per year, while the "average fee for a full course [was] only $50.00 per annum."48 "Our nearest educational centres are Montreal and Boston, about 800 to 1000 miles distant by rail, respectively. A student's expenses at the former are about $800.00, at the latter about $1000.00 - prohibitive to all but our wealthy boys. We must meet the demand, and educate our own." The Maritimes had about one million people in i9ii.49 In the year following reabsorption (1911/12), Medicine was Dalhousie's second-largest faculty in enrolment, number of lecturers/professors, and value of fees (see Table 5.1). The Rockefeller gift of $500,000 to the medical department was not the first international philanthropic interest in the region. The Rockefeller Foundation first appealed for a personal donation from J.D. Rockefeller, Sr, in 1914, following the Newfoundland sealing disaster,50 and later advised the Halifax Explosion relief effort. The Foundation also supported the work of the Massachusetts-Halifax Health Commission. By the time Carnegie decided to join the Foundation in giving $500,000 to Dalhousie medical school, Carnegie had already given Dalhousie $45,ooo.51 Dalhousie's alumni were considerably less affluent and numerous than McGill's. It had fewer sources for funds for the costly expansions needed in the 19005 and 19105. Rebuilding Halifax after the explosion of 6 December 1917 was expensive. Twenty-two hundred Haligonians died, and "several thousand were scarred or maimed for life," Waite writes; "the Senate decided that in view of the damage to university buildings, all classes would have to be stopped until after the Christmas holidays."52 Classes resumed in January. University President A.S. MacKenzie was not, however, too timid to solicit aid. Only five days after the explosion, he telegraphed the Carnegie Corporation, seeking money to repair the damaged Science Building. As Waite explains, the Corporation replied that it would "consider it a privilege" to pay for the repairs to all of Dalhousie's buildings. Even when repairs cost twice MacKenzie's estimate of $10,000, the Carnegie Corporation still gave.53

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Bouncing Back at Dalhousie

Table 5.1 Faculties at Dalhousie, 1912

Arts and Science Medicine

Law Dentistry

Professors

Lecturers

Enrolment

12 6 2 —

10 24 7 —

340 73 60 17

Annual fees ($) 12,862 5,036 2,474

—

Source: "Present Undertaking/' President's Office, Rockefeller Foundation, 1912-1919, MS-3, A883, DUA. Notes: The categories of "Prof." and "Lect." are handwritten above the typed chart. I infer enrolment and fees from similar charts and data earlier in this report. Dalhousie served as only an examining faculty for dentistry; instruction took place at the affiliated Maritime Dental College.

Dalhousie and the War Previous chapters have made much of the role of Canada's war participation in "encouraging" the Rockefeller gift to Canadian medical education. As at Toronto and McGill, men at Dalhousie quickly answered the call to war, and the medical faculty played a large role. Dalhousie contributed personnel (by 1915, 165 Dalhousie graduates and staff members and 83 undergraduates had enlisted)54 and lost fees and space (the Forrest Building, which housed dentistry, law, medicine, and pharmacy, became a convalescent hospital for more than twenty-four thousand Canadian casualties of the 1916 Battle of the Somme; this would necessitate renovation of the old Halifax Medical College building for its own use). The Hospitals Commission constructed Camp Hill, open by the autumn of o^iy.55 Finally, Halifax was a primary embarkation point for many ships carrying personnel and supplies. Like Toronto and McGill, Dalhousie organized a hospital unit for the war: No. 7 Stationary Hospital. It had a staff of 162, including twelve doctors, twenty-seven nursing sisters, and one dentist.56 In all, half of the medical faculty left teaching to join the war effort, including Colonel Dr John Stewart, later dean of Medicine I9i9~32.57 As with the Toronto and McGill hospital units, the Dalhousie men spent their first six months overseas at Shorncliffe (January-June 1916). No. 7 then went on to Le Havre for the remainder of 1916. From December 1916 until the winter of 1919, it moved about: to Harfleur, Arques, Etaples, Rouen, and Camiers. It returned, first to Le Havre (February and March 1919) and then to Shorncliffe (March and April 1919), before going home to Canada. All these postings, except Shorncliffe, which is 35 kilometres east of London, were in northern France.58

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ROCKEFELLER EVALUATION

As at Toronto and McGill, the Faculty of Medicine at Dalhousie Uni versity learned of the $5 million Rockefeller Foundation gift for Canadian medical education on 24 December 1919. Once again, the announcement cited the Canadian war sacrifice and the close bond "of race, language and international friendship" with "the Canadian people ... our near neighbours."59 President MacKenzie replied: No institutions in Canada have probably suffered as much as those Universities which are not state supported, for not only did they lose the very flower of their student body for a period of five years, but financially they have been put in a very serious condition. Dalhousie, for instance, in order to carry on during the war and do its fullest possible share behind the lines, had to incur serious deficits. Now, with diminishing returns from endowments and practically doubled expenses, and with a demand from the public for broadening all departments of education, the situation of the University is not an enviable one. Assistance of the kind promised in this noble gift of Mr. Rockefeller, therefore, will come at a very opportune time. We hope when the facts about the Medical School of the University are laid before the Foundation that it may be deemed worthy of a very generous share of Mr. Rockefeller's gift.60

Yet another form of war sacrifice by the medical faculty was the lack of stability in both staff and space. Many faculty members had volunteered to serve overseas. Despite already inadequate space for the faculty in 1914, the military commandeered medical rooms. By 1919, enrolment was growing, costs were soaring, and the faculty needed more room and improved facilities to become a small, yet state-ofthe-art medical school. To outline the school's important role, an amended eight-page report, originally drawn up 5 April 1918 and sent to Henry S. Pritchett of the Carnegie Corporation, listed key historical factors and future needs. By 1919/20, enrolment had grown to 134 from 71 in 1916/17, salaries totalled just over $20,000 per year, and lab material for the teaching of anatomy, pathology, and physiology had more than doubled in cost from the previous year to $5,000 in 1919/20, yet endowments totaled only $67,000 in capital.61 Furthermore, although some of the basic science courses were taught in the Dalhousie Science Building, and pathology had its own building (part of Victoria General Hospital), by 1919, 23,000 square feet in the medical building was no longer enough. Like the medical faculties at Toronto and McGill, the post-war period at Dalhousie called for expansion and

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giving newer medical subjects their own departments, space, and staff. Although Flexner rated the Halifax Medical College much below the facilities in Toronto and Montreal, by 1919 medical education in Halifax had uniquely positive points. The provincial capital was the base of the Royal Navy's North Atlantic fleet and military headquarters for the Maritime Province district. Finally, as a busy seaport, it received sailors' unusual cases. As headquarters of the Eastern Military Department and Canada's major naval station, it had other special types of cases. As a centre for so many medical departments and hospitals, it had many medical men for its size - potential university instructors. Its practitioners were abler than the city's size would suggest.62 There were at least twelve hospitals near Halifax, with a maternity hospital and sanitarium for tubercular patients being built in 1920. The 'new' Military Hospital at Camp Hill had 600 beds, for wounded and convalescent soldiers; the 'old' one, 150, primarily for infectious and venereal cases; the Naval Hospital for Canadian and Imperial navies, 50; the Children's Hospital, adjacent to the medical building, 70); the Infants' Home, 50; and the Nova Scotia Hospital for the Insane, in Dartmouth, 500. The area also had the (Dominion) Trachoma Hospital and Quarantine Hospital.63 MacKenzie quickly addressed potential Foundation concerns and substantiated the claim that medical teaching in Halifax was crucial not only to the 85,000 Haligonians but also to the entire Maritimes. Presciently, he touched on a number of Foundation-supported issues in the three-page letter that accompanied the eight-page report sent to Vincent in January 1920. MacKenzie championed medical schools with strong university ties yet complimented the heroic efforts of the founders of Halifax's proprietary medical college; touted efficiency and high standards in medical education; acknowledged Flexner's evaluation while applauding the founders of the Halifax Medical College and Dalhousie, which rescued Maritimes medical education when "the time came which such [proprietary] schools could not train for modern Medicine"; mentioned the wartime sacrifices; staunchly advocated self-help ("We are not ... sitting back asking others to come in and help us without having shown complete indications, I hope, of helping ourselves," as with the fund-raising campaign of 1912 and that of 1920, planned well in advance of any Foundation gift); and noted that "to put the Medical School on a proper basis for thorough work would take about a million and a half, and it is only by the assistance of some such body as the Rockefeller Foundation that this can be done."64

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Although Vincent mentioned a visit to Halifax, dates were not confirmed until Pearce returned from Europe in early February. This did not, however, stop MacKenzie from planning an itinerary for the Foundation representatives and from trying to procure funds from the federal government. In a letter to Acting Prime Minister Sir George E. Foster, he appealed for matching Dominion funds, adding his voice to that of Dr Alexander McPhedran of Toronto's Faculty of Medicine. MacKenzie cited the medical schools' role in the Great War, "supplementing the Army Medical Corps" with hospital staff overseas, "a debt to the universities which I think the Dominion Government might well recognize in this practical way."65 MacKenzie also appealed to Foster's nationalism. Like President Falconer in Toronto, he was aware that until medical research grew in Canadian schools, students would go to Europe or to the United States for further training, all too often staying abroad: I am sure it will not be necessary for me to urge upon you the necessity for having at least one or two medical schools in Canada where the highest and broadest types of medical research can be carried on, so that our medical students do not have to go away as they do today, to the United States or across the water to receive that education which they should be enabled to receive at home. It is true that McGill and Toronto medical schools are very excellently equipped today to do the ordinary teaching for medical students, but most of the other medical schools, and I can speak for our own in particular, are quite a way from that stage yet, and the endowment needed these days to teach modern medicine is so great that it is difficult for the various universities from the Atlantic to the Pacific, who are in strategical medical centres, to get the money needed to carry on proper medical education.66

McPhedran used a similar line, particularly with regard to the "brain drain" to the United States: none of our Institutions are sufficiently well equipped to provide the best advanced work for the able men entering medicine who desire to pursue their work further. They, therefore, leave Canada for foreign countries, most of them going to the United States. Few of these men return, as they secure lucrative appointments, and most of the Institutions in the United States have one or more of our men on their staff, Canada thus losing most of the very best of our medical graduates, a loss that no young country can sustain without serious damage."67

Foster replied noncommittally. He reminded MacKenzie that educa tion was in provincial jurisdiction. Still, Foster said, the matter would

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receive consideration.68 By 27 May 1920, Foster had decided to give no financial aid.69 MacKenzie's efforts turned to planning for Pearce and Vincent's visit. By mid-February, they confirmed that they would arrive 15 March and leave 17 March: "the officials of the Foundation have no preconceived plans which they wish to urge upon you. Their aim is to understand your need and to work with you in an effort to help you realize your natural ambition to increase the efficiency and usefulness of your institution."70 Yet hopes for full-time teaching always lay just beneath the surface. Up to this point the Foundation had set no fixed dollar values. Each school had its needs and sought a substantial portion of the total. Less than one week before Pearce and Vincent's March 1920 visit to Halifax, an article in the Toronto Star told of a plan to reorganize the Toronto medical school. It called for full-time heads of departments, with salaries of $10,000, and a limit of 125 students, down from 416. This plan required an increase of $200,000 per year or a capital outlay (at 5 per cent) of $4 million, to raise the cost from $143,000 to $343,ooo.71 But this report, prepared by the faculty for the university's board and the Foundation, had been leaked to the press. On 12 March 1920, Falconer apologized to MacKenzie, explaining the situation and that his university had not made any specific request. "It is a matter for deep regret that an impression may have been made that this University has been so unmindful of the needs of the rest of the Dominion as to seem to wish to secure an undue share of the gift which, unsolicited by the Dominion or by this University, has been generously offered by the Trustees of the Rockefeller Foundation."72 With that settled, Dalhousie prepared for the visitors. Pearce and Vincent spent their time seeing the medical school, meeting with the premier, and attending dinners held in their honour. Vincent also gave an address on public health. The local papers followed every move. A number of articles explained the visit and reviewed Vincent's address, including the Halifax Chronicle (16 and 17 March) and the Halifax Herald (12 March). The latter printed a lengthy feature, "What Rockefeller's Millions Are Doing for Humanity World-over." Everyone in Halifax was on their best behaviour, trying to impress the guests. Following this first visit, Vincent wrote to thank MacKenzie for his hospitality. He intimated that it would be all right to use the gift as leverage "to secure essential conditions of success".73 MacKenzie would not miss the advice. The next step in the evaluation of Dalhousie was a second visit by Pearce, from 6 to 9 April 1920. In preparation, Pearce requested documents from MacKenzie, including: a plan of development for the

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medical school, which covered several years; plans for developing instruction in public health as it related to the medical school and any provincial or municipal organizations; problems related to the hospital, specifically regarding staff appointments and introduction of full-time teaching residents; any ideas on limiting enrolment and lengthening the course; and an itemized statement of all costs for medical education. Pearce had an ulterior motive. He did not want any subsequent changes to appear mandated by the Foundation: "If there are any changes to be made which might be criticized eventually on the basis that such changes were influenced by the attitude of the Rockefeller Foundation, might not these changes be considered and announced before we proceed very far? I have in mind the question of changes in appointments to the hospital, possible resignations from your Faculty, and the- possibility of a new dean. I do not mean that any of these are necessary, but if they are contemplated it might be well to have them precede any definite activity on the part of the Foundation."74 The tone of Mackenzie's correspondence with Pearce and Vincent is interesting. The noticeable warmth and sense of genuine friendship contrast with the cordial but formal tone between the Foundation and McGill and Toronto. Following their first visit to Halifax, Pearce commented, "I feel now that I have a thorough grasp of the Dalhousie situation but look forward with pleasure to the necessity for a return visit,"75 and Vincent wrote, "Looking forward with pleasure to a second visit to Nova Scotia."76 Pearce and Vincent got along well not only with MacKenzie but also with the medical faculty and "the citizens of Halifax with whom we came in contact."77 Pearce and Vincent found that Dalhousie's setting had few urban distractions and that nature offered welcome respite. Pearce enjoyed fishing. MacKenzie invited him on another visit - "if you will only come back and do a little fishing, and let Medical matters not worry you, we will be glad to show you what the country can do in the way of sport."78 Pearce replied, "I often think of my visits with you and of how enjoyable they were and if the opportunity ever arises for returning for a little fishing I assure you I will not debate the matter very long."79 E F F E C T S OF THE G I F T

Just as Vincent had suggested to MacKenzie, the Rockefeller Foundation's gift was wonderful leverage. On 16 June 1920, MacKenzie wrote to Premier G.H. Murray to outline the conditions of the gift. First, the university should build and maintain an out-patient facility for all hospitals in the vicinity, with an accompanying dispensary, social services department, and follow-up centre. Second, it should

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Bouncing Back at Dalhousie

enlarge the pathology building, part of the Victoria General Hospital; the cost would be $150,000. Third, it should join forces with the Halifax Dispensary to carry on the out-patient and Health Centre clinic.80 Although the Foundation gave $200,000 to allow Dalhousie to fulfil the first condition, the pathology building was the government's responsibility. Indeed, the leverage worked, and the government pledged the money for extension and more. A Foundation memorandum dated 20 April 1921 noted that the province was responsible for maintenance of a pathology department; for maintenance of a new department of hygiene; and for additions to both the Pathology Building and the Victoria General Hospital.81 In fuller terms, the plan of development set out by MacKenzie was to be as follows: (a) Maintenance by the University of its present budget for the Medical School (b) New resources as follows: To be raised by the University: Development of the laboratory and clinical departments involving increases of salaries of $25,000 a year - requiring endowment $500,000 Increase in cost of maintenance $15,500 a year - requiring endowment 310,000 New equipment 26,500 Remodeling Medical Building $25,000 to 50,000 50,000 An addition to Medical Building 150,000 Dispensary and Health Center 200,000 Support by Provincial Government: Maintenance of pathological department at $8,000 a year, capitalized value $160,000 Maintenance of new department of hygiene Addition to pathological building 150,000 Addition to Victoria General Hospital 525,000 Contribution by Halifax Dispensary: Present plant valued at Contribution by Massachusetts Health Commission: Present pledge $5,000 to $10,000 a year for at least three years

$100,000

$15,000 $2,186,500^

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The Rockefeller gift, $500,000, was awarded to Dalhousie on i September 1920. Of course, all the above represented the commitment made by the university, the provincial government, and existing organizations. In a remarkable turnaround from its normal conditions of gift, the Foundation earmarked the money for buildings. (a) Remodeling the present medical building (b) Addition to the present medical building (c) Building and equipping dispensary and public health center (d) Equipment (primarily for laboratories) (e) Endowment

$ 30,000 150,000 200,000 20,000 ioo,ooo83

The Carnegie Corporation's gift of $500,000 was to endow chairs in the Department of Medicine. Whereas, at McGill and Toronto, the Rockefeller Foundation insisted that the province handle building costs, it was considerably more lenient with Dalhousie. Perhaps it saw Dalhousie as the most worthy recipient - despite Flexner's scathing review, Dalhousie now seemed to be on the right track. A forward-looking president acknowledged its strengths and weaknesses: its medical staff formed a team, serving an entire region, with an appetite for modern medical teaching. Dalhousie had much further to go to catch up to the modern ideal of Johns Hopkins or even of Toronto and McGill. I believe that this informed the Foundation's lenience vis-a-vis its gift. Dalhousie had to improve its pre-clinical science departments, having struggled for so many years as a proprietary college. The war years and the Halifax Explosion had only further delayed development. Rebuilding the city and upgrading Dalhousie fell to a relatively small population (see Table 5.2). Yet the Foundation acknowledged the need of maintaining a medical school for the Maritimes and set about aiding it. It made little mention of introducing the full-time system at Dalhousie because, I believe the pre-clinical subjects first required a firmer footing. Even the Foundation representatives could see that aiding the school was far better than letting it close or struggle in ignominy. They respected the faculty's efforts at improvement and assisted a school with nineteenth-century facilities and methods. I do not think that Pearce or Vincent imagined that the gift would make Dalhousie a leading research centre, but they hoped for a solid centre for teaching modern medicine, producing able general practitioners for the Maritimes. Unlike Toronto, Dalhousie received the pledged amount ($500,000) in 1920; an additional $50,000 arrived in 1922. Thus Dalhousie's gift was actually larger than $500,000 because the rate of exchange on i September 1920 was favourable to the Canadian dollar; it was the

ia8

Bouncing Back at Dalhousie

Table 5.2 Population of Toronto, Montreal, and Halifax, 1921 City Toronto Montreal Halifax

Population

Rank among Canadian cities

521,893 618,506 58,372

2 1 11

Province

Population

Ontario Quebec Nova Scotia

2,933,662 2,360,510 523,837

Source: Sixth Census of Canada, 1921, vol. 1, and Leacy, ed., Historical Statistics of Canada.

single largest portion of the funds distributed in 1920. McGill and Toronto waited until 1921 for any money. McGill received $1,052,602.74 that year and an additional $500,000 in 1924. Toronto received its endowment in annual instalments. Often the Foundation said that a school had to meet a particular set of conditions, or risk losing the remainder of the gift. Dalhousie had a hybrid of full- and part-time teachers. While the clinical instructors were all part time, local practitioners and the professors of anatomy, pathology, and physiology were full time. Pearce knew this and did not seem to worry about it in evaluating Dalhousie. He sought to strengthen its medical program, first in the basic sciences, and then in clinical teaching. Dalhousie's goal was to offer a solid medical education, with those keen on better clinical training going elsewhere. Dalhousie Medical Education after 1920 The best overview of Dalhousie's spending appears in Report on Dalhousie University Medical School for the Rockefeller Foundation. Dated 6 April 1920, this comprehensive overview of up-to-date pedagogy conveys Dalhousie University Medical School's view of itself. The report discussed decreasing enrolment to raise standards and investing in post-graduate opportunities. Dalhousie had a good idea of where modern medical education was going: The Dalhousie Medical School will remain a relatively small school, the clinical facilities of Halifax setting a natural limit to its size for efficient teaching. But it should teach Medicine as well as a large school. This means that it must be able to attract to its chairs men of the highest ability. And this means that it must pay salaries as large as the best schools and must offer its permanent staff adequate facilities for research in assistants, apparatus and libraries. There are obvious things, of course, which it cannot offer them; the very biggest men must gravitate toward the great medical centres. Dal-

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housie should be at the least a breeding and resting ground for some of these men.84

There is no mention of the full-time system, probably because Dalhousie had more basic needs and saw full time as suitable for betterestablished schools, with strong foundations in the pre-clinical years programs. In addition to the Rockefeller and Carnegie gifts, the university sought $1 million in a fund-raising campaign in 1920. But the money raised would go to the Faculties of Arts and Science and of Law. Medical teaching had benefited from its reintroduction to Dalhousie in 1911. The university had had to fund a maternity hospital ($150,000); accommodation ($100,000); three full-time professors and a part-time staff ($10,000 per year); and apparatus and equipment for the departments of Physiology and Pathology ($6,000). It gave the Salvation Army $150,000 to build the Grace Maternity Hospital and responsibility for day-to-day operations, but the university would appoint the medical staff and could use free beds for clinical instruction. This arrangement launched clinical instruction in obstetrics in Halifax.85 Considerable work was necessary in the departments of Bacteriology, Biochemistry, Embryology, Histology, Pathology, Pharmacology, and Physiology. "Only a mere beginning has been made"86 in Biochemistry, Embryology, Histology, and Physiology, and Bacteriology and Pathology needed more staff members, a larger building, and more equipment. Furthermore, the specialty of Pharmacology had to be created. Although biology, chemistry, and physics were university subjects and benefited from the new Science Building, their increased number of students necessitated more teachers and more equipment. Hence scientization of medical education was the single greatest cost in Dalhousie's modernization. A full-time anatomy professor at Dalhousie received $2,500 to $4,000 per year and the Eaton Chair of Medicine at Toronto $10,000. Although Dalhousie said that it "must pay salaries as large as the best schools," this discrepancy seems to stand out. I believe that the explanation is a combination of two factors: the Toronto faculty's higher regard within the profession and Toronto clinicians' (with large practices) not teaching subjects such as anatomy. Increasingly, clinical medicine was becoming the "senior service" within a medical faculty, and salaries reflected this throughout U.S. and Canadian medical schools. In addition, the time seemed perfect to update Hygiene and Public Health, still taught only via lectures. Now a full-time professor was to have lab assistance and the requisite facilities. Public health was a

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dominant theme in this era of rebuilding, particularly in the Rockefeller worldview. Because Dalhousie was the major university in an economically depressed and underdeveloped area, the Foundation determined that to assist public health and hygiene was to aid the Maritimes. Reid notes that, during the 19205 and 19305, it saw the Maritimes and Newfoundland as "a pioneer and poverty-stricken country," even as change was under way. Reid posits that these diverging perceptions made the area "an ideal testing ground for new ventures" in the eyes of philanthropic foundations. Given that the Rockefeller and Carnegie foundations spent more than $4 million between 1918 and 1940, Reid's hypothesis would seem accurate.87 Rockefeller grants included $75,400 to Dalhousie for hygiene and public health projects and $72,788 to the governments of New Brunswick, Nova Scotia, and Prince Edward Island, mostly in the 19305, for the same reason.88 Dalhousie University was the beneficiary of two major gifts, which equalled the $1 million received by Toronto and McGill. It was the only school, however, viewed as less than excellent. Dalhousie obtained support because it was the only medical school in eastern Canada, and the Rockefeller Foundation planned for its future vis-avis a population that would require more physicians. Its gift arrived in one lump sum and went largely for buildings. Whereas the Foundation all but forbade such use in Montreal and Toronto, it acknowledged Halifax's need for more teaching and laboratory space. And while it expected Torontonians and Montrealers to generate matching funds, it saw Haligonians as having gone through too many recent trials to bear the costs of a medical school overhaul. They could contribute, but two American philanthropists would help them through much of the 19203. Reid notes that Dalhousie's medical faculty received more than $610,000 from the Rockefeller Foundation between 1920 and 1938, and the Carnegie Corporation almost matched the amount with $604,000 between 1920 and 1937-89

Conclusion: Medical Education Transformed

CATALYST FOR R E F O R M

Even before the publication of the Flexner Report in 1910, Canadian medical schools were participating in an age of reform. In that spirit, they erected new buildings and added new subjects, such as bacteriology and biochemistry, to the curriculum in a bid to modernize and "scientize" their programs. Scientization brought a definition of professionalism that ensured physicians' autonomy and a degree of elitism that would sustain their status and high earnings. This was a reaction, as Ludmerer says, to competing medical sects in the early nineteenth century, including Thomsonianism, which flourished in the 18305. As Ludmerer explains, U.S. Thomsonianism assumed that the practice of medicine was simple enough for any person to understand. This, coupled with limited medical knowledge and what Ludmerer calls "therapeutic pessimism," made reform of medical teaching necessary in the later nineteenth century.1 All the Canadian reforms, supported by the Rockefeller Foundation, the Carnegie Corporation, and the Eaton Endowment, centred on improving medical teaching in Toronto, Montreal, and Halifax. In the process, as this chapter shows, they also transformed instruction, increased public and government support, professionalized medicine, and destroyed myths. Following decades of reform influenced by developments in first France and then Germany, by 1910 the schools were aware of

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Conclusion

advances in clinical and laboratory medicine, but none of the universities could afford to implement these reforms wholesale. Ludmerer views 1870 as a turning point in North American medical education. By this point, many Canadians and Americans were travelling to Europe for post-graduate training, including men such as Macallum, Osier, and Charles Eliot, president of Harvard and initiator of reform at its medical school. They brought back new methods and knowledge, particularly in the laboratory-based sciences. In Paris, Ludmerer says, they learned to link pathology and physical diagnosis and saw how the hospital could form an integral part of medical teaching and research; in Germany, they noted how scientific subjects could enhance a physician's basic knowledge while he was pursuing experimental medicine.2 It was as if the medical schools in Toronto, Montreal, and Halifax were ready and willing but not able to push through their ideas. Further frustration for advocates of change such as Macallum followed when the Great War interrupted teaching for almost five years. This was why the announcement of Rockefeller money for Canada was so exciting in 1919. At last Canadian schools, particularly Toronto and McGill, could endeavour to keep pace with the leading American schools, while Dalhousie could avenge Flexner's scathing review. Through the scientization of medicine and the full-time system, gifts changed medical teaching and the profession in North America in a number of ways. First, the money helped to limit access to medical school by raising the standards for prospective applicants. Savitt shows this for U.S. black medical schools: only two remained in 1923, and so fewer black students could study medicine.3 Weisz illustrates another example. He notes the pressure to raise entrance requirements at McGill to keep up with U.S. state licensing requirements; McGill had many American medical students during the 19005 and 19105. McGill also limited entering classes to 100: by 1929 it required students to have a BA or BSC with training in the sciences. This was not the case at the francophone medical schools in Montreal and Quebec City. Standards there were lower, partly because they were serving a different market, training students to become practitioners. The French-language schools did not obtain many American students and, so could afford lower entrance requirements.4 Each of the three schools at Dalhousie, McGill, and Toronto also decreased the number of places in first year. They did this in earnest only after 1920, to allow interested servicemen a place. Also limiting access was higher tuition. By 1924/25, McGill would cost a student $1,200 over six years, Dalhousie $1,132 and Toronto $950. This represents an increase of about 200 per cent since 1904/05

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for each of the three schools. This too began to restrict registrations. Young farm boys (such as Fred Banting) may have been able to attend when four years cost $400. But by 1924, the course had been lengthened to six years at all three schools, and, with all the new subjects and more time in labs and clinics, it was too difficult to begin classes in October and fit everything in. So classes began in September, and farm boys had to miss the harvest - for some, too much of a sacrifice. In response to growing scientization and the expanding curriculum, all three schools added a year to their four-year program. McGill led the way, in 1907/08, with Toronto following in 1908/09. Dalhousie did so in 1911/12, after it reabsorbed the Halifax Medical College. By 1919/20, to keep up with the leading U.S. schools, both McGill and Toronto had introduced a six-year program, with Dalhousie following in 1921/22. Higher fees helped pay for expanding the program. This was perhaps the most striking effect of the foundations' gifts. They helped raise awareness, via the condition of matching funds, of the costs and needs of modern medical training and research. By the time of the discovery of insulin in 1921/22, the benefit of medical research was clear. If the goal, as at Toronto, was service to the people of the province, then the goal had been ably met. Finally, all these elements came together to raise the status of physicians. Whether as a consequence of the Flexner Report or despite it, the number of U.S. and Canadian medical schools fell by half, and the remaining schools improved. Medicine became a highly trained profession, anchored in science and technology. Markowitz and Rosner cite the power achieved by a handful of elite U.S. physicians who oversaw the reforms funded by the foundations. This group ensured that U.S. reforms "centralized, bureaucratized, modernized and expanded medicine and medical education in the interests of physicians' own professional needs and with little regard for the needs of the public."5 Rockefeller's 1919 investment of $5 million in Canadian medical education amounted to the equivalent in 2004 of $45-50 million. In donating the money in such an organized fashion, the Foundation set an example for large-scale gift-giving that began a trend still in evidence today.6 Without the Rockefeller benefaction, change to modern medical teaching would have been far slower. Innovations were taking place, but at a rate that was threatening to stall. Canada embraced the scientization of medicine, introduced in the 18705, but as the cost increased, a science-based curriculum emerged slowly until the Rockefeller gift. In 1920, the Foundation planned to give McGill $1 million; by 1926

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it had given McGill $1,552,602. For other institutions the figures were Toronto $1 million ($1,123,047); Manitoba $750,000 ($533,784); Alberta $500,000 ($586,000); Dalhousie $500,000 ($550,000); and Montreal $500,000 ($151,163; $225,000 by 1935). Montreal received $25,000 each year from 1920 to 1935, except for $12,500 in 1920 and $13,663.86 in 1924. Reserve funds of $750,0007 in 1920 had fallen to $278,357 in 1926. The gifts to Montreal, Manitoba, and Alberta were part of a second wave. Relying on Flexner's report as well as visits to these schools, the Foundation had decided to give money first to the schools that it deemed excellent (Toronto and McGill), as well as one that Flexner called "feeble" (Dalhousie) but needed in the region. Then it gave money to the other "feeble" school (Montreal, formerly Laval in Montreal), to Manitoba ("a distinct effort toward higher ideals"), and Alberta, which had not yet begun medical instruction in 1910. The total Rockefeller investment in medical education in Canada pales in contrast to the General Education Board's in the United States. Between 1914 and 1960, the board made gifts to more than twenty-five schools totalling $94,083,372.74.8 Vanderbilt, Chicago, Johns Hopkins, and Meharry received over half of this amount.9 But it is dangerous to evaluate these gifts strictly on the basis of dollars. The Canadian schools were able to push on with reform, begun as early as 1880. Dalhousie obtained $500,000 at a time when it needed help. In fact, Dalhousie received more than did seven of the twenty-five schools assisted by the General Education Board.10 By contrast, the Foundation helped the University of Alberta to become a complete medical school. By 1920, it was still offering only the three pre-clinical years, after which students would transfer to Toronto or McGill. The intended gift of $500,000 - annual grants, with the principal to follow - recognized Edmonton's work to create a first-rate medical school. These efforts included a major provincial commitment, namely to construct a new laboratory building; to give an additional sum of not less than $25,000, above and beyond that budgeted for 1920/21, for the development of clinical subjects; and to guarantee an annual increase of between $65,000 and $90,000 in maintenance of the University Hospital.11 The clinical curriculum and facilities still had to be organized, and the Foundation wished to help this school establish itself as the only medical school in the Canadian west. "It occupies an important position in relation to the farther Northwest of Canada and its development should be aided."12 The goal was therefore to have a nearby University Hospital complete by 1922 and to have the clinical years set up by 1923.

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Finally, Manitoba also benefited from the Foundation's $5 million. In 1920, it was the only complete medical school west of Toronto, with an enrolment of 219. Begun as a proprietary college in 1883, it had affiliated with the university in 1918 and was held in high regard by Pearce. He recommended $500,000 for the school if the province gave $400,000 for a new medical building and increased by at least $20,000 its general grant, over and above the assigned $88,435. This was the only school for which Pearce recommended an additional $250,000 gift, on condition that the university raise matching funds.13 The balance of $750,000 in the original $5 million, Pearce noted, "should be held with the reservation on the part of the Foundation that it could eventually be applied, if other disposal seems advisable, to the development of a school at Vancouver in connection with the Vancouver Hospital and the University of British Columbia." Other ideas for the remaining funds included maintaining the principal and putting the income to "schools being reorganized, to experiments in medical education and to the support of fellowships" or towards establishing chairs of preventive medicine at Queen's and Western. Queen's and Western had applied for aid to the Rockefeller International Health Board and, Pearce wrote, could receive $250,000 each towards those chairs.14 Toronto, McGill, and Dalhousie used subsequent gifts and then some for a diverse group of projects that supported research, education, and establishment of new departments. While the University of Toronto's medical faculty received its money in instalments, McGill and Dalhousie were given theirs at once. McGill received its capital on 20 December 1921. It appealed to the Foundation because, as Vincent wrote to Falconer, "it seems that McGill, in anticipation of collections from its campaign, had subscribed to a million dollars' worth of Dominion Bonds, and was carrying these by means of notes at the banks. The Trustees of the University asked the Foundation whether it would be convenient to make cash payment in order that these notes might be taken up. It so happened that maturing investments enabled the Foundation to do this without sacrificing in an unfavourable market."15 The Foundation wished to keep some leverage over Toronto - not to dictate changes but to ensure raising of the matching funds. This is a far cry from the General Education Board, after it decided in 1913 to devote all of its money in medical education to instituting full-time clinical plans. As Rothstein noted, "grants were awarded on the condition that the funds would be returned if the full-time plan was altered."16 But by 1919, after failures and growing resentment

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towards this restriction, the General Education Board allowed variations, such as geographic full-time and part-time appointments. Hence, by 1920 the Rockefeller Foundation no longer tied recipient schools to a rigid plan.17 Although the Foundation would never have pulled out of its investment in the provincial university, it did want Toronto to believe that it might, to keep up the pressure for matching funds and stated goals. Pearce wrote Falconer on 15 June 1923 that the Foundation was "prepared at this time to consider the payment of the capital sum," contingent on Toronto's having met the four conditions: erection of an anatomy building; expansion of the pathology laboratory; construction of a psychiatry clinic, to be maintained by the city, and with clinical facilities available to university medical students; and "that the budget of the University be increased so as to allow added salaries for the Medical faculty."18 Despite a delay in constructing a lab for clinical pathology instruction, by 6 December 1923 the Foundation had resolved to give the $1 million to the University, with no further obligation by the Foundation to make interest payments. Although the $5 million was the only general gift made by the Rockefeller Foundation to aid medical education, Canadian schools continued to receive Rockefeller funding for specific projects as well as fellowships. Toronto gained more than $920,000 in added Rockefeller aid for projects ranging from a school of hygiene to help for nursing education and paediatric and psychiatric research. The first such benefaction was an additional $650,000, to establish a School of Hygiene in 1924/9 A grant of $40,000 followed in 1929 to the Department of Pediatrics for research. The laboratory staff already included five full-time researchers: Dr Gladys Boyd, Miss A.M. Courtney, Dr T.G.H. Drake, Mrs M.M. Johnston, and Dr F.F. Tisdall, all supervised by head of department Dr Alan Brown. Research projects during the five years of the grant included nephritis and diabetes studies; investigation of the acid base metabolism of the tissues of small animals, with reference to changes produced by conditions comparable to those found in the acute intestinal disturbances of infancy; studies of the oxygen content of blood and the chemical effect produced by the use of various mixtures of oxygen in pneumonia; and the value of bananas in children's diets.20 The grant for paediatric research was used to acquire more staff members and to pay their salaries; by 1933, the Sub-Department of Pediatrics had twenty-three members, including nine physicians, one bacteriologist, and seven technicians, and a lengthy list of research publications.

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In 1932, the Faculty of Nursing received $87,500 over five years to strengthen its program and its ties to the medical faculty. Finally, the Foundation pledged $106,080 for research in psychiatry from i January 1939 to 30 June 1944. McGill received an additional $1,879,588 from 1924 -$500,000 to endow the University Medical Clinic - to 1937 -a $2,500 grant for research in pharmacology. The largest single Rockefeller Foundation gift was not the original $1 million for general medical education, but a gift of $1,232,652 in 1932 towards the development of teaching and research in neurology, which led to the Montreal Neurological Institute, headed by Wilder Penfield. The other McGill gifts were $85,000 for research and experimental surgery (1929); $5,936 for research in pharmacology (1934); $10,000 for spectroscopic analysis of biological material (1934); $17,000 for genetics research (1935); $24,000 for spectroscopic analysis of biological material (1935); and $2,500 for research in pharmacology (1936). There were also grants, totalling $217,500, for a study of child life and social science research between 1925 and 1936.21 I believe that the Foundation's high opinion of McGill and the school's not being a state institution were what made it the largest recipient of Foundation funds in Canada. Dalhousie received an additional $120,142 from the Rockefeller Foundation: $50,000 in 1921 for medical school development; $10,000 in 1928 for teaching in the Department of Hygiene; and $60,142 from 1933 to 1938 for teaching in public health.22 The Carnegie Foundation for the Advancement of Teaching also continued to give to the university. It contributed $50,000 in 1921 towards hospital teaching facilities, $4,000 in 1934 for the Department of Pathology, and $50,000 in 1937, for a medical school library, for an additional total of $iO4,ooo.23 It is obvious that the Foundation had shifted its giving to specific projects. The era of general aid had passed, as had, it hoped, the need for wholesale aid. The Rockefeller Foundation's trend towards projects grew as the medical schools found firmer footing. For example, between 1917 and 1950, it sponsored 1,263 medical fellowships, allowing bright scholars and physicians to study abroad. Among the Canadians benefiting from this initiative were two of the four men responsible for the discovery of insulin. Charles Best studied in England, Denmark, Germany, and France in 1925 and 1926, and James Collip, in the United States and Canada in 1921 and 1922. During the program's thirty-three years, fifty fellowships went to Canadians, behind England (136), other countries (101), Germany (82), and the United States (79)-24

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Conclusion TEACHING TRANSFORMED

The Rockefeller Foundation's investment helped resolve a number of issues in recipient schools. As is obvious from the plans that each school prepared for Pearce and Vincent, the announcement of gift crystallized a re-evaluation and new vision of teaching facilities and equipment. The period immediately following the war was perfect for another look at medical education in Europe and the United States and for adopting the best elements. War veterans were more worldly, and the marketplace for learning was increasingly global, as is clear in the "wish lists" that the medical faculty drew up for the Rockefeller Foundation. After decades of wanting change but not having the money, the capital was available. Jonas comes to a similar conclusion. Viewing philanthropists, not as policy-dictating controllers but as "friendly outsiders," he sees partnership with beneficiaries. The gift-givers can supply the wherewithal and help creative individuals isolate their needs.25 I believe that the Rockefeller philanthropies were in the second of three phases of giving. The first had been one of total control, led by Frederick Gates, and set a firm direction that led to the Rockefeller Institute. The second saw relinquishing of total control, but with a close eye on spending. One example is the fight by Columbia University. In May 1922 the school began Flexner's strict full-time system, but after two years it switched to geographic full-time clinical teaching. This breach of agreement almost cost it $2 million. Only the quiet diplomacy and sound arguments of Dr Walter W. Palmer saved the endowment.26 This was the situation when the Foundation gave money to the Canadian schools. At Toronto, the Foundation held on to the purse strings, waiting until 1923 to see that all of its conditions had been met. The third and final phase saw no active interference. We can see this in the tenure (1932-55) of Warren Weaver, director, Division of the Natural Sciences of the Rockefeller Foundation. After applicants had submitted a research proposal and their research projects were chosen for funding, they could pursue their research. Even when they asked him for advice, Weaver gave none, preferring to allow them their professional independence.27 Part of the reason for greater control between 1890 and 1925- was that this was the period of many of the Foundation's "big" projects the Rockefeller Institute, the University of Chicago, and the Peking Union Medical College. As Jonas writes, the Foundation shifted focus in the mid-i92os. It no longer supported only a few top scientists but developed new fields that, lacking in resources, could use aid.28

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Although this tack often proved risky, one can see a similar calculated gamble in supporting Dalhousie. Furthermore, the Foundation's cachet led the schools to create their wish lists. These projections helped them to move beyond their more modest, day-to-day assessments of need. While they did so, the Foundation had not mentioned amounts, and so schools budgeted for more rather than less. They extrapolated on their baseline needs to create a vision of the future. This vision helped them to raise the calibre of teaching and support staff and to expand programs. The faculty committees that made up these plans did have considerable experience. Many members had seen the equipment and techniques, particularly in laboratory teaching, while post-graduate students in Germany. They had long proposed the adoption of these new scientific medicine methods. McRae cites Macallum and Wright as some of the early workers in scientific medicine. Wright introduced the idea to Toronto when his biology laboratory group joined with the university medical school in 1887. This effective partnership, which introduced lab methods and hands-on training, improved the pre-medical curriculum.29 Furthermore, medical science at Toronto had a fine reputation by the 18905 and only improved during the ensuing decades. It did not therefore emerge from the discovery of insulin, McRae argues.30 Unfortunately, there was no money between 1890 and 1919 to modernize medical teaching. Reality could not keep up with ideas, and Foundation conditions of gift pressed the provinces and the people of Toronto, Montreal, and Halifax to support scientific medicine. The expansion of the pre-medical program complemented the change to full-time clinical teaching. By 1918, eighty of the eightynine U.S. colleges required two years of college for entry into a medical program.31 Science and particularly lab training had become necessities. With these, schools reduced enrolment to shrink the surplus of physicians. Atwater and others call this the period one of medicine as an "elite activity." Each school aimed, with its five- and six-year programs, to produce the best-trained practitioners and researchers possible. Faculties grew as they added new subjects and sub-specialties, which would later lead to the structure of core programs plus electives. Some students could stay on, as junior fellows, under the full-time instructor, with a view to becoming an instructor. This effort would attempt to combat the "brain drain." Now, Canadian schools could offer the complete package; they could train their own teachers completely, instead of relinquishing them for further study elsewhere, where they might stay. This problem lasted well into the interwar years. By 1928, of 513 Canadian scientists, almost 50

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per cent (254) trained at Toronto, but 42 per cent of the 513 no longer lived in Canada.32 The Full-Time System Introduced

As a condition of support, albeit unspoken, full-time clinical teaching was a provocative and progressive change. Though not written into any official document that passed between the Foundation and Canadian faculties of medicine, it appeared often in background memoranda and letters. The gossip in these exchanges shows that many North American medical schools knew of the Foundation's support for full-time as the way of the future. After the announcement of the gift in December 1919, school administrators scrambled to draw up their plans of action and find out crucial conditions. They knew, for example, that Western Reserve University forfeited its opportunity for Rockefeller support when it failed to provide an adequate plan of action for its anticipated gift. Initially, a Rockefeller philanthropy's contract stipulated that only if it adopted the strict full-time scheme would a school receive Rockefeller money. Johns Hopkins and Washington University's early contracts with the General Education Board required return of the funds in the absence of strict full time.33 Schools with solid private endowments, such as Harvard, could negotiate for a compromise, to appease wealthy clinicians.34 According to Rothstein, Harvard refused $1.5 million from the board in 1913 rather than going full time. Columbia's University's medical school also declined support for full time in 1918 but accepted $2 million from the board in 1921 to institute a compromise that proved unworkable and was altered in 1922. Strict full time, although it had its supporters, had many critics. There was pressure on the Rockefeller trusts to bend these contractual demands, and by 1919 they were themselves questioning whether to support instead wellstaffed and -equipped labs, modern hospitals, and "a strengthening of the educational as against the professional motive on the clinical side."35 Full time required the kind of capital investment that only this size of grant could offer, particularly as much of the gift also supported expansion of resources, including space and equipment. The salaries of full-time professors also helped to give better structure to medical educators' remuneration. Until 1920, salaries, except perhaps for the highest, tended to be lower than they should have been, a vestige of the last fight for proprietary schools. By 1920, all salaries were higher. Men interested in research and laboratory work could now consider

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a full-time career with little consultation. It was by no means as lucrative as just seeing patients, but still rewarding. GREATER SUPPORT

Because one condition of gift was matching support, private giving increased. Medicine was for the betterment of the people and therefore deserved the public's support. Just after the war, many patriotic Canadians did so as a fitting memorial to a loved one; others, out of duty and civic pride. No matter how a school identified itself, whether as the national, provincial, or regional university, local residents were among the first asked for funds and the first to give. The mechanism of giving at McGill also drew on the war effort. The campaign of 1920 used a military style of fund-raising, dispersing squadrons of volunteers to solicit gifts. These efforts paid off - $6.5 million raised in just one week. They also generated a legacy of private support. The Rockefeller gift also began a tradition of increased provincial support. As a condition of acceptance, Ontario, Quebec, and Nova Scotia had roles, although each acted differently. In Toronto, the province supported education. Yet a major American trust gave $1 million to a state institution and set the course of medical education for the next decade. Despite the Drury inquiry, the grant went through with no other resistance. The government gave increasingly to medical education and even set up the Banting and Best research grant. Physicians, whether practitioners or researchers discovering insulin, Pablum, or heparin, were products of the provincial university, which served the people of Ontario. Legislators wanted the best methods, facilities, and instructors available to teach the best students so that Ontarians had the best health care possible. As McKillop notes, the discovery of insulin "helped link the practice of medicine and the conduct of medical research to the interests of the state" and "demonstrate the value of the university as a servant of society."36 The Rockefeller Foundation also showed the province that the two bodies could work together as partners and not rivals. Although the Foundation set up the building program for new medical teaching, it did so in consultation with the premier(s) and other local leaders. It encouraged, even shamed, the government into raising annual support, even as it educated government officials as to why they had to do so. With the Foundation's encouragement, medicine had entered the costly era of scientific and research-oriented teaching.

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Conclusion

Practitioners, though still valuable, could no longer do it all. Medical knowledge required full-time dedication to whatever sphere a physician chose: research, general practice, or one of various specialties. And giving, as we saw above, followed this pattern closely. REDEFINING THE PROFESSION

The Rockefeller gift also helped to redefine the medical profession. By changing medical teaching, it altered the culture of medicine. Students learned more subjects, with more laboratory time, and in clinical subjects, from pioneering full-time instructors. Any clinicians who did not grasp the merits of laboratory analysis of disease were left behind. Just as the profession's late-nineteenth century icon was Osier, standing at the patient's bedside, so the twentieth-century's would be the full-time clinician, seeing patients, serving as a role model for students, and bending over a microscope or a petrie dish in the laboratory. When Osier left Johns Hopkins in 1905, aged fiftysix, he allegedly told his colleague, Franklin P. Mall, "Now I go and you have your way."37 The gift encouraged yet another improvement in the standards of entrance and education, which reinforced the case for lowering enrolment. Despite the peak immediately after the war, faculties decreased class sizes to obtain the best possible applicants. This might have had a more marked effect on the physician-to-population ratio had not a wave of new medical schools opened during the 19205. The gift also supported 'prioritizing' improvements and lengthening the medical course. As subjects multiplied, schools had to expand the course or cut hours from the curriculum. This curriculum expansion led to specialties and sub-specialties and devaluation of the general practitioner. The evolution of the specialist is one hallmark of modern-day practice. Although the Rockefeller gift occurred before the era of the specialist, it did help to set the tone and even to fund fellowships. Finally, the full-time system cast a shadow over the profession. In addition to the internal, professional rows, there was a sea change in the relationship between physicians and the public. As Lepore explains, the full-time system assumed that medicine was a science. But this led to the system's downfall, because medicine is an art, not a science. Lepore argues that full time failed because it was "sciencecentred not service-oriented."38 It took clinicians out of their day-today contact with patients and placed them on hospital wards and in laboratories, working from nine to five. This, Lepore says, also cut them off from valuable fundraising opportunities.39 He explains: "Flexner, by demeaning the participation of the university professor

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in private practice, was cutting off the lifeline of financial support for the medical center from the surrounding community."40 Philanthropists gave to the hospitals where their own doctors were on staff. Examples include the Harkness family's generosity to Columbia-Presbyterian Medical Center; gifts from the private patients of Dr Frank Billings to the University of Chicago; and the work of Dr William S. McCann, which attracted more than $20 million to the University of Rochester. Hence, the profession seemed more elitist and less approachable during the strict full-time experiment. Helping Research

One natural extrapolation from the scientization of medicine was research. When funding supported various levels of full-time research within the universities, teams of researchers could receive training. Jonas argues that the principal responsibility of medical schools was to train practitioners. Biomedical research took place in facilities such as the Rockefeller Institute. Research would help practitioners stay "sharp." This model echoes that of Germany, where institutes housed first-rate researchers in bacteriology, biochemistry and physiology. Jonas says that in the United States it was only after 1945 with significant funding of research, that research became a major factor in clinical appointments.41 The full-time system affected people's positions and created a network of paid assistants and associates. Without a practice, they could spend all their time on teaching and research. A career avenue opened up for those whose interest lay in research. Research no longer had to be just a hobby. As expertise and technological developments grew, each of the research positions divided into sub-specialties, creating a web of highly specialized and knowledgeable individuals. Research journals grew exponentially after 1920. They mirror the splintering of the profession into subspecialties. One of the anomalies was the discovery of insulin. It saw the marriage of two worlds. Banting represented the last of the hobbyist researchers, a practitioner who took up the challenge of insulin. Best and Collip were of the younger generation, trained in scientific, laboratory medicine. Though only a year older than Collip, Banting had trained as a practitioner. Best, the youngest of the trio, was born in 1899. The project worked because of the different expertise of each, in addition to the leadership of J.J.R. Macleod. It would probably not have succeeded if all four men had been full-time practitioners, with just a casual interest in biochemistry and endocrinology. As Bliss

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concludes, "The single most important technical achievement was that made by Collip in the purification of the extract. On their own, Banting and Best would probably not have reached insulin."42 Compare their work with that of the University of Toronto's paediatric department of the 19305, and it is obvious that the full-time research culture had caught on and was highly productive as it worked on myriad projects. As McKillop notes, the discovery of insulin represented the definitive example of the university's potential value as a "servant of society."43 Another aspect of this interest in research was the control that hospitals gave to universities. Universities took over appointments, with heads of hospital departments cross-appointed as professors. Universities could look beyond their small pool of local practitioners for qualified individuals to teach in university hospitals. It had been the custom, about 1900, to select the individual who had climbed within the local profession and become chief of service at the hospital as professor of the clinical subject. As such, he controlled the beds required for clerks and house officers' clinical instruction. This was a stifling practice. For example, in 1890, "the entire senior medical faculty [at Harvard] was Boston-born and -trained."44 By 1920, only two local physicians held clinical positions at Harvard.45 This shift of control allowed schools to look further afield for clinical instructors and fulltime role models for their students in the teaching hospitals. This change did not sit well in Toronto. The dismissed part-time clinicians felt that they had lost what was rightfully theirs. After losing their prestigious association with the university, they rallied, and the provincial inquiry of 1923 ensued. There was, however, no easy way to change from part- to full-time clinicians; the process had to be surgical. Fortuitously the funds existed to support this change. Despite setbacks, the evolution of research medicine helped to fix medicine in the public mind as worthwhile. First with insulin and later with projects such as Pablum, which, though not readily viewed as scientific, carried a high public profile, research served the public good. If tax dollars were necessary to learn more about illness and potential cures, then so be it. Furthermore, as Atwater notes, for a number of years after 1920, and then again after 1945, Canada and the United States enjoyed considerable prosperity. People were more willing to spend on better health and increased longevity46 Clinical researchers led this search, with generous funding from the public, via government and private funds. This movement towards McKillop's "scholarship of utility" was part of the industrialization of North America on two fronts.47 First, the large Rockefeller and Carnegie donations to education and other

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projects were possible only because of immense wealth, made during the late nineteenth century's industrial revolution. Second, the scientization of medicine included not only lab instruments but also machines for diagnosis and treatment such as the X-ray machine. Whole industries sprang up to make chymographs, radiology equipment, and other biomedical machines. McKillop's idea of "utility" resulted in practical applications for the new sciences associated with medicine such as bacteriology and clinical research. This new research ideal was costly to support but promised great dividends. MYTHS DESTROYED

The Rockefeller Foundation's evaluation of Canadian medical schools helped to destroy myths built up by Flexner's report of 1910. One of the most prevalent misconceptions is that Flexner's report set into motion sweeping changes in medical education. The recent literature has discounted this opinion, often simply by examining the data. Jonas states that the report did not start the reforms, although it did "catalyze, strengthen and publicize" them.48 Publicizing medical education reform was no small feat. This was one of the crucial achievements of Flexner's work. It gathered support for reform, both from forward-thinking educators and from private donors. It made reform the "medical education issue of the hour."49 Nevertheless, Jonas agrees with Ludmerer50 and Hudson51: there had already been considerable success in teaching medicine in a "more thorough and scientific way" and in involving students in a more practical way in the laboratory and the clinic.52 Because the Foundation was so thorough in its investigations, and because of its excellent archival records, one can see how the schools appeared to Pearce and Vincent in 1920. Toronto and McGill were the Canadian ideals for Flexner, but both had deficiencies. McGill had serious problems in some of its departments - Physiology had lacked a full-time instructor for thirty-three years. Toronto had gaps in its teaching, and a state-of-the-art building, erected in 1903, was already overcrowded and old. Meanwhile, Dalhousie University's medical school was not half as ill-equipped as Flexner reported. It did have laboratory equipment and facilities and was working towards improving them. There is a valuable historiographic lesson in this. One must treat all sources with some skepticism, read between the lines with regard to their conclusions, and consider the data that they may be leaving out or overlooking to reach a particular conclusion. Despite seeming parallels between Quebec's French-speaking medical schools and U.S. women's or African-American medical

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Conclusion

colleges, this comparison would be simplistic. A delay in financial aid to the French schools was just that - a delay. Obviously the situation was sensitive, for Canadian politicians and powerbrokers as well as for Foundation representatives. Pearce and Vincent were aware of its significance from the start. There are countless letters from and records of discussions between the Foundation staff and Vincent Massey and W.L. Mackenzie King on funding a francophone medical school. Massey and King noted that 80 per cent of Quebec's population spoke French and would not attend McGill. King stated his concerns frankly in a letter to George Vincent dated 21 January 1920. In offering his solicited opinion, King advised consideration of the faculties of medicine at Laval University and the Universite de Montreal. "Were their [sic] any oversight of their needs, it might be thought that this had been due to some discrimination on the ground [sic] of either race or religion, which would be unfortunate."53 Pearce noted in his diary on 10 March 1920 that during discussions in Toronto, Massey "takes pessimistic view of French-Canadian education. Admits that French-Canadian doctors, however, must be trained and that they will not resort to English Protestant institutions."54 The following day, in Ottawa, Pearce visited King. Pearce notes, "Mr. K. believes that something should be done for a French Catholic medical center. Does not urge it on political grounds but because the large population needs medical men." After a 12 July 1920 visit to Ottawa, George Vincent reported in his diary that King and Macallum were pressing the "importance of introducing scientific education among French Canadians."55 French Canadians required physicians, and, as there were two French-speaking medical schools more than forty years old, it would be judicious to support one. The two schools were the Laval University Medical Department in Quebec City, opened in 1848, and the Laval University Medical Department in Montreal, opened in 1878. By 1910, both offered a five-year, French-language medical course. The Quebec City school had, in 1910, 92 students and a staff of 22. It ran on student fees and "an appropriation by the university" and offered clinical instruction at the Hotel Dieu, with additional, abundant opportunity for obstetrical teaching. The Montreal school had 217 students and a teaching staff of eight. It ran solely on student fees, "most of which are distributed among the teachers," and had two associated teaching hospitals for clinical instruction. Although Flexner recommended maintaining the Quebec City school, ten years later the Rockefeller Foundation would support the Montreal school.56 Furthermore, there is no parallel between the way that the Flexner

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Report affected the black U.S. colleges and its effect on the Frenchlanguage schools in Quebec. Savitt argues that Flexner crushed many of the black medical schools with his criticisms in igio.57 By 1923, the number of black schools had dropped to two, from ten in 1900. Although the General Education Board did support the remaining two schools, chosen as the black "peaks," the closing of the others seriously decreased the number of black students who could study medicine. Howard University (1869) and Meharry Medical College (1876) were long-established schools but alone could not graduate the same number of physicians. By comparison, in Canada, the two French-language schools evaluated by Flexner remained open. There has also never been the same sort of racist overtones that Savitt finds in the history of black medical education. Although tentative educational reforms were already under way before the Flexner Report, the document made a tenuous situation worse by outlining each school's good and bad points and by advocating school closures, while revealing racist attitudes.58 Nothing like this occurred in Canada. It is, however, true that support brought policy control in both Canada and the United States. Gamble, in her discussion of black hospitals during the 19205 and 19305, says that by 1939 ten black hospitals offered black doctors American Medical Association-approved internships. All ten institutions had external support. The price that they paid, she argues, was surrendering control to the white philanthropists. The white donors determined the role and the function of the black hospitals and even, she contends, maintained a racial hierarchy within the hospital administration.59 Markowitz and Rosner concur. They acknowledge the aid but recognize that its cost was a loss of independence. Although scientization of medical education and promotion of the research ideal needed considerable capital, these reforms, they argue, did not occur in the best way. The changes concentrated power in an elite group of practitioners.60 In Canada, the situation was not as extreme, and no one has argued as strongly that reform cost Canadian schools their independence. By comparison, one can see the leverage potential in place in the reorganization of the Universite de Montreal. When Pearce first visited the school in 1920, he gave no indication of support but made a number of pointed "suggestions." Among these were pre-medical courses in biology, chemistry, and physics related to medicine; new chairs of pathology and histology; and obtaining "men from Tulane, New Orleans, rather than from France" to fill out the French-speaking faculty.61 Weisz observes that changing the standards and scientizing the curriculum at the two French hools would have doomed both.6a

148

Conclusion

Even with the promise of Rockefeller aid, Montreal did not reinvent itself along the lines of McGill, with strict undergraduate science training as a requirement for entry. All that it did was to introduce a year of pre-medical science. An examination followed, and if the student passed, he could continue on to the first year of medical school. Essentially, Weisz argues, this strategy was a consequence of 'niche marketing.' McGill was competing for medical students in a market that included Johns Hopkins and Harvard. With so many Americans attending McGill and then returning home to practise, it had to meet the requirements of the American Medical Association and state licensing boards and to maintain higher standards, especially in the sciences. By 1930, there were 277 Americans studying medicine in Canada, 75 per cent of them at McGill.63 In the French-language schools, particularly Laval in Quebec City, raising standards would have priced them out of their market, Weisz argues. Seventy-five per cent of Laval's Quebec students during the 19205 came from rural eastern Quebec and from Quebec City.64 The cost of a medical education was lower at Laval, which still had a fiveyear program in 1921, than an the Universite de Montreal (now separate from Laval). Students paid $90 per year at Laval, versus $175 for each of six years at Montreal.65 Weisz admits that none of this evidence shows conclusively that Laval students came from less privileged social strata. But it does tie into the idea that changing admission standards, such as requiring a baccalaureate or considerable science training, would prove more difficult for students at Laval than in Montreal's urban marketplace. The Universite de Montreal had its own challenges. Its chief impediment was poor pre-medical training. In a report on the Canadian gifts, Pearce wrote, "The authorities promise to remedy this; have appropriated $55,000 for next year to establish a 'faculty of sciences' to teach pre-medical physics, chemistry and biology; and agree to increase the medical school budget of $40,000 last year to $113,000 for next year. This is considered the medical school's share of $5,000,000 raised in last spring's campaign for funds."66 The Universite de Montreal obviously garnered the Foundation's respect for its zeal in fund-raising. Furthermore, the Foundation does not appear to have been prejudiced against Quebec's French-speaking majority. It was sensitive to individual challenges, such as "church control of education," but no more so than towards the denominational colleges battling Dalhousie for government grants, which the Foundation was aware of and disliked. Hence, it decided to aid the "new, more progressive" Universite de Montreal, using annual interest grants based on a principal gift of $500,000. If the school met the con-

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ditions of proper development of the pre-medical sciences as well as the laboratory sciences, then it would receive the principal as well. Montreal did not have to improve its clinical instruction, as did many of the other schools; its matter of first order was to build a better foundation for the scientization of medicine. Always sensitive to feelings of the French, Pearce concluded his report: "The plan of annual grant is acceptable to the authorities, and can arouse no criticism on the part of the French, in that the same course is recommended for the provincial (English-speaking) University of Alberta, also in process of development."67 As we saw in the preceding chapter, a number of subsequent gifts followed that of the $5 million. Many were quite ambitious, such as the School of Hygiene in Toronto and the Montreal Neurological Institute associated with McGill. Obviously, the Foundation and these schools had forged a relationship during the 1920 visits and through the seemingly never-ending correspondence. Even during times of duress, such as the Drury inquiry, which threatened to destroy the full-time inroads at Toronto, or the disputed appointment of surgeon Sir Henry Gray at McGill, the Foundation continued its low-key support and weathered the storm. Often, for example, faculty deans would look to the Foundation for help in finding the best possible individual to fill a position. Vincent and Pearce often provided advice on a candidate and a contact whom the dean might use as a reference. In this way too Canadian schools belonged to a larger network. From John D. Rockefeller, Sr's, comment - "My attention has been called to the needs of some of the medical schools in Canada" - came a relationship that drew together first Pearce and Vincent and then Falconer, Martin, MacKenzie, and later Gregg. Their common goal was to offer better Canadian education and training in a world of medicine that had become more scientific and more research-oriented. By 1930, medical teaching had received a boost from the capital investment made by the Rockefeller Foundation and by likeminded governments and private citizens. This continued with the fellowship program for individual physicians and specific research projects funded by the Foundation. The Foundation's 1919 gift proved to be the basis for many subsequent Canadian peaks.

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Notes

INTRODUCTION

i Toronto and McGill were each to receive $1 million, and Dalhousie, $500,000. The remainder of the $5 million was to go as follows: $750,000 to Manitoba; $500,000 each to Alberta and Montreal and $750,000 undesignated. Ultimately, McGill's Faculty of Medicine would see the greatest single portion of that "undesignated balance." Between 1920 and 1926, it received $1,552,602, or $552,602 extra. Toronto obtained $1,123,047; Alberta, $586,044; Dalhousie, $550,000; and Manitoba, $533,784 (though promised $750,000). Montreal received $225,000, half the original commitment; the initial payment of $12,500 took place in 1920, augmented by instalment gifts of $25,000 each year from 1921 until 1935, except in 1924, when the gift was only $13,663.86. From Rockefeller Foundation History - Source Material, vol. 21, 5336, RAC. 2 Brown's 1979 classic, Rockefeller Medicine Men, began a wave of historical analyses of medical education in the twentieth century. In addition to Brown, there have been numerous books and edited volumes analysing medical education, particularly in the United States, including: Barzansky and Gevitz, Beyond Flexner; Berliner, System; Bonner, Becoming a Physician; Jonas, Circuit Riders; Lepore, Death of the Clinician; Ludmerer, Learning to Heal; Numbers, The Education of American Physicians; Rothstein, American Medical Schools; and Starr, Social Transformation. But the overwhelming majority have dealt with American examples. The only publication hinting at the Rockefeller gift to Canadian medical schools was a nine-page article, written by Spaulding in 1993, "Why Rockefeller Supported."

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Notes to pages 4-5

3 Medical education forms just part of a broader institutional history in the following: on the University of Toronto, the recent sesquicentennial history by Friedland, The University of Toronto; the previous history of Ontario's university published in 1927, Wallace, A History, which outlines the process of medical school amalgamation after Trinity folded into the Toronto faculty in the 19005; and University of Toronto and Its Colleges (1908), which has a chapter on the Faculty of Medicine and a financial history of the university to that time. On McGill, please see Frost, McGill University, 2 vols.; and MacLennan, McGill. On Dalhousie, there is Waite, Lives of Dalhousie. More generally, on Ontario's universities, see McKillop, Matters of Mind, and on higher education in Canada, Harris, A History of Higher Education. 4 Greenlee, Sir Robert Falconer. Greenlee shows how Falconer risked his own university presidency by supporting the change to full-time clinical teaching at Toronto. There are also commemorative biographies, one of which is In Memoriam, published the year after Falconer died; it includes a lengthy bibliography. Unfortunately, Falconer instructed his son to destroy his personal papers after his death, and, to the best of my knowledge, he did so. It was Falconer who pushed Toronto to keep pace with U.S. universities, even if that meant upholding a commitment to the new clinical teaching system in the face of the unbridled anger of the existing faculty. 5 Kerr and Waugh, Duncan Graham. The resistance to the full-time system is also central to the biographies of Graham, who held the first Eaton Chair of Clinical Medicine at Toronto and, to a lesser degree, of Osier. Other biographies that offer some perspective on the Rockefeller gift include Bliss, William Osier, and Gillen, The Masseys. 6 Volume two of Frost's McGill University describes emotionally charged resentment from other Canadian universities in 1920 when the Carnegie Corporation announced a grant of $1 million for McGill, in part acknowledging McGill's wartime sacrifices. Other Canadian universities, particularly Toronto, were quick to point out that they too had lost faculty members, alumni, and students in the Great War. 7 In addition to his biography of Osier, Bliss's contributions to Canadian medical history include Banting and The Discovery of Insulin. 8 Gingras, Physics. Gingras has also collaborated on: Gingras and Jarrell, Building Canadian Science, and Gingras and Gagnon, "Engineering Education." 9 Li, J.B. Collip. In addition to Li's examination of the Canadian research endeavour, there is also Thistle, Inner Ring, and Eggleston, National Research. 10 McRae, '"Scientific Spirit.'" 11 The secondary literature on philanthropy and non-profit organizations

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continues to grow. Although little of it is specific to medical education, the work of scholars such as Hall and Lagemann offers a historiographical context for this work. The contextual history of private giving is the focus of chapter 2 here. Hall's "Inventing" and other essays in Inventing outline some of the pitfalls in doing research on philanthropic organizations. Other scholars have written on philanthropy and its influence on education and society, although the bulk of material examines influence by American philanthropists on various U.S. groups: Alchon, Invisible Hand; Curti and Nash, Philanthropy, Berman, Influence; Ostrower, Why the Wealthy Give; Thompson, Philanthropy; and Zurcher, Management. 12 McRae, '"Scientific Spirit.'" The Faculty of Medicine at the 'Provincial University' came to win international praise using the research ideals of experimental biology, as applied to medicine by Ramsay Wright and A.B. Macallum. "'Scientific Spirit'" offers valuable background, though concentrating on just one school, on the period immediately preceding that discussed here. McRae's dissertation outlines the climate of "zealous scientific, education and political reform" that led to the growth of the 'scientific spirit' in medicine at the University of Toronto from 1880 to 1910. For the case of Queen's University in Kingston, Ontario, there is Travill's commemorative Medicine at Queen's. An article by Spragge, "Trinity Medical College," deals with the last proprietary medical school in Toronto to fold into the University of Toronto's medical faculty. 13 Li, J.B. Collip. Li bases her book on her dissertation, completed in 1992. She examines the role played by biochemist James Bertram Collip in establishing medical research in Canada. In addition to his contributions to the discovery of insulin, Collip experienced at first hand the challenges of being one of the first clinical researchers to woo both private and public sources for research dollars. As Bliss points out in Discovery of Insulin, 98, Collip was on sabbatical leave from his position as full professor and head of the new Department of Biochemistry at the University of Alberta when he joined Banting and Best in 1921. A Rockefeller Traveling Fellowship negotiated for him by University of Alberta President H.M. Tory eased Collip's financial burden. See Li, J.B. Collip, 18-31. 14 Gidney and Millar, Professional Gentlemen. Gidney and Millar show how, during the nineteenth century, Ontario government support of university-trained physicians, lawyers, and clergymen was individual to each case; little money was given until the Conservatives took power in 1905. Gidney and Millar examine four professions, including medicine. Other works to look into the relationship between the province and the university include a pair of doctoral dissertations: Ayre, "Universities and the Legislature"; and Edward E. Stewart, "Role of the Provincial Government."

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Notes to pages 5-9

15 McKillop, Matters of Mind. Like Gidney and Millar, McKillop restricts his examination of education to Ontario, although he covers from 1791 to 1950. 16 Hanaway and Cruess, McGill Medicine. 17 MacKenzie, "Beginnings of Dalhousie," and C.B. Stewart, "100 Years of Medical Education." 18 Penney, "'Marked for Slaughter.'" CHAPTER ONE

1 Ludmerer, "Reform at Harvard," 370. 2 Included among the matching funds are provincial monies, other private gifts and major private gifts, in kind from the Carnegie Corporation and the Eaton family. Later chapters discuss the impact of these gifts. 3 Among the sources available on Canadian medical history are Shortt, ed., Medicine in Canadian Society; Hanaway and Cruess, McGill Medicine; Roland, ed., Health, Disease and Medicine; and Robins, Harris, A History of Higher Education in Canada. Specific to Ontario, there is Godfrey, Medicine for Ontario. 4 Frost, McGill University, vol. 2,11-14. 5 Flexner, Medical Education in the United States and Canada, known commonly as "the Flexner Report" or "Carnegie Bulletin Number Four." This 1910 study was commissioned by the Carnegie Corporation. 6 Among those who argue that reforms were already under way in 1910 are: Ludmerer, "Reform of Medical Education at Washington," 149; Hudson, "Abraham Flexner," in Barzansky and Gevitz, eds., Beyond Flexner, 2; and Jonas, Medical Mystery, 201. As Ludmerer observes in "Reform of Medical Education at Washington," in the 18905 and 19005 about thirty schools had improved their medical programs. 7 Gidney and Millar, "Reorientation of Medical Education," 53. For background on the American schools, see Fox, "The New Historiography," 116-24; Hudson, "Abraham Flexner in Historical Perspective," 545-61; Ludmerer, "Reform of Medical Education at Washington," 149-73, and "Reform at Harvard," 343-70; Markowitz and Rosner, "Doctors in Crisis," 83-107; Numbers, ed., Education of American Physicians; and Rothstein, American Medical Schools. 8 Penney, "'Marked for Slaughter/" 27-51. 9 Flexner, Medical Education (1910), 8. Here he writes of a historical trend at the medical faculties associated with Harvard, Pennsylvania, and Yale. For more on Flexner, see Bonner, Iconoclast. 10 Weisz, "Geographical Origins," 93-119. 11 Canniff, Medical Profession, 11-12 and 28.

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12 Ludmerer, "Reform at Harvard," 345-6. 13 Canniff, Medical Profession. Canniff includes biographies of early physicians in Upper Canada and the proceedings of the Upper Canada Medical Board, 1819-50, and College of Physicians and Surgeons of Upper Canada, 1839-41. 14 Ibid., 29. 15 Duffin, Langstaff,shows how more time could often be spent in transit than in treatment. 16 Canniff, Medical Profession, 30. The question mark after "mile" is Canniff's. 17 Much of what is now Ontario was historically Upper Canada (1791-1841) and Canada West (1841-67). Similarly, Quebec was Lower Canada and Canada East (same years, respectively). 18 MacNab, Legal History, 4. MacNab's text is a first-rate source, summarizing the major acts to regulate the practice of medicine and other health sciences. 19 Ibid. 20 Gidney and Millar, Professional Gentlemen, 168-9. 21 Ibid., 168-9. 22 Grove, Organized Medicine, Appendix 9, "Chronology of Major Landmarks in the History of Organized Medicine in Canada." 23 MacNab, Legal History, 13-14. MacNab outlines all the major legislative changes, and attempted changes, to medical practice since 1792 in Ontario. Since the publication of Professional Gentlemen, Gidney and Millar have been researching the medical school experiences of late-nineteenth- and early-twentieth-century students. 24 MacNab, Legal History, 31-2. 25 Hanaway and Cruess, McGill Medicine, 19. 26 Ibid., 53. 27 Ibid., 19. 28 Ibid., 27. 29 Ibid., 53-4 and 115. 30 Ibid., 28-30. 31 Warner, "Medical Sectarianism," in Bynum and Porter, eds., Medical Fringe. 32 Connor, "Minority Medicine." Connor estimates that, between 1840 and 1851, the number of licensed practitioners in Canada West grew from 160 to 520, making competition much stiffer. This figure did not include members of the medical sects. 33 Gidney and Millar, Professional Gentlemen, 54. 34 Howell, "Elite Doctors," 106-7. 35 Ibid., 119. 36 Starr, Social Transformation, outlines the economic challenges facing

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39

40 41 42 43 44 45 46

47 48 49 50 51 52 53 54

55 56

57 58 59 60 61

Notes to pages 15-22

nineteenth century traditional practitioners, which inspired changes in training and practice. McRae, "'Scientific Spirit.'" Hanaway and Cruess, McGill Medicine, discuss the situation at McGill (92-3), while Penney examines the shortage of material at Halifax Medical College in '"Marked for Slaughter/" 43-7. This information comes from McGill calendars for the dates noted. For a more comprehensive analysis of the McGill medical school experience in its early years, see Hanaway and Cruess, McGill Medicine. Neatby, Queen's University, vol. i, 211. Ibid., 213. Neatby, Queen's University, vol. i. Latour, Pasteurization of France, 116. Ibid., 119-20. Ibid., 135. Section 93 of the British North America Act, 1867 (now the Constitution Act, 1867), assigns legislative responsibility for education to provinces. There is no specific mention of professional training. Gidney and Millar, Professional Gentlemen, 159. Ibid., 159. McKillop, Matters of Mind, 74-5. Ibid., 77. Ibid., 77. Penney, '"Marked for Slaughter.'" Hanaway and Cruess, McGill Medicine, 93. Ibid., 101. Changes continued at McGill. A new wing added to the medical building in 1886 had the most up-to-date lab space for medical students. Ibid., 102. Raymond Fosdick attributes this phrase to Wickliffe Rose, a trustee of the Rockefeller Foundation from its founding in 1913 to 1928. Rose was also director of the Foundation's International Health Division from 1913 to 1923. As Fosdick points out in The Story of the Rockefeller Foundation, Rose used the phrase to express the idea that, "as the standards in first-class institutions were progressively raised, the radiating effect would spread not only through an entire region but across an entire country," 100. Hanaway and Cruess, McGill Medicine, 57-9 and 184-5. Flexner, Medical Education (1910), 60. Flexner attributes the first laboratory to Purkinje, a physiologist, in Breslau, Germany in 1824, 62. Ibid., 63. Mazumdar, "Anatomy, Physiology, and Surgery," 137-8. Mazumdar, "Anatomical Physiology," 246.

Notes to pages 22-32 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79

157

Kremer, "Building Institutes," 107. Ibid., 109. Ibid., 107. Warner, "Rise and Fall," 140. Ibid., 141. Warner, "Physiology," 70-1. Hudson, "Abraham Flexner," 3-4. Another source for this information is Geison, ed., Physiology in the American Context. Latour, Pasteurization of France, 121 and 126-7. Rothstein, American Medical Schools, 160-1. Berliner, System, 141-2. Hudson, "Abraham Flexner," 3-4. See Table 1.3, page 26. Brown, Rockefeller Medicine Men, 158-67. Ibid., 161. Ibid., 176. Ibid., 176. Ludmerer, "Reform at Harvard," 370. Weisse, Medical Odysseys, 2.2.0. CHAPTER TWO

1 Thomas B. Appleget, "Brief History of the Rockefeller Foundation," RF, Program and Policy papers, RG 3, series 900 history, box 6, folder 62, RAC. Appleget was vice-president 1929-1949. 2 Fosdick, Story; Adventure in Giving; and John D. Rockefeller. Board members Frederick Taylor Gates and Abraham Flexner have also written on the Foundation's aid to medical education: Gates, Chapters in My Life, and Flexner, I Remember. Flexner also wrote Medical Education and Funds and Foundations. Biographies of the Rockefellers keep appearing, one of the most recent being Chernow, Titan. 3 Berliner, System of Scientific Medicine; Brown, Rockefeller Medicine Men; and Ludmerer, Learning to Heal. 4 Harr and Johnson, Rockefeller Century, 80-1. Vanderbilt received $17,560,378.45; the University of Chicago, including Provident Hospital, $14,505,721.83; and Johns Hopkins, $11,126,126.41. The sums received by these top three schools represent almost half of the total. In fourth place was Meharry Medical College, with $8,673,702.12. Meharry was one of two African-American colleges to receive support, the other being Howard University in Washington, DC ($587,759.32). Fosdick, Adventure in Giving, 328. 5 John D. Rockefeller, Sr, contributed more than $61 million to the institute bearing his name. Members of successive generations, including

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9 10 11 12 13 14 15 16 17 18 19

20

21 22 23 24 25 26

27

Notes to pages 32-6

John D., Jr, and his five sons, particularly the youngest, David, continued support as Harr and Johnson note in Rockefeller Century, 70. RF, General Program, RG 3.1, series 900, box 22, folder 165, 3, RAC. Ibid. Raymond B. Fosdick penned an 'insider's history' of the Rockefeller Foundation, The Story. Fosdick was, as president of the Rockefeller Foundation 1936-48, privy to much information on the Foundation's directional changes over its first four decades and on the history of its influence throughout the world. Ludmerer, Learning to Heal, 191, part of the chapter titled "The Era of Medical Philanthropy." Ibid., 191-2. Ibid., 206. Ibid., 210. Ibid., 211. Berliner, System, 5. Brown, Medicine Men, 175. Berliner, System, 163. Ludmerer, "Reform at Harvard," 370. Ibid., 366-7. Atwater, "Clinical Education," 37. Atwater notes that, by 1918, eighty of eighty-nine American medical schools had raised their entrance requirements to include two years of college preparation, up from five of 162 schools in 1906. He argues that this, coupled with the rise of fees from $75 per year to $700 per year between 1910 and 1925, meant that schools could finally afford a full-time clinical faculty and wellequipped clinical laboratories. Applying both the exchange rate and the rate of inflation (consumer price index, or CPI), each Foundation $1 million represents almost $9 million in today's Canadian dollars, if we calculate the foreign exchange conversion for the time of gift (i.e., 1920). This makes the total of the announced gift equivalent to approximately $45 million in 2004 dollars. For the record, the U.S.-Canadian exchange rate in 1920 was such that one U.S. dollar equalled Can$i.1211143. Penfield, Difficult Art of Giving, 355. Zurcher, Management of American Foundations, 7. Ibid., 24. Ibid., 25. Hall, Inventing the Nonprofit Sector, 46. This is the definition by F. Emerson Andrews, whom Zurcher calls "America's leading authority" on foundations in Zurcher, Management of American Foundations, 6. Other studies of philanthropy include: Lagemann, Politics of Knowledge

Notes to pages 36-41

28 29

30 31 32 33 34

35 36 37 38 39 40 41 42 43 44 45 46

47 48

159

and Private Power; Curti, American Philanthropy Abroad; Curti and Nash, Philanthropy in the Shaping; Ostrower, Why the Wealthy Give; and Minerva: A Review of Science Learning and Policy (fall 1997). This special issue reprinted papers delivered at an April 1996 conference to mark the twentieth anniversary of the RAC'S opening for scholarly research. All U.S. values appear in historical U.S. dollars (those of the time), unless I state otherwise. Fosdick, Story, ix. The Foundation absorbed the majority of the assets and projects being supported by the Laura Spelman Rockefeller Memorial in 1928. Finally, the International Education Board, able to fund foreign education initiatives, started in 1923 with an endowment of $20,050,947.50. American Foundations, 22-3, 31. RF, RG III 20, series Rockefeller Boards, box 31, folder 317, Rockefeller Sr Gifts, i, RAC. Rockefeller Foundation History, RG Source Material, vol. 5,1238-42, RAC. Izant, "John D. Rockefeller," 837. A copy of the legal document outlining the terms of the Eaton Endowment appears as Appendix A in Kerr and Waugh, Duncan Graham. It is also in the holdings of the Archives of Ontario (AO), "Special Committee to Inquire into the Organization and Administration of the University of Toronto" (1922-3), RG 49-107. Graham was the first to hold the fulltime chair of clinical medicine endowed by Sir John Craig and Lady Eaton. Office of Messrs. Rockefeller, RG III 20, series 30.1, box 25, folder 256, RAC. William Osier to H.S. Birkett, RF, RG 1.1, series 427A - Canada, sub-series McGill, box 6, folder 55A, RAC. William Osier to H.S. Birkett, ibid. Chesney, Johns Hopkins Hospital, and Harvey et al., A Model of Its Kind. Flexner, Medical Education (1910), 235. Spaulding, "Why Rockefeller Supported," 67-76. Harr and Johnson, Rockefeller Century, 128-9. Ibid., 136-8. Ibid., 142-4. Gillen, The Masseys, 153-4. Nevins, John D. Rockefeller, 14. John D., Jr, tells his father of King's discovery in a letter dated 4 January 1935. This letter is part of a series that show the close relationship between father and son collected in Ernst, "Dear Father"'/"Dear Son," 199-200. Flexner, Medical Education (1910), 320-6. Gidney and Millar, "Reorientation of Medical Education," 53.

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56 57 58 59 60 61

62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77

Notes to pages 41-6 Flexner, Medical Education (1910), 13. Hudson, "Flexner in Perspective," 2. Steven Jonas, Medical Mystery, 201. Ludmerer, "Reform of Medical Education at Washington," 151. Steven Jonas, Medical Mystery, 201-2. "Excerpt from Press Release," RF, RG 1.1, series 42/A - Canada, box 6, folder 55A, 2, RAC. A.B. Macallum promoted the ideals of experimental biology and their application to medicine to make medical education more "scientific." See McRae, "'Scientific Spirit/" Ludmerer, "Reform at Harvard," 343-70. For more on this, see chapter 3 below. Ibid., 369. George Vincent to Vincent Massey, 30 Dec. 1919, RF, RG 1.1, series 427A Canada, RAC. Vincent Massey to George Vincent, 3 Jan. 1920, ibid. Ibid. For Vincent Massey's committee suggestions, see Vincent Massey to George Vincent, 15 Jan. 1920, RF, RG 1.1, series 427A - Canada, RAC. Also see W.L. Mackenzie King's suggestions to George Vincent for prominent Canadians to visit while in Montreal, Quebec City, and the Maritime provinces, W.L.M. King to George Vincent, 21 Jan. 1920, ibid. George Vincent to W.L.M. King, 5 Jan. 1920, ibid. W.L.M. King to George Vincent, 8 Jan. 1920, ibid. W.L.M. King to George Vincent, 9 Jan 1920, ibid. W.L.M. King to George Vincent, 10 Jan. 1920, ibid. George Vincent, 16 Jan. 1920, ibid. For Macallum's contributions to the scientization of medicine, see McRae, "'Scientific Spirit.'" W.L.M. King to George Vincent, 21 Jan. 1920, RF, RG 1.1, series 427A Canada, RAC. Pearce's notes on conference with A.B. Macallum, Ottawa, 11 Aug. 1920, ibid. RF Board Minutes, 25 Feb. 1920, ibid. Ibid. RF, RG 12.1, Diaries, Richard M. Pearce (1916-21), Bound Volume, Report on Canadian Schools, 7, RAC. Draft Report of the Committee, i March 1920, University of Toronto Archives (UTA). Pearce, Bound Volume, Report on Canadian Schools, 8. Ibid., 9. RF, RG 1.1, series 427A - Canada, 4, RAC. "March 11 - Ottawa," ibid.

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78 "Summary of Reports on Medical Education in Canada," Table 3, ibid. 79 "Canadian Medical Program, December 19,1919," Rockefeller Sr to the Rockefeller Foundation, ibid. 80 George Vincent to J.D. Rockefeller Jr, 6 April 1920, ibid. 81 Pearce, Report on Canadian Schools, 6-7. 82 Ibid., 6-7. 83 Flexner, Medical Education (1910), 150-1. 84 RF Board Minutes, 26 May 1920, RF, RG 1.1, series 427A - Canada, RAC. 85 Williams, "Rockefeller Foundation," 106-18. 86 Ibid., 113. CHAPTER THREE

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8 9 10 11

12

The University of Toronto and Its Colleges, 178. Ayre, Universities and the Legislature. Ibid., 299. Ibid., 300. Wallace, A History, 171. Connor, Doing Good, 176. Connor outlines the main points and the personalities making them. He writes that the debate evolved into enumerating the drawbacks of the German model. Dean Reeve "believed that the appointment of a 'sort of autocrat such as the physician or surgeon is in a German hospital'" would not work well in Toronto. J.F.W. Ross, president (1903-4) of the Ontario Medical Association, also criticized the German system. Only Alexander McPhedran championed it, particularly for supporting medical research and continued study. Connor, Doing Good, 177-8. Connor cites W.A. Young, editor of the Canadian Journal of Medicine and Surgery, who lampooned the reorganization with congratulations to the new "Crowned Heads where the headgear fits" and with a commemorative stanza: "The arrangement of Toronto General Hospital staff / Has but resulted in making some men laugh. / Others have been treated in a way that is rough / Don't you think that their lot is decidedly tough?" Connor, Doing Good, 180. "Bill: An Act respecting the Toronto General Hospital," RF, RG 1.1, series 427A - Canada, box 10, folder 79, U of T Medical Faculty, RAC. Wallace, A History, 178. For a short summary of the changes within both the university and the Faculty of Medicine, see Wallace, A History, 207-12, or Harris, History of Higher Education, 266-9. Wallace, A History, Appendix B, "Recent Benefactions to the University of Toronto," 299-302. Wallace cites a total of more than $6 million in gifts between 1907 to 1927.

162

Notes to pages 51-6

13 Ibid. 14 Shorncliffe is 35 kilometres east of London, England, while Basingstoke is 75 kilometres southwest of London. Salonika, also known as Thessaloniki, is on the Greek mainland, 320 kilometres northwest of Athens. Kalamaria (presumably Kalimerianoi in modern-day atlases) is about 100 kilometres northeast of Athens, on the Greek island of Euboea. 15 Smith, ed., Roll of Service, Appendix, "Canadian General and Stationary Hospitals." Smith includes a brief history of No. 4 General Hospital in the preface (xxx-xxxiii). 16 W.R. McPhedran is not Alexander McPhedran, who received his medical degree at Toronto and returned there to be professor of medicine from 1900 to 1919. Alexander McPhedran also served as president of the Canadian Medical Association in 1905 and 1906. There were a number of McPhedrans associated with the Toronto medical faculty. In 1920/21, the Department of Medicine alone included A.G. McPhedran, J.H. McPhedran, and W.F. McPhedran, all "Clinicians in Medicine" under Duncan Graham, with Alexander listed in the calendar as "Emeritus Professor of Medicine." 17 University of Toronto Calendar, 1920-1921, 400. 18 Smith, ed., Roll of Service, 530-1. 19 "President's Report Is Published," 130. 20 Wallace, A History, 187. 21 University College was second, with 340 men and 400 women that year. "President's Report Is Published," 129. 22 Ludmerer, Learning to Heal, 211. 23 Bliss, "The Aetiology," 333-46. 24 Ibid., 337-8. Hence Bliss acknowledges the earlier efforts, antedating the Flexner Report, towards medical reform in Toronto. 25 Ludmerer, Learning to Heal, 211. 26 Berliner, System, 150-7. 27 Fosdick, The Story, 96-7. Berliner, System, 163. 28 Rothstein, American Medical Schools, 168-9. 29 Ibid., 169. 30 Bonner, Becoming a Physician, 305. 31 Cassidy, "Raising Money," 18. 32 "The Campaign's Progress," 50. 33 McQueen, "Editorial," 45. 34 "The Month's Events," 183. 35 RF, RG 1.1, series 427 - Canada, box 10, folder 79, "Statement of July, 1918," 19, RAC. 36 Ibid., 19. 37 Ibid., 20. 38 Greenlee, "The Highroad of Intellectual Commerce," 192. Greenlee goes into greater depth on this in Greenlee, Sir Robert Falconer, 264-73.

Notes to pages 56-62

163

39 RF, RG 1.1, series 427A - Canada, box 10, folder 79, "U of T Medical Faculty" Notes, 31, RAC. 40 Ibid., 32. 41 Statutes of Ontario, "Toronto General Hospital Act, 1911," Chapter 80, 1911, 531-8. 42 Assent was given on 24 March 1911 to the act, which included Schedule i, agreed to i December 1910. James P. Whitney introduced it on 8 February 1911, and it achieved third reading on 13 March 1911. Schedule i was signed by B.E. Walker and J.W. Flavelle, chairs, as well as by F.A. Moure, bursar, and A.F. Miller, secretary of the hospital, in addition to A.M. Gall and W.T. White. 43 "Toronto General Hospital Act, 1911," 532-3. 44 Ibid., 535-6. 45 Ibid., 536. 46 Ludmerer, Learning to Heal, 211. 47 Berliner, System, 156. 48 The full-time system, and the misunderstanding regarding Flexner's influence on medical education, are also discussed in Berliner, System, and Barzansky and Gevitz, eds., Beyond Flexner. 49 Excluding the foreign exchange of the stronger American dollar in 1920. 50 Tarbell, History of Standard Oil. 51 Greenlee, Sir Robert Falconer, 266. 52 University of Toronto Medical Faculty, RF, RG 1.1, series 427A - Canada, box 10, folder 79, 20, RAC. 53 "Special Committee to Inquire ... " (Drury Inquiry), RG 49-107-0-3 (Exhibits), Exhibit No. 29, AO. Also in Kerr and Waugh, Duncan Graham, Appendix A, 110-12. 54 Eaton, Memory's Wall, 140. 55 Kerr and Waugh, Duncan Graham, 30-1. 56 "A Postscript," Varsity Graduate, Dec. 1959, 34, 60, 62, 64-5. 57 Kerr and Waugh, Duncan Graham, 41-5. 58 Ibid., 41. 59 Ibid., 41-2 60 Falconer to Goldie, 16 Nov. 1918, Faculty of Medicine Papers, A67-ooo7, box A88-OO1O/OO1, UTA. 61 Goldie to Falconer, 10 Dec. 1918, ibid. 62 Minutes of 12 July 1919 Meeting, ibid. Kerr and Waugh, Duncan Graham, 31, quote a letter from Falconer to Eaton that refers to a "Mr. Walter Wiley." I presume that Wyly and Wiley are the same person. 63 Graham to Falconer, 8 Sept. 1919, A67-ooo7, box A88-ooio/ooi, UTA. 64 Kerr and Waugh, Duncan Graham, 48.

164 65 66 67 68 69

70 71

72

73 74 75

Notes to pages 62-4 Bliss, Canadian Millionaire, 204-5. Weisse, Medical Odysseys, 220-1. Norton, New Dimensions, 230-1. "A Postscript," Varsity Graduate, Dec. 1959, 64. A brief account of the inquiry and its effect appears in Wallace, A History, 197-9. Wallace makes no mention of Graham, the Batons, or the Rockefeller Foundation; he simply summarizes the objections of some individuals to full-time professorships in medicine. McKillop also summarizes the inquiry and its effects in Matters of Mind, 352-4. He sets the context within the emotional aftermath of war. Because the dismissed physicians were veterans, a charge of discrimination was levelled at the faculty and the university, and Premier E.G. Drury took up the soldiers' cause, McKillop notes. George Vincent Notes, Macallum on Toronto situation, RF, RG 427A, series Canada, RAC. Canadian Practitioner and Review changed its name to Canadian Practitioner in January 1922. Describing itself as "a monthly journal of medicine and surgery, established 1876," it contained a mix of editorials, medical news from across Canada as well as from the United States and Europe, and articles on medical research, new treatments, and the politics of medical teaching and practice. It was published in Toronto. Francis John Shepherd (1851-1929) graduated from McGill in 1873 and went on to Europe for post-graduate clinical training and advanced anatomical techniques before joining McGill as demonstrator of anatomy in 1875. He took the chair of anatomy in 1883. He encouraged dissection and introduced a laboratory examination. He was also a surgeon at the Montreal General Hospital and was one of Canada's first dermatologists. This quotation is at odds with his enlightened views, described in Hanaway and Cruess, McGill Medicine, Vol. i, 183-6. Hanaway and Cruess tell of how Shepherd taught anatomy in the late 18905, incorporating knowledge of the new physiological and biochemical sciences and how his work in dermatology built upon that of Kaposi, a Viennese physician with whom he had studied. A well-respected colleague of William Osier and Thomas Roddick's, Shepherd was dean of medicine from 1908 until 1914. This quotation has been incorporated, perhaps even out of context, to support the editor's opinion. "Editorial: Whispers," 115-16. "Editorial: Echoes," 116-18. H.A. Bruce is Herbert Alexander Bruce (1868-1963). He attended the University of Toronto and sought further training in Paris, Berlin, and Vienna. During the First World War, he served in the Canadian Army

Notes to pages 64-8

76

77

78 79 80 81 82 83 84 85 86 87 88 89 90

91

165

Medical Corps before returning to practice in Toronto. He was a professor of surgery at Toronto, was president of the Ontario Medical Association (1911-12), and helped found Wellesley Hospital. In addition to his career in medicine, Bruce served as lieutenant-governor of Ontario (1932-7) and as a member of Parliament (1940-6). See Godfrey, Bruce. "Full Time Clinical Teachers," 238, merely outlines five possible interpretations of the term, ranging from "no private practice and no outside employment" to "unlimited private practice within the hospital." The source of the explanation is a 'Dr. Darrach' of New York. "The University of Toronto," 282-6, makes a case for the dissolution of the board of governors and greater graduate representation probably in anticipation of the Drury Inquiry. Canadian Practitioner, March 1921, 94-5. Ibid., Aug. 1921, 318. Ibid., 313-17. Ibid., Sept. 1921, 277. Ibid., 278. Ibid., 278. Ibid., Jan. 1922,15. Ibid., 16. Ibid., March 1922, 103. Ibid., April 1922, 174-8. Saturday Night, 6 May 1922, i. Report of the Special Committee, 6. These meetings took place in Toronto on the following days: 16 and 17 November 1922; 12 and 13 December 1922; 10,11,12,17,18, and 30 January 1923; 15 and 22 February 1923; and 27 April 1923. Among those who testified were Dr H.B. Anderson, president, Ontario Medical Association (1915-16); Mr C.S. Blackwell, chair of the board of trustees of Toronto General Hospital; Dr Bruce; Dr Irving H. Cameron; Sir Joseph Flavelle; Dr Marlow; Dr Mcllwraith; Sir William Meredith; Dr George Naismith; Dean Alexander Primrose; Dr Ross; Dr Clarence Starr; and Colonel Gibson, who asked at the preliminary organization meeting on 25 October 1922 to act as counsel on behalf of a number of physicians. Graham had revoked Ross and Anderson's appointments - as demonstrator in clinical medicine and associate professor in medicine, respectively - as part of the reorganization. Bruce was "involuntarily retired" from the Department of Surgery, even though he had not yet reached the stipulated age for retirement. Royal Commission on Oxford and Cambridge and Royal Commission on Oxford and Cambridge Universities: Appendices. The report is 256 pages long, and the appendices are 372 pages. Medical education at Oxford involved the BM (Bachelor of Medicine) and BCh (Bachelor of Surgery)

166

92 93 94

95 96 97

Notes to pages 68-74 degrees. In 1920-21, the number of candidates for both first and second examinations in these combined degree streams were 156 (first examinations) plus no (second examinations), for a total of 266. Medical education at Cambridge began in 1883, and the numbers of candidates for the three years of the MB degree were 456 (year I MB) plus 357 (year II MB) plus 254 (year III MB) in 1921 (Appendix 6, 241-3). Drury Inquiry, RG 49-107-0-10, AO. Colwell, Medical Education. Included in RG 49-107-0-10, AO. Colwell, Medical Education, 7. Colwell was still secretary of the Council on Medical Education and Hospitals of the American Medical Association and a physician. Ibid., 8. Ibid., 8. RG 49-107-0-13. Report of Royal Commission on University Finances, 9, AO.

98 99 100 101 102

103 104 105 106 107 108 109 no in 112 113 114 115 116 117 118 119 120

Ibid., 10. Ibid. Minutes of the Parliamentary Committee (Drury Inquiry), 29-30, AO. Falconer was called on the morning of the first day of public testimony. His testimony is in Drury Inquiry, Blue Book i, 47-63, AO. Falconer needed only to look to his predecessor James Loudon, and the storm of controversy that led to Loudon's effective resignation some two decades earlier. Blue Book i, 53-4, AO. Ibid., 98. Blue Book 2,178-92, AO. Ibid., 181. Ibid., 187-90. Ibid., 191-2. Blue Book 3, 275-8, AO. Ibid., 283. Ibid., 284. Ibid., 311. Ibid., 315-16. Ibid., 331-2. Ibid., 341. Ibid., 346-7. Ibid., 355. Primrose outlined as well the procedure for appointment in place since 1920 (359). McKillop, Matters of Mind, 352. RG 49-107-0-3, Exhibit No. 19, AO. This represents the full ten-point summary by Dr F.W. Marlow. RG 49-107-0-3, Exhibit 25, Letter from Dr G.W. Ross to Special Commit-

Notes to pages 74-9

121 122 123 124 125 126 127 128 129

130 131 132 133

134 135 136

137 138 139

140 141 142

167

tee, no date given, 3, AO. The statute cited is Ontario Statute i, Geo. V, Chapter 80 (Section 6 of By-Law, Schedule i to Statute) providing for separate services within Medicine, Surgery, and Gynaecology and Obstetrics departments of the provincial university. Ross to Special Committee, RG 49-107-0-3, Exhibit 25, 4-5, AO. Ibid., 5. RG 49-107-0-3, Exhibit 34, Memo, AO. The author of the memo is not known. Ross to Special Committee, ibid., Exhibit 25, 6, AO. RG 49-107-0-3, AO. Ross to Special Committee, ibid., Exhibit 25, 7, AO. "What the University Inquiry Showed," 2. Ibid., 2. RG 49-107-0-1, "Report of Special Committee Appointed by the Legislature to Inquire into the Organization and Administration of the University of Toronto," 1923,15-16, AO. Ibid., 17. Package III, #26, RG 49-107-0-11, AO. "Report of Special Committee," "Summary of Recommendations," 19. Statutes of Ontario, Chapter 56, "An Act to provide for an Annual Grant to the University of Toronto for the promotion of Medical Research," 1923,191. R.M. Pearce to C.F. Martin, 31 May 1923, RF, RG 1.1, series 427 Canada, McGill, box 6, folder 55, Correspondence, RAC. Excerpt from Pearce's Diary, 4 June 1923, after meeting with Martin in New York, ibid. Macallum (1859-1934) took his BA at Toronto in 1880. He received his doctorate at Johns Hopkins in 1888 and his medical degree at Toronto (1889), adding an MA, also at Toronto, in 1899. He was a lecturer in physiology even while studying for his medical degree, according to his entry in Macmillan Dictionary, 427. A.B. Macallum to R.M. Pearce, 4 Jan. 1923, RF, RG 1.1, series 427A Canada, RAC. "Shelving of 'Varsity Bill/ " i. See McKillop, Matters of Mind, 317-21, for more on university education during the 19203 and 19305. This was a frequent point of argument: the university had a disproportionate number of students from Toronto and environs and hence was of economic benefit to the city. What, people asked, did the rest of Ontario obtain for its support? A similar query to the Nova Scotia government about Dalhousie led to a denial of provincial money. "State Service," 71-3. Ibid., 72. Ibid.

168

Notes to pages 80-5

143 Cangi, "Abraham Flexner's Philanthropy/' 160-74. This is another example of resistance to the full-time system, as funded by the Rockefeller philanthropies. A similar case appears in Lepore, Death of the Clinician, who discusses Columbia's two-year struggle with strict full time. Columbia-Presbyterian Hospital so angered Flexner when it gave up on full time in favour of geographical full time that it almost lost its $2-million gift from the Rockefellers. 144 Cangi, "Abraham Flexner's Philanthropy," 168. 145 Ibid., 171. 146 Ibid., 169. 147 Ibid., 169. 148 Ibid., 169. 149 Ibid., 172. 150 Ibid., 173. Heuer's successors, first Mont Reid and then Burr Noland Carter, continued the "Halsted-Heuer surgical tradition" after Heuer left Cincinnati in 1932. Heuer became first chair of surgery at New York Hospital-Cornell University Medical Center. Both Reid and Carter had accompanied Heuer to Cincinnati in 1921, all three from Johns Hopkins. 151 The Canada Year Book, 1920, "Universities of Canada: Financial Statistics, 1919/20," 156-7. All information on the University of Toronto does not include figures for two federated colleges - Victoria University and the University of Trinity College - neither of which then had an affiliated medical school. 152 Ibid., 156-7. 153 McRae, "Scientific Spirit," 315-24. 154 Ludmerer, "Reform at Harvard," 346-7, and Hudson, "Flexner in Historical Perspective," 3-4. Ludmerer even denotes two camps among physicians (347). 155 Ludmerer, "Reform at Harvard," 347. 156 Warner, "Fall and Rise," 141. 157 Bonner, Becoming a Physician, 305. 158 Li, "Collip and Research," 283. Li has taken the analytic model described by Yves Gingras in Physics and the Rise, 3-8, and applied it to Collip. 159 Statutes of Ontario, Chapter 56, "An Act to provide for an Annual Grant to the University of Toronto for the promotion of Medical Research," 1923,191. CHAPTER FOUR

1 Frost, McGill University, 15. 2 McGill Calendar, 1918/19, 34-5.

Notes to pages 86-90

169

3 "Revenue and Expenditure of the Faculty of Medicine for the Year Ending 3oth June, 1919," RF, RG 1.1, series 42/A - Canada, sub-series McGill, box 6, folder 55A, RAC. 4 Ibid. 5 Frost, McGill University, 11. 6 Ibid. 7 Ibid. 8 MacLennan, McGill: The Story, 82. 9 Frost, McGill University, 13. 10 Ibid., 14. Macdonald succeeded Smith as McGill's chancellor in 1914 and died in 1917. 11 MacLennan, McGill: The Story, 86. 12 Fosdick, Adventure, 328. 13 Frost, McGill University, 86. 14 A.B. Macallum to R.M. Pearce, 26 Aug. 1922, RF, RG 1.1, series 427A Canada, sub-series McGill, box 6, folder 55, RAC. 15 Frost, McGill University, 44. This faculty had begun as a rival school to McGill in 1871. It was organized by a McGill graduate, Francis Wayland Campbell, who served first as registrar and then as dean until his death in 1903. 16 MacLennan, McGill: The Story, 93. 17 Ibid., 82. 18 Frost, McGill University, 167. Students could also see patients at the Montreal Maternity Hospital, as noted in the McGill University Calendar of 1911/12. 19 Frost, McGill University, 49. 20 Ibid., 50. 21 Ibid., 11. 22 Ibid., 82-3. 23 Ibid., 82-3. 24 Ibid., 85. 25 Ibid., 85. Adami, appointed in 1892, stayed at McGill until his retirement in 1919. His successor was Horst Oertel who came to McGill in 1914 and retired in 1938. 26 Ibid., 85. The Carnegie Foundation for the Advancement of Teaching began providing "free" pensions for professors past the age of 70. This initiative continued for McGill professors until 1929, when the Teachers' Insurance and Annuity Association was set up (125). 27 Ibid., 107. Subsequent support from the Carnegie Corporation included grants to support professional training of librarians in 1927 (302) and to establish the McGill University Rural Adult Education Service in 1938 (295)28 Ibid., 99.

170

Notes to pages 91-6

29 A list of those who took part and a preface on McGill's wartime record appear in McGill Honour Roll. 30 Ibid., 13. Additional accounts of McGill's war record are in two works by R.C. Featherstonhaugh. McGill University at War examines its role in both world wars, while his No. 3 Canadian General Hospital offers a history of this field unit. 31 McGill Honour Roll, 228. 32 In fact, a two-page "Scheme for a Medical Curriculum (Preliminary)," RF, RG 1.1, series 427A - Canada, sub-series McGill, box 6, folder 55A, RAC, advocates a seven-year program. Following high-school matriculation, medical students would first take a pre-medical year, comprised of "cultural and partly scientific" subjects, and a second, made up of scientific subjects. Then students would enter the medical phase, in which Years i and 2 included primary medical courses in anatomy, bacteriology, general pathology, physiological chemistry, and physiology, Years 3 and 4 were didactic and clinical, including clinical medicine, clinical surgery, clinical therapeutics, gynecology and obstetrics, medical jurisprudence and hygiene, mental diseases, ophthalmology, otolaryngology, paediatrics, pharmacology and therapeutics, and special pathology. Year 5 was to be spent in the hospital as a resident. The author of this document and its date are not given. 33 "McGill Report to Rockefeller Foundation," RF, RG 1.1, series 42/A Canada, sub-series McGill, box 6, folder 5$A, RAC. 34 Frost, McGill University, 119-20. 35 William Osier to H.S. Birkett, 29 Aug 1919, RF, RG 1.1, series 42/A Canada, sub-series McGill, box 6, folder 55A, RAC. 36 William Osier to H.S. Birkett, 29 Aug. 1919, ibid. 37 Ibid. 38 Ibid. 39 Ibid. 40 Ibid. 41 Ibid. 42 Memo following ibid. 43 Ibid. 44 Ibid. 45 "Record of Canadian Trip," RF, RG 12.1, Officers' Diaries, R.M. Pearce, 1916-21, box 51, RAC. 46 Ibid., 5. 47 Ibid. 48 Savitt, "Abraham Flexner and the Black Medical Schools," 65-81. 49 Fosdick, Adventure in Giving, 328. 50 Gamble, "Black Autonomy," 247-67. 51 Weisz, "Geographical Origins," 93-119.

Notes to pages 96-104 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66

171

Markowitz and Rosner in "Doctors in Crisis," 105. Rothstein, American Medical Schools, 165-6. Ibid., 332. McRae, "Scientific Spirit," 319. In fact, McGill badly neglected physiology for almost twenty-five years. Frank D. Adams to Sir H. Vincent Meredith, 3 March 1920, RF, RG 1.1, series 42/A - Canada, sub-series McGill, box 6, folder 55A, RAC. Ibid. RF, RG 1.1, series 427A - Canada, sub-series McGill, box 6, folder 55A, RAC. Ibid. Ibid. Ibid. Ibid. Ibid. Ibid. Flexner, Medical Education, 117-18. RF, RG 1.1, series 427A - Canada, sub-series McGill, box 6, folder 55A, RAC.

67 Ibid. 68 Berliner, System, 146. These tensions are also discussed in Rothstein, American Medical Schools, 160-78. 69 Berliner, System, 147. 70 RF, RG 1.1, series 427A - Canada, sub-series McGill, box 6, folder 55A, RAC. 71 "Revenue and Expenditures of the Faculty of Medicine for the Year Ending 3Oth June, 1919," ibid. 72 RF, RG 1.1, series 427A - Canada, sub-series McGill, box 6, folder 55A, RAC. 73 Ibid. 74 Ibid. 75 Ibid. 76 Ibid. 77 Longo, "Obstetrics and Gynecology," 218-19. 78 Ibid., 222-5. 79 RF, RG 1.1, series 427A - Canada, sub-series McGill, box 6, folder 55A, RAC. 80 Ibid. 81 Ibid. 82 Ibid. 83 Ibid. 84 Edwin R. Embree to A.W. Currie, 17 Nov. 1920, RF, RG 1.1, series 427A Canada, box 5, folder 55, RAC.

172

Notes to pages 104-11

85 A.W. Currie to Edwin R. Embree, 18 Nov. 1920, ibid. 86 This marks the first push towards scientization at McGill, which was even stronger than that at Toronto. As McRae illustrates in "Scientific Spirit," where Toronto already had a solid foundation in science, via biology and physiology, McGill had concentrated on strengthening clinical medicine. 87 Frost, McGill University, 122. 88 Canadian Medical Association Journal 13, no. 10 (Oct. 1923), 759. 89 Ibid., 13, no. 11 (Nov. 1923), 833. 90 RF minutes for 30 Nov. 1921, RF, RG 1.1, series 427A - Canada, sub-series McGill, box 6, folder 55, RAC. 91 George E. Vincent interview with Sir Arthur Currie, A.B. Macallum, Dr Armstrong, 8/23/1922," ibid. 92 "McGill's Debt to John D. Rockefeller," McGill News, Montreal 18, no. 4 (autumn 1937), 48. 93 William Osier to H.S. Birkett, 29 Aug. 1919, and revisions to Osier's plan in Frank D. Adams to Sir H. Vincent Meredith, 3 March 1920, both in RF, RG 1.1, series 427A - Canada, sub-series McGill, box 6, folder 55A, RAC. 94 C.F. Martin to R.M. Pearce, 20 March 1923, RF, RG 1.1, series 427A Canada, sub-series McGill, box 6, folder 55, RAC. 95 Pearce to Martin, 4 April 1923, ibid. 96 C.F. Martin to J.C. Meakins, 11 Oct. 1923, ibid. 97 Ibid. 98 C.F. Martin to R.M. Pearce, 17 Nov. 1923, ibid. 99 A.W. Currie to R.M. Pearce, correspondence, RF, RG 1.1, series 427A Canada, sub-series McGill, box 6, folder 55A, RAC. CHAPTER FIVE

1 2 3 4 5 6 7 8 9 10

Waite, Lives o/Dalhousie, Vol. One, Appendix 3, 290-1. Harris, Higher Education, 10-11. Markowitz and Rosner, "Doctors in Crisis," 105. Harris, Higher Education, 103. Cueto, "Science under Adversity," 233-45. Flexner, Flexner Report, 321. Ibid., 323. Ibid., 324. Waite, Lives. Volume one covers the years 1818-1925. Penney, "'Marked for Slaughter,'" 27-51. Like Acadiensis: Journal of the History of the Atlantic Region, other Maritimes journals have covered the history of medical education and professionalization for the region. Among articles are Howell, "Reform," 3-22; and Stewart, "100 Years,"

Notes to pages 111-17

11 12 13 14 15 16 17 18

19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42

1

73

149-52. Stewart concludes, in a brief history of medical teaching at Dalhousie, that 1968 marked the centennial of an event - the establishment of the first Dalhousie Faculty of Medicine - but not of one hundred continuous years of medicine at Dalhousie. Twohig's 1999 dissertation, "Organizing the Bench," examines laboratory research at Dalhousie, and a revised version has appeared as a book, Labour in the Laboratory. Twohig has also published "The Rockefellers." Howell, "Reform," 21. Reid, "Health, Education, Economy," 65. Ludmerer, "Reform," 343-70. Penney, "'Marked for Slaughter,'" 33. Ibid., 33-4. Ibid., 35. Stewart, "100 Years," 150. William Johnson Almon, born in Halifax in 1816, was also a politician. He represented Halifax in the House of Commons 1872-74 and served as a senator 1879-1901. See entry in Wallace, Macmillan Dictionary, 11. Spragge, "Trinity Medical College," 86-7. Penney, "'Marked for Slaughter,'" 36. Ibid., 36. Waite, Lives of Dalhousie, 165. Ibid., 165-6. Stewart, "100 Years," 151. Waite, Lives of Dalhousie, 167. Ibid., 165. Penney, "'Marked for Slaughter,'" 48. Ibid., 44-5. Ibid., 44-5. Ibid., 46. Waite, Lives of Dalhousie, 168. Penney, "'Marked for Slaughter/" 46. Waite, Lives of Dalhousie, Appendix 3, 291. Penney, "Marked for Slaughter," 47. Waite, Lives of Dalhousie, 203. Ibid., 203. Penney, "'Marked for Slaughter,'" 47. Ibid., 46. Waite, Lives of Dalhousie, 203-4. Ibid., 202-4. Atlee, "Dalhousie Medical School," 22. "Financial History," MS-3, A883, President's Office, Rockefeller Foundation, 1912-1919, Dalhousie University Archives (DUA).

174

Notes to pages 117-23

43 A.S. MacKenzie to John D. Rockefeller, Sr, 4 Jan. 1912, MS~3, A883, President's Office, Rockefeller Foundation, 1912-1919, DUA. 44 Ibid. 45 Waite, Lives ofDalhousie, 166-7. 46 "Present Financial Condition," MS-3, A883, President's Office, Rockefeller Foundation, 1912-1919, DUA. 47 "Present Undertaking," ibid. 48 Ibid., 6. 49 Ibid., 8. 50 There were two major disasters in the sealing industry in 1914. In the spring, seventy-eight to eighty crew members of the sealing ship Newfoundland froze to death on the ice when they were unable to communicate with other ships because the wireless set had been removed from their ship (from Rowe, History of Newfoundland and Labrador, 368). Tait, Newfoundland: A Summary, tells about the loss of the sealing vessel Southern Cross in a gale; she was carrying a crew of 170 men and 17,000, seals and no one survived (91). 51 Reid, "Health, Education, Economy," 68. 52 Waite, Lives of Dalhousie, 236-7. 53 Ibid., 238. 54 Ibid., 224. 55 Ibid., 233-4. 56 Ibid., 226-7. 57 Stewart served as dean of medicine from 1919 until 1932. Ibid., 238. 58 University of Toronto Roll of Service, 1914-1918, 600. Le Havre is a port city, 175 kilometres northwest of Paris, and Harfleur is five kilometres east of Le Havre. Arques is inland, about 195 kilometres north of Paris, and Rouen is no kilometres northwest of the French capital. Etaples, 185 kilometres north of Paris, is on the northern coast of France, on the Dover Strait. Finally, Camiers is a town 20 kilometres south of Boulogne-sur-Mer on the northwest coast. 59 George E. Vincent to D. Fraser Harris, 24 Dec. 1919, MSi-3, A874, President's Office, Rockefeller Foundation, 1919-1921, DUA. 60 A.S. MacKenzie to George E. Vincent, 27 Dec. 1919, ibid. 61 "Dalhousie University: Equipment for Medical Teaching," 14 Jan. 1920, 8, ibid. 62 Ibid., 5-6. 63 Ibid., 6-7. 64 A.S. MacKenzie to George E. Vincent, 14 Jan. 1920, MSi-3, A874, President's Office, Rockefeller Foundation, 1919-1921, DUA. 65 A.S. MacKenzie to Sir George E. Foster, 20 Jan. 1920, ibid. 66 Ibid.

Notes to pages 123-33

175

67 Alexander McPhedran to John Stewart, 13 Jan. 1920, MSi~3, A874, President's Office, Rockefeller Foundation, 1919-1921, DUA. 68 George E. Foster to A.S. MacKenzie, 27 Jan. 1920, ibid. 69 Alexander McPhedran to A.S. MacKenzie, 27 May 1920, ibid. 70 Charles Caton to A.S. MacKenzie, 18 Feb. 1920, ibid. 71 Penney, " ... Plan.," 72 Robert Falconer to the Editor, 12 March 1920, MSi-3, A874, President's Office, Rockefeller Foundation, 1919-1921, DUA. 73 George E. Vincent to A.S. MacKenzie, 20 March 1920, ibid. 74 Richard M. Pearce to A.S. MacKenzie, 24 March 1920, ibid. 75 Richard M. Pearce to A.S. MacKenzie, 9 April 1920, ibid. 76 George E. Vincent to Dr. F.V. Woodbury, 7 Aug. 1920, ibid. 77 George E. Vincent to A.S. MacKenzie, 20 March 1920, ibid. 78 A.S. MacKenzie to Richard M. Pearce, 14 April 1920, ibid. 79 Richard M. Pearce to A.S. MacKenzie, 21 April 1920, ibid. 80 A.S. MacKenzie to George H. Murray, 16 June 1920, ibid. 81 Memorandum for Dr. A.G. Nicholls, 20 April 1921, ibid. 82 "Dalhousie University Medical School" Minutes, Division of Medical Education of The Rockefeller Foundation, 29 April 1925, ibid. 83 Ibid. 84 "Report on Dalhousie University Medical School for the Rockefeller Foundation," 6 April 1920, 9, MSi-3, A&74, President's Office, Rockefeller Foundation, 1919-1921, DUA. 85 Ibid. 86 Ibid. 87 Reid, "Health, Education, Economy," 65. 88 Ibid., 79. 89 Ibid., 79-81. CONCLUSION

1 Ludmerer, "Reform at Harvard," 345. See also Connor, Minority Medicine. 2 Ludmerer, "Reform at Harvard," 345-6. 3 Savitt, "Abraham Flexner," 65-81. 4 Weisz, "Geographical Origins," 106-9. 5 Markowitz and Rosner, "Doctors in Crisis," 107. 6 The Rockefeller Foundation's George E. Vincent advised his cousin Vincent Massey on the organization of the Massey Foundation in 1918. Another familial tie links key players in this history. Alice Parkin, wife of Vincent Massey, had a sister, Maude, who married William L. ('Choppy') Grant, who was a son of Queen's Principal George Munro

176

7 8 9 10

11 12 13 14 15 16 17 18 19

20

21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36

Notes to pages 131-41

Grant. William became a professor at Queen's and later principal of Upper Canada College in Toronto. From Gillen, The Masseys, 153. Pearce, "Summary of Reports on Medical Education in Canada/' RF, RG 1.1, series 42yA - Canada, box 10, folder 79, i, RAC. Fosdick, Adventure in Giving, 328.1 am not sure if this figure has been adjusted for inflation. Ibid., 328. See above chapter 2, note 4, for a breakdown of these gifts. Ibid., 328. The seven schools, which included Duke and Emory universities as well as the Universities of Georgia, Pennsylvania, and Wisconsin, received gifts ranging from $12,500.00 to $309,675.55. Pearce, "Summary of Reports," 5. Ibid. Ibid., 4. Ibid., 6-7. George E. Vincent to Robert Falconer, 20 Dec. 1921, RF, RG 1.1, series 427A - Canada, box 10, folder 79, RAC. Rothstein, American Medical Schools, 166. Ibid., 168. Richard M. Pearce to Robert Falconer, 15 June 1923, RF, RG 1.1, series 427A - Canada, box 10, folder 79, RAC. This figure eventually grew to $687,500, and the breakdown of appropriation over the four years 1925-28 was as follows: $262,500 in 1925; $162,500 in 1926; $12,500 in 1927; and $250,000 in 1928. "Memorandum Concerning the Laboratory of the Sub-Department of Pediatrics, University of Toronto," RF, RG 1.1, series 427A - Canada, Pediatrics, box 10, folder 80, RAC. McGill News, Montreal 18, no. 4 (autumn 1937), 48. Reid, "Health, Education, Economy," 79. Ibid., 80. The Rockefeller Foundation Directory of Fellowship Awards for the Years 1917-1950 (Table lib). Jonas, Circuit Riders, 351. Lepore, Death of the Clinician, 147-58. Kohler, Partners in Science, 397. Jonas, Circuit Riders, 116. McRae, "Scientific Spirit," 318. Ibid., 315. Arwater, "Clinical Education," 38. McKillop, Matters of Mind, 344. Berliner, A System, 163. Rothstein, American Medical Schools, 166. Ibid., 168. McKillop, Matters of Mind, 347.

Notes to pages 142-9 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67

177

Atwater, "Clinical Education," 36. Lepore, Death of the Clinician, 321. Ibid., 321. Ibid., 321-2. Jonas, Medical Mystery, 216, 227-8. Bliss, Banting, 65. McKillop, Matters of Mind, 347. Atwater, "Clinical Education," 39. Ibid. Ibid., 38-9. McKillop, Matters of Mind, 361. McKillop notes that between the world wars, the university departments of engineering and commerce were also demonstrating how they might serve public needs. Jonas, Medical Mystery, 202. Markowitz and Rosner, "Doctors in Crisis," 104-5. Ludmerer, "Reform at Harvard," 343, and "Reform of Medical Education," 149. Hudson, "Flexner in Historical Perspective." Ludmerer, "Reform at Harvard," 343. W.L. Mackenzie King to George E. Vincent, 21 Jan. 1920, RF, RG 1.1, series 427A - Canada, box 6, folder 55A, RAC. Richard M. Pearce, Diaries, 1920, RF, RG 12.1, RAC. George E. Vincent, Diaries, 1920, RF, RG 12.1, box 65, 84, RAC. Flexner, Medical Education, 324-5. Savitt, "Black Medical Schools," 65. Ibid., 72. Gamble, "Black Autonomy," 233-45. Markowitz and Rosner, "Doctors in Crisis," 106-7. Richard M. Pearce to George E. Vincent, Memo, RF, RG 1.1, series 427A Canada, sub-series McGill, box 6, folder 55A, RAC. Weisz, "Geographical Origins," 93-119. Ibid., 108. Ibid., 111. Ibid., 112. Pearce, "Summary of Reports," 3. Ibid.

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References

N O T E ON S O U R C E S

The majority of the archival material came from the Archives of Ontario (AO), the Dalhousie University Archives (DUA), the Rockefeller Archive Center (RAC), and the University of Toronto Archives (UTA). Although I made two visits to the McGill University Archives (MUA), I found material there censored (names and dollar amounts and certain other information "blacked out"), at the archivist's discretion, following a new provincial law. Therefore I seldom refer to primary material from that source; fortunately, much of the material was duplicated, in full, at the RAC. In the notes I abbreviate 'record group' to RG. ARCHIVES

Archives of Ontario (AO), Toronto "Special Committee to Inquire into the Organization and Administration of the University of Toronto" (1922-23) (Drury Inquiry), RG 49-107 - Blue Books - Exhibits - Minutes (also published) - Report (also published)

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Index

Acadia University, 85 Adami, J.G., 90, 1691125 Adams, Frank D., 97 African-American medical schools, 95, 132,145,147; hospitals, 147 Almon, William Johnson, 112,173ni8 American College of Surgeons, 66 American Medical Association (AMA), 115,116, 147,148 American schools, competition with, 24-5 Anderson, H.B., 64, 69, 71, 75 Andrews, F. Emerson, I58n26 Appleget, Thomas B., 45 Archibald, E.W., 78,106, 107 Armstrong, George, 98, 100,106 Army Medical Corps, 52 Atlee, H.B. ('Benge'), 115, 116 Atwater, Edward, 34,139, 144

Ayre, David J., 50 bacteriology, 23, 29,143 Bank of Montreal, 87 Banting, Frederick, 52, 73, 81,133,143-4 Banting and Best Medical Research Act, 1923, 77, 84 Banting Medical Research Foundation, 105, 141 Beatty, E.W., 93 Berliner, Howard, 24, 33, 53,100 Best, Charles, 52, 73,137, 143-4 Bethlehem Steel, 39 Billings, Frank, 143 biochemistry, 29,105, 143 Birkett, H.S., 28, 38, 91, 92, 93 Birks, William, 93 Bishop's University, 14, 88 Black, Rufus S., 28,112 Blackader, A.D., 91, 98 Blackfan, Kenneth, 80 Bliss, Michael, 4, 52, 143-4 Bonifield, Charles, 81 Bonner, R.J., 55

botanies. See Thomsonians Boyd, Gladys, 136 "brain drain" to United States, 82,123,139,140 Britain, 5, 63,107 British model, clinical teaching, 50, 64 Brown, Alan, 60, 61, 72, 136 Brown, E. Richard, 27, 33 Bruce, H.A., 64, 69, 75, i64n75 Buller, Francis, 21 Caldwell, J.A., 80 Cambridge University, 85, 112 Cameron, I.H., 57 Canadian Army Medical Corps (CAMC), 61 Canadian Journal of Medicine and Surgery, i6in7 Canadian Medical Association (CMA), 11, 64, 65 Canadian Medical Association Journal (CMAJ), 79, 105 Canadian Pacific Railway (CPR), 87

194 Canadian Practitioner, 64, 65, 66,1641171 Canadian Practitioner and Review. See Canadian Practitioner Cangi, Ellen Corwin, 80 Canniff, William, 9 Carnegie, Andrew, 35, 90 Carnegie Corporation of New York: criticism of, 64; endowment value, 36, 37; gifts to Dalhousie University, 47, 119,121, 127; gifts to McGill University, 90, 92, i6gn27 Carnegie Foundation, 33, 90, 91,130; for Advancement of Teaching, 68, 69, 90,137, i6gn26; philanthropy, 36, 81 Cassidy, R.A., 54 Chambers, Graham, 74, 75 Chipman, W.W., 98, 99, 101, 102 chiropractors, 11 Christian R. Holmes Hospital of the University of Cincinnati, 81 Cincinnati College of Surgery, 80 Clarke, C.K., 28, 51, 62 Cleveland, 37, 40 Cody, H.J., 69 College of Physicans and Surgeons of New York (CPS), 26,112 College of Physicians and Surgeons of Ontario (CPSO), 11 Collip, J.B., 52, 83,137, 143-4,153^13 Columbia University, 53, 138,140,143, i68ni43 Colwell, N.P., 68, 69,116 Connaught Anti-Toxin Laboratories, 51 Connor, J.T.H., 15, 50 Conservatives, Ontario, 50, 78, 79 Cornell University, 54

Index Council on Medical Education, 47, 68,115 Courtney, A.M., 136 Cueto, Marcos, no curriculum, 142-3; see also under individual universities Currie, Arthur, 28, 92, 93, 104, 105, 108 Dale, Henry, 60 Dalhousie University, 38, 79, 85,117; alumni support, 54,117; anatomy, in, 129; Anatomy Act, 1870, 111; bacteriology, 114, 129; biochemistry, 129; biology, 129; buildings, 54, 117, 118-19, 126-7, 129; Camp Hill, 120, 122; chemistry, 129; clinical instruction, 112, 126, 128, 129; cost, 117; curriculum, 113,114, 127; embryology, 129; enrolment, 17, 25, 111, 112, 115, 121, 125, 128; equipment, 115, 128, 129, 145; facilities, 112, 121, see also buildings; faculties, 119, 120, 129; faculty, first medical, 112; fees, 16, 25, 26,112, 119, 132; financial campaigns, 118, 122, 129; First World War, 115, 120-1,123,127; Flexner Report, 1910, reaction to, 115,116,145; fulltime system, 114,128, 129; "Great Row," 113, 114,118; Halifax Medical College, relationship with, 14,19, 111-15,118-19; histology, 129; history of medical education at, 6, 8,14, no, 111-16; hospitals, 111, 113,122, 125,129; hygiene, 126, 129,130,137; impact of

RF gift, 125-30, 134; laboratories, 115, 126,127, 145; length of medical course, in, 112,114, 125,133; medical school library, 137; nursing, 114; obstetrics, 129; other RF projects, 130, 137; pathology, 114, 121, 126,129,137; pharmacology, 129; physics, 129; physiology, 114, 129; private support, 117, 118; professional training, 109,117; progress, RF grant, 126, 127; provincial support, in, 113,117,118,127, 141; public health, 125, 129,130,137; research, 123; RF gift potential recipient, 3,47, 97,139; salaries, 112,114,118, 126, 129; U.S.-trained competitors, in; visits by RF officers, 123,124, 125 Dawson, J. William, 21, 28 Deaver, John B., 66 Deroche, A.P., 69 Dewart, Herbert H., 67 disasters, maritime, 119, I74n50 Drake, Joseph Morley, 13 Drake, T.G.H., 136 Drury, E.G., 67, 78, 80, 84 Drury Inquiry, 1923, 67-80, 144, i65-6ngi; composition of, 165^0; draft bill, 76-80; effect of, 82, 141, 149; report, 76-80 Duke of Devonshire, Governor General, 46 Eaton, Rev. Dr Charles Aubrey, 37 Eaton, Cyrus S., 38 Eaton, Flora McCrae (Lady), 59, 61, 62 Eaton, John Craig, 59, 60, 61, 75; benefactions, 38,

Index 49, 61, 75; full-time system, 45, 58 Eaton, Robert Y., 59 Eaton, T., Co. Ltd, 38, 59 Eaton Endowment, 54, 58-63, 79, 107, I59n34; effect on RF gift, 42, 54, 58; full-time system, 45, 57, 58, 63, 71, 76, 84; opposition to, 67, 75, 80; terms of, 58, 59, 75, 62, 81 eclectics, 9 Edinburgh, 12, 106 Elder, J.M., 64, 91 Eliot, Charles, 132 Elliott, T.R., 60 Embree, Edwin R., 104 enrolment, 17,18, 26, 47, 49' 52 Europe, continental, 5,103 Falconer, Robert, 4, 28, 73, 152114; Drury Inquiry (1923), 68, 69, 70, 71, 75; Eaton Endowment, 75; full-time system, 58, 60, 106, 152114; fundraising, 54, 136; medical education reform, 50, 58, 62; RF gift, 149; selection of Duncan Graham, 60, 61 Farrell, Edward, 15, 112 Fee, Frank, 80 fees, 16,18, 25, 26, 27 Ferguson, George H., 67, 78,79 Fielding, William Stevens, 113 Finley, KG., 98,100, 101 First World War. See Great War; under individual universities Flavelle, Joseph, 49, 50, 57' 59' 6o Flexner, Abraham: fulltime system, 33, 39, 53, 83; on laboratories, 21, 83; visits to medical schools, 26, 68, 95 Flexner Report, 1910, 7,

27, 48, 55, no; AfricanAmerican colleges, 95, 96,145, 147; backlash to, no, 115; effect in Canada, 5, 8, 41, 47, 131; effect in United States, 5, 8, 34, 41, 96, 116; on French-Canadian schools, 146; on Halifax Medical College, 115,116,122 Fordham University, 54 formal advisory committee, 42, 43 Fosdick, Raymond, 36 Foster, George E., 122 Fotheringham, J.T., 64, 65, 74/75 foundations, 35, 36 Fraser, William, 13 French-language medical schools, 46, 47, 86, 145-9 Frost, Stanley B., 87, 88, 89, 90, 91,104 full-time system, 66, 142-3,144, see also under individual universities; Canada, 27, 78, 84; clinical teaching, 29, 53, 58, 68, 83,142-3, 165^6; at Columbia University, 138; criticism of, 65, 78, 140; funding of, 27,100; at Johns Hopkins University, 66, 96-7, 100,140; at McGill University, 100, see also McGill University: full-time system; outgrowth of scientization of medicine, 4, 21, 29, 52,139; Rockefeller Institute, 24, 143; salaries, 33, 52, 53, 66, 76, 77,140-1, 143; structure of, 33; at University of Cincinnati, 80, 81; at University of Toronto, 52, 60, 65, see also University of Toronto: full-time

195 system; at Washington University, 140; U.S., 27, 68, i58ni9 Gall, A.M., 59 Gamble, Vanessa, 147 Gates, Frederick Taylor, 19, 24, 36,138 Geddes, Auckland, 28, 91, 92 Geikie, Walter Bayne, 18-19 General Education Board (GEB), 24, 32, 36, 37, 40, 81, 88; full-time system, 68; medical education reform, 31, 33, 53; policy of, 37,79; schools funded by, 31, 96,134,157114 General Electric, 39 geographical full-time system, 33, 35, 53, 83, 136,138 "German methods," 64, 131 German model: clinical teaching, 50, 53, i6in6; laboratory, 82, 100,113, 139 Gibson, T., 65, 70, 71 Gidney and Millar, 5, 8, 11,15,18, 41 Gillen, Mollie, 40 Gillies, D.B., 65 Gingras, Yves, 4, 83 Girdwood, Gilbert Prout, 21 Goldie, William, 59, 60, 61, 62, 63 Gooderham, Col. A.E., 51 Gourlay, Robert, 9 Graham, Duncan, 4, 59, 72, 80; Drury Inquiry, 68, 69, 71, 72; full-time system, 57, 62, 63, 72, 74, 106; reorganizaton, 74/ 75' 77' 84; selection of, 61, 62, 72 Grant, George Munro, 16 Gray, Henry, 78,106,107, 149 Great War, 32, 132,137.

196 See also under individual universities: First World War Greenlaw, Frank H., 67 Greenlee, James G., 56, 58 Gregg, Alan, 34,149 Halifax, 45, 46,118,122; hospitals, 111,113,122; population, 128 Halifax Chronicle, 124. Halifax Dispensary, 126 Halifax explosion, 1917, 61, no, 119,127 Halifax Herald, 124 Halifax Medical College, 4, 6, 8, 14,19; Flexner Report, no, 115-16, 122; history of, 112-15; provincial support for, 8 Hall, Peter Dobkin, 35, 36 Halsted, William Stewart, 80 Hanaway and Cruess, 12, 19, 20 Harkness family, 143 Harr and Johnson, 39 Harris, Fraser, 79, 80 Harris, Robin S., no Harvard University, 26, 144, 148; benefactions, 34, 42, 54,140; fulltime system, 33,140; "Harvard Plan," 33; reform, teaching, 7, 9, 33, 132 Hattie, Alexander G., 112 Hendrick, A.C., 71, 72 heparin, 141 Heuer, George, 80, 81, i68ni50 Holmes, Christian R., 81 Hotel Dieu (Montreal), 95, 146 Howard, Robert Palmer, 21, 28, 87

Howard University, 96, 147 Howell, Colin, 15, in Hudson, Robert, 23, 24, 41, 82,145

Index Hudson's Bay Company, 87 Huntington, Arabella, 34 Hutchison, J. Alexander, 98,100 Industry and Humanity, 39 insulin, 53, 63; higher profile for research, 81, 105; reputation at University of Toronto, 139, 141,143-4; research service to people, 141, 143-4 International Harvester, 39 Jonas, Steven, 41,138, 143, 145 John F. Slater Fund, 35 Johns Hopkins University, 26; benchmark, 24, 115; challenges at, 33, 53, 96-7,100; full-time system, 24, 53, 100,140; obstetrics, full-time, 102; RF gifts, 66, 100, 134 Johnston, M.M., 136 Journal of Medicine, 81 Kerr and Waugh, 59, 60 King, W.L.M., 39, 40, 41, 43,44 King's College, n, 14, 86 Knight, A.P., 17 Kramer, Samuel P., 81 Kremer, Richard L., 22 laboratory: equipment, 5, 15,16, 29, 99; instruction, 64, 82, 96; research in Germany, 23, 64, 82, 100; revolution, 82, 84, 99,105,132; space, 5, 29; "worship," criticism of, 65, 75; see also under individual universities: laboratory Lash, S.A., 59 La tour, Bruno, 17, 23 Laura Spelman Rockefeller Memorial, 36

Laval University, 86, 88, 146,148; RF gift potential recipient, 3, 95 Lawson, George, 112 Lepore, Michael, 142 Li, Alison, 4, 5, 83 licensing, n, 132,148, I55n32 Lindsay, A.W.H., 15,115 Lister, Joseph, 15 Lloyd, F.E., 98 Longo, L.D., 102 Loudon, James, 28, i66nio2 "Ludlow Massacre," 39 Ludmerer, Kenneth, 42, 82; Flexner Report, 7, 34, 41; full-time system, 35, 52; need for funds for reform, 7, 29, 32; Thomsonians, 9,131; turning point in medical education, 132, 145 Ludwig, Carl, 13, 24 Mall, Franklin P., 24, 142 Macallum, A.B., 105, i67ni36; Drury Inquiry, 63, 78; RF confidant, 41, 44, 88; scientization of medicine, 82, 83,132, 139, i6on55 Macdonald, William, 89; benefactions, 8, 42, 87, 88, 90; on McGill, 85 Mackenzie, A.S., 28,149; budget, 126; conditions of RF gift, 125-6; Maritimes medical education, 122; matching funds, 117, 119,123; RF visit, 124-5; war sacrifice, McGill, 121, 123 Macleod, J.J.R., 52,143 MacMurchy, Angus, 65 MacNab, Elizabeth, 10,12 Manitoba Medical College, 14, 89, 94, 116. See also University of Manitoba Maritimes schools: Dal-

Index housie as only regional medical school, 4,116, 122,127, 130; other universities, 109-10; provincial aid, 118 Markowitz and Rosner, 96, no, 147 Marlow(e), Fred, 64, 69, 73 Marshall, Thomas, 67 Martin, C.F., 28, 77, 91, 149; clinical medicine, 89, 100,101; Gray's appointment, 106,107 Massachusetts-Halifax Health Commission, 119,126 Massey, Chester, 40, 49 Massey, Hart, 40 Massey, Raymond, 40 Massey, Vincent, 40, 41, 42, 43, 46, 49 Massey Foundation, 40, I75~6n6 Massey-Harris Company, 40 matching funds, 3, 48, I54n2; condition of RF gift, 4, 42, 45, 104, 141; Dalhousie University, 47,117,126; McGill University, 86, 87, 93, 104,135; University of Toronto, 45, 87, 141; Vancouver, 135 Mazumdar, P.M.H., 22 McCallum, Hugh, 64, 65 McCann, William S., 143 McCollum, John, 75 McCrea, Charles, 67, 70 McGill University: alumni support, 54, 87, 93; anatomy, 12, 87, 92, 98, 103; bacteriology, 103; biochemistry, 78, 83; biology, 98,101,103, 104; botany, 88,103,104; chemistry, 88, 98,101, 103; "child life," 106, 137; clinical appointments, fight over control of, 106-8; clini-

cal instruction, 89, 93, 97, 98, 99,100,103, 106-8; cost, 13, 86, 89, 92, 97,103,108; embryology, 98; enrolment, 17, 25, 87, 89, 92, 93, 132; equipment, 98-104; facilities, 87, 89, 90, 92, 93, 98, 102, 103, 104, 105; fees, 16, 25, 86, 92,132; finances, 89, 90; financial campaigns, 1906, 1911, and 1920, 90, 93, 104; as finishing school, 89, 94,112; First World War, 54, 90-2, 93, 98, I52n6; full-time system, 67, 93, 97, 98, 99,100, 101,106,107; gynaecology, 97, 98, 99,101,102, 103; histology, 87, 98; history of medical education at, 5, 86, 87, 88, 89; hygiene, 87, 98,101, 103; impact of RF gift, 82, 86,104-8,133; laboratories, 89, 99,100,101, 102, 103, 104; length of course, 87, 92, 93, 98, 101,115,133, i7on32; medicine, 97, 98, 99, 101,103,107; neurology, 106; obstetrics, 98, 99, 101,102, 103; opposition to full-time system, 101; other RF projects, 34, 70, 105, 106; paediatrics, 91; Pathological Institute, 104; pathology, 64, 87, 90, 91, 92, 93, 98, 99, 103,104; pharmacology, 87, 91, 98,101,104,106, 137; pharmacy, 93; physiology, 13, 20, 87, 93, 98,103,104,145; private support, 54, 71, 82, 86, 87, 88, 93,118; progress, 44, 85,105, 106,135; provincial support, 8, 82, 88, 141; psychiatry, 93,103; research, 98, 99,106,

197 137; "Revenue and Expenditures of the Faculty of Medicine for the Year Ending 3oth June, 1919," 98; RF gift potential recipient, 3, 5, 38, 42, 46, 47, 48, 77, 78, 89, 97; salaries, 90, 92, 94, 98, 99,100,101,102, 103,104; scientization, I72n86; social science, 106,137; Strathcona Medical Building, 90; "Supplementary Report to the Rockefeller Foundation from the Medical Faculty of McGill University," 1920, 86, 98; surgery, 97, 98, 100, 103, 106,107,137; therapeutics, 91, 98, 101; University Medical Clinic, 137; visits by RF officers, 94, 104; zoology, 103, 104 McGill University College of British Columbia, 88, 94 McKillop, A.B., 5, 19, 73, 141, 144-5 McLeod, Roy, 43 McMaster University, 14 McNamara, Joseph, 67 McPhedran, Alexander, 55, 123, i62ni6 McPhedran, W.R., 52, i62ni6 McPherson, Marshall D., 43 McQueen, W.N., 54 McRae, John, 91 McRae, Sandra, 4, 5, 82, 97,139 Meakins, J.C., 107 Medical Alumni Association, 71 medical education: Canadian faculties, 14; history of, 5, 7, 9, 21; scientization of, 6 Medical Education, 1918-1920, 68, 69

198 medical practice: regulation of, 10,11 Medical Record, 66 Medical Society of Nova Scotia, 11 Medico-Chirurgical Society of Upper Canada, 11 Meharry Medical College, 95, 96,134,147 Memorial Campaign of 1919 (Toronto), 54 Memorial University (Newfoundland), 14,19 Meredith, H. Vincent, 95, 97 Methodist National Campaign, 61 Millar, W.P.J. See Gidney and Millar millionaires, 32, 35,144-5 Molson, J.H.R., 87 Molson's Brewery Limited, 87 Montreal, 45, 46, 54, 77, 90, 93, 94, 96,118; anglophones, 5, 46, 86, 88, 95, 96; francophones, 46, 47, 88, 95, 146; population, 128; Royal Club, 95 Montreal Children's Hospital, 89 Montreal General Hospital, 38, 89, 95,101, 103 Montreal Maternity Hospital, 101,102, 103 Montreal Medical Institution, 10,12 Montreal Neurological Institute, 34, 89, 92,137, 149 Montreal School of Medicine, 95 Moorhead, Andrew, 75 Morgan, J.P., 34 Morris, Roger, 80 Mount Allison University, 85 Moure,}., 59, 70 Moynihan, Berkeley, 105 Munro, George, 117

Index Murray, George H., 125 Mustard, W.P., 55 myths, destroyed: Flexner Report started reforms, 145; parallel between African-American and French-Canadian . schools, 145-9 National Institute for Medical Research, 60 National Research Council (NRC), 78, 83 New York Herald, 44 New York Tribune, 44 Norton, Alan, 63 Notre Dame Hospital, 95 Nova Scotia, population, 119, 128 No. 3 General Hospital (McGill), 52, 91 No. 4 General Hospital (University of Toronto), 52, 61, i62ni4 No. 5 Stationary Hospital (Queen's), 52 No. 6 General Hospital (Laval), 52 No. 7 General Hospital (Queen's), 52 No. 7 Stationary Hospital (Dalhousie), 52, 120, i74n58 No. 8 Stationary Hospital (Saskatchewan College of Physicians and Surgeons), 52 No. 9 Stationary Hospital (St Francis Xavier), 52 No. 10 Stationary Hospital (Western), 52 Norton, Alan, 63 Notre Dame Hospital, 95 Nova Scotia, population, 119, 128 Oertel, orst, 98, 99, 100, 103 Ontario, population, 128 Ontario government. See provincial government

Ontario Medical Association (OMA), 73, i6in6 Osier, E.B., 50 Osier, William, 38, 50, 142; consultation fees, 57; full-time system, 27, 53; Johns Hopkins University, 38-9, 49, 53; McGill University, 13, 21, 93, 97,106; Oxford, 38, 53 Pablum, 141,144 Palmer, Dudley, 80 Palmer, Walter P., 138 Peabody, 35 "peaks," 44, 48, no, 147, 149,156n56 Pearce, R.M., 149; background, 55, 58,145; confidants, 41; Dalhousie University, 124; distribution of RF gift, 135; Drury Inquiry, 77-8; Gray appointment, 106-8; investment of grant, 44; McGill University, 77, 88, 95, 97, 105; report, 47; Universite de Montreal, 147; University of Alberta, 94-5; University of Toronto, 46; visits, 45, 46 PEI Medical Association, n Peking Union Medical College, 138 Penfield, Wilder, 137 Penney, Sheila, 6, in, 113, 115, 116 Peterson, William, 28, 87, 88, 89, 90, 92 pharmacology, 105 philanthropy, history, 5 Phillips Exeter Academy, 54 physiology, 21, 23, 29, 53, 105; in Germany, 22, 143; in Prussia, 22 postgraduate training, 4, 29, 68, 84,132 Primrose, Alexander, 28, 45, 5L 73

Index Princeton University, 71 Principles and Practice of Medicine, The, 19 Pritchard, Henry S., 121 professional identity, 4, 7, 9,11, 23,131,133,142-3 proprietary schools, Canada, 14 provincial government: amendment to University Act, 1914 (Ontario), 50; funding of medical education, 50, I53ni4; New Brunswick, 138; 1906 legislation (Ontario), 50, 56, 67; Nova Scotia, 113-14, 117,126, 141; Ontario, 49, 84, 141; Prince Edward Island, 130; Quebec, 87, 93/141 provincial inquiry. See Drury Inquiry Quebec, 96; anglophones, 86, 87; francophones, 86, 96,132, 146-7; population, 46,128 Quebec City, 45, 46, 95, 96, 146 Quebec government. See provincial government Queen's University, 16, 46, 67, 69, 85,I75~6n6; RF gift potential recipient, 3, 42, 45, 47, 48,135 Radium Institute, 88 Ransohoff, J. Louis, 80 Reeve, R.A., 28, 51 Reford, Robert, 90 reform: physiology, 21; teaching, 4, 49, 78, 79, 83, 84,131,138-41,142 Reid, Alexander P., 28,112 Reid, John, 130 Remsen, Ira, 53 remuneration: clinical medicine, 68, 72, 84,100; laboratory scientists, 53, 62,100; part-time instructors, 27, 53, 60, 76

research: in Canada, 4, 83, 84; "ideal," 20, 24, 83, 84,100,143-5; journals, 143 "retail giving," 36 Roberts, J.A., 51, 75 Rockefeller, J.D., Jr, 31, 32, 37, 40, 41, 46, 47, 97; "Ludlow Massacre," 39 Rockefeller, J.D., Sr, 19, 24, 35, 36, 40, 46, 52, 58, 90, 117; reason for Canadian gift, 37, 41, 90, 121, 149 Rockefeller Foundation (RF), 33, 36, 55, 58, 78; Division of Medical Education, 41; Division of Natural Sciences, 138; full-time system, 78, 135; International Health Board, 135; other projects, 34, 38, 81,130,137 Rockefeller Foundation gift: composition, 44, 46, 47, 133,135, i58n2o; conditions of, 72, 73, 78, 80, 81, 83, 96, 100, 104, 125; long-term impact, 6, 34, 46, 63, 77, 79, 133-4; opposition to, 67, 75, 76, 80, 81,100, 135-6; personal ties, 32, 46, i75-6n6; potential recipients, 39, 94, 114, 121, i5ini; preliminary survey, 43, 44, 45, 124-5, 138; report, 47; supported projects, 32, 134 Rockefeller Institute, 24, 32, 36,100, 138, 143, i57-8n5 Rolph, John, 14,18 Rosner. See Markowitz and Rosner Ross, G.W., 74, 75 Ross, John, 93 Rothstein, William, 24, 53, 96-7,135,140 Royal Military College, 85

199 Royal Victoria Hospital (Montreal), 38, 46, 87, 89, 95,101,103,104, 106,107,108 Rudolf, Col., 74 Russell, T.A., 69 Russell Sage Foundation, 36 Ruttan, R.F., 98, 101 Ryerson, E.S., 52 sacrifice, wartime, 41, 64, 65, 74, 75, 80. See also under individual universities: First World War St Francis Xavier College, 85,109 St Michael's Hospital, 56 Saturday Night, 64, 67, 75, 78 Savitt, Todd, 95, 96,132, 147 Scane, J.W., 98 Scientific and Industrial Research, Honorary Advisory Council, 44 scientization of medicine, 5, 9, 15-20, 23, 83,131, 142,145,147; at Dalhousie University, 15, no, 112,115,116,129; at McGill University, 19-20; at University of Toronto, 18-19, 65, 72, 82 Shepherd, F.J., 21, 28, 64, i64n72 Sick Children's Hospital, 56,59 Slayter, William Bruce, 112 Smith, Donald (Lord Strathcona), 8, 20, 42, 87, 89, 90; endowments, 87, 89 Smith, Margaret, 87 Somers, John, 112 Somerville, C.R., 69 Spaulding, William, 39 Special Committee of 1923 (Drury Inquiry), 63-80

2OO

Special Committee of the General Council of Medical Education and Registration (Ontario), 1890,11-12 specialization, 24, 62, 63, 68, 75, 79, 83,102,142, 143 Spragge, George, 113 Starkey, T.A., 98,103 Starr, Clarence, 75 Stephen, George, 87 Stewart, C.B., 111 Stewart, John, 28,120 Strathcona, Lord. See Smith, Donald studying abroad, 22, 23, 61 Swayze, Charles R, 67 Sydenham, Thomas, 105 Tait, John, 98, 99,103 Tarbell, Ida, 58 teaching ratios, medical schools, 25 Thistle, Major, 75 Thomsonians, 9, 23,131 The Times, 105 Timothy Eaton Memorial Wing, Toronto General Hospital, 61, 75 Tisdall, F.F., 136 Toronto, 45, 46; population, 128 Toronto General Hospital, 61; clinical teaching beds, 56, 59, 60, 84; Drury Inquiry, 67, 72, 76; new surgical wing, 61, 75; relationship with university, 50-1, 62, 67, 72,76 Toronto General Hospital Act, 1911, i63n42; bylaw (25 January 1911), 56; by-law 5454 (25 April 1910), 56; fulltime system, 52, 57, 58; Joint Hospital Relationships Committee, 68 Toronto School of Medicine, 14,18

Index Toronto Western Hospital, 56 Tory, H.M., 45, 94 Trinity Medical College, 14,18, 49, 87,112-13 Trinity University, 14 Unionist Party, 43 United Farmers of Ontario, 67, 78. See also Drury, B.C.; provincial government: Ontario United States, 5; Department of the Interior, Bureau of Education, 68; medical schools, 8 Universite de Montreal, 14, 88,134,147-8; RF gift potential recipient, 3, 48' 97 University of Aberdeen, 106 University of Alberta, 14, 116,149; full medical course, 46, 95,134; later years at McGill University, 85, 89, 94; RF gift potential recipient, 3, 45, 47, 48; University Hospital, 134 University of British Columbia, 14, 88, 89, 134, 135; RF gift potential recipient, 3 University of Calgary, 14 University College Hospital, 60 University of Chicago, 53, 90, 134,138,143 University of Dublin, 85 University of London, 22 University of Manitoba, 85,116; RF gift potential recipient, 3,42,47,48, 94 University of Montreal. See Universite de Montreal University of Ottawa, 14 University of Oxford, 68, 85,112 University of Rochester, 32,143

University of Saskatchewan, 14; RF gift potential recipient, 3 University of Toronto: alumni support, 54, 81, 82; anatomy, 65, 69, 104, 136; Applied Science, 71; bacteriology, 56, 57, 61, 62; biochemistry, 62, 78; biology, 139; board of governors, 49, 56, 59, 64-5, 70, 72; botany, 65; budget, medical budget, 7, 55, 71; chemistry, 65; clinical instruction, 53, 58-9, 68-9, 72-4; College of Education, 67; Commission on University Finances, 1921, 69; cost, 54, 55, 74; dermatology, 56; dismissal of part-time medical instructors, 63, 65, 73, 75, 77, 100; enrolment, 17, 25, 26, 56, 76; facilities, 40, 51, 54, 59-60, 75, 145; Faculty of Applied Science, 71; Faculty of Arts, 71; fees, 16, 25, 26, 56, 62,132; finances, 55; finishing school, 112; First World War, 51, 52, 54, 61, 64, 75, i62ni4; full-time system, 55, 60, 61, 62, 65, 76; geographic fulltime system, 33, 60, 83; graduate instruction, 55; gynaecology, 56, 57, 74, 77; history of medical education at, 87; hospital control, 50, 53, 56-7, 68, 77,144; hygiene, 69,104,136, 149,176ni9; impact of RF gift, 63-7, 69-80,134; laboratories, 49, 51, 55, 104,135,136,139; length of medical course, 51, 55,115,133; matching funds, 81,135;

Index medicine, 51, 57, 58, 59, 62, 74, 75, 76, 77, 80, 97; Monthly, 55; neurology, 56; nursing, 136, 137; obstetrics, 56, 74; opposition to full-time system, 63, 66, 71-6, i64n6g; opthalmology, 56; other RF projects, 34; otology, rhinology, and laryngology, 56-7; paediatrics, 57, 58, 60, 136, 144; pathological chemistry, 56, 57; pathology, 51, 56, 57, 61, 62,136; pharmacology, 55; pharmacy, 55, 93; physics, 65; physiology, 62, 78, I72n86; private support, 71, 76, 82; progress, 5, 44, 49, 77, 85, 97; provincial support, 8, 50, 54, 77, 82, 88,141, i67ni39; psychiatry, 136; remuneration, 56, 57, 58, 65, 71, 76; report for RF, 56; research, 54, 63, 69, 77, 81, 82,136,144; retirement age, 57, 75, 77, 80; retiring allowances, Carnegie, 70; RF gift potential recipient, 3, 42, 47, 97; salaries, 53, 65-6, 71-2, 76, 136; Senate, 71, 72; "servants to society," 79-80, 143-4; surgery, 56, 57, 71/ 74, 75, 76, 77> 8°;

teaching, 77; University College, 71; Varsity Graduate, 63; visits by RF officers, 44-6, 55; zoology, 97 University of Western Ontario, 43, 64, 65, 69, 85; RF gift potential recipient, 3, 45, 48 Vancouver, 46, 135 Vancouver Hospital, 135 Vanderbilt University, 53, 134 Vaughan, J.J., 59 Victoria, 14 Victoria College, 61 Victoria General Hospital, 113-14,116, 128 Vincent, George E., 40; Canadian medical schools, 41, 44-5, 47, 145, 149; confidants, 42-3, 44, 46, 63; Dalhousie University, 124, 127; McGill University, 94, 97; RF policy, 32, 37; tours, 45, 97; University of Toronto, 49, 58, 63, 78, 94, 97 Virchow, Rudolf, 23 voluntarism, 35 Waite, P.B., 111, 113, 114, 119 Wallace, J. Alexander, 69 Wallace, W. Stewart, 50, 51 Warner, John H., 15, 22, 23,82

201 Washington University, 53, 140 Watson, Edgar, 67 Waugh. See Kerr and Waugh Weaver, Warren, 138 Weisse, Allen B., 62 Weisz, George, 8,132, 147-8 Wellcome Physiological Research Laboratory, 60 Western Reserve University, 29, 45, 140 Western University. See University of Western Ontario White, Thomas, 72 Whitnall, S.E., 98,103 Whitney, E.C., 50 Whitney, James, 50, 79 "wholesale philanthropy," 36 Wiggers, Carl J., 29, 62 Williams, Greer, 48 Williams, John Whitridge, 102 Willison, J.J., 69 Winnipeg, 45, 46 Women's College, 14 Woodill, Alfred H., 112

Wright, Ramsay, 82, 83, 139 Yale University, 53, 71 Young, W.A., i6in7 Zurcher, Arnold, 35