tion have been well stated by our President, Dr. Pepper (Introductory Address, Philadelphia, 1877.): 1. The establishment of a preparatory examination. 2. The lengthening of the period of study to at least three full years. 3. The careful grading of courses. that the best interests of the public will be observed by assigning the duties of the State licensing power to the various State Boards of Health. The regulation of all forms of education should, on the other hand, be vested in a central power consisting of a single board, to be known as a State Bureau of Education, with power to 4. The introduction of ample clinical and laboratory regulate all educational institutions granting degrees, instruction. 5. The establishment of fixed salaries for the teachers. In a general way we may obtain some notion of the improvement which has been made by a study of the report of the Illinois State Board of Health for 1891. According to this report there are now 148 medical schools of all kinds in the United States and Canada. The number of those requiring certain educational qual ifications for matriculation is 129. The number of schools requiring attendance on three or more courses of lectures was, in 1882, twenty-two. In 1891 the number was eighty five. There has been also a gradual increase in the dura tion of the lecture terms from an average of 23.5 weeks in 1882-83 to 26.3 weeks in 1890-91. In 1882-83 there were eight colleges that had but sixteen weeks; the number of colleges having terms of six months or more is now 111. The number of colleges which have gradu ated students at the end of the second course of lectures the present year is less than 40 per cent of the whole number of schools in the country. There are now in the United States thirty two examining and licensing bodies that do not give instruc tion. Although the work of these licensing boards is far from uniform, a great deal has been accomplished by them. There are at the present time fifteen States with Practice acts that require an examination of all persons desiring to practice medicine in the respective commonwealths. These States include nearly 50 per cent of the entire population. In many States the whole complexion of the medical practice has been changed by the clarifying influences of these bodies. The reports on medical education by the Illinois board, I do not hesitate to say, have exerted a more powerful influence on the movement in education than any other publication which our medical literature has produced. The effect of these Medical Practice acts which establish a minimum of time spent at medical lectures and provide an examination for those who wish to become practitioners, are shown in the statistics which have just been given. At the present time State examina tions are required in Minnesota, North Dakota, Mon tana, Washington, North Carolina, Alabama, Florida, Virginia, New Jersey, New York, Nebraska, Maryland and Utah. (Millard. "The Necessity and Best Meth ods of Regulating the Practice of Medicine," Jour. Am. Med. Ass'n, July 30, 1892). together with the power of granting charters and revoking the same; particularly should this apply to all institutions wishing to afford the community any of the various forms of higher or special education. Having thus sketched the progress of medical educa tion up to the present time, let us now glance at some features of the present system in which it is desirable that further improvement should be made. The importance of a preliminary training for the study of medicine is a problem which has occupied the attention of our most prominent teachers. That the medical student should have received a fair amount of education goes without saying. The importance of a proper preliminary education is thus forcibly stated by that most experienced of German teachers, Professor Billroth. He says in reply to the objection to a preliminary study of the natural sciences as a basis of a medical education: "The educated of all nations should not fail to encourage to their utmost, knowledge and study--in all countries and stations of life they should not fail to maintain the standard which they have set up, both for themselves and others; they should not fail to support the government in all efforts directed towards this end. "The physician, the lawyer, the school teacher and the clergyman form the nucleus of culture in the community; they are, especially in the country or small towns, the representatives of the educated element of society. The people seek their advice in time of need, and they are their sole source of knowledge in many things. "To neglect the education of such persons, to lower their mental and scientific standard, to bring them up so that they know no better education than the tradesman, the tailor and the cobbler, would be, in my opinion, the suppression of the educational development of a nation and is a policy both corruptible and immoral in principle, as it would inevitably ruin a nation and bring it prematurely to that point of decadence where it would become the prey of others." The importance of these views is fully appreciated in Germany, where the professional schools are integral parts of the university, and the entrance to the profes sional schools depends upon the previous completion of the course in philosophy, a course which corresponds to that of our academic degree. In Dr. Holmes' suggestive article (The Forthcoming Millard, who has had experience in framing the act Report of the Bureau of Education on Professional Edof Minnesota, believes that it would be an improvement ucation in the United States," Jour. Am. Med. Ass'n, upon the Medical Practice acts at present in existence, January 14, 1893) on this subject it is shown that while to separate the two functions of the board, the licens the increase in the total number of medical students has ing power and the educational supervision. He thinks been very great during the last decade, the increase in "There are many students in our school who have had one or two years of college life either as special or regular students, and these have entered the medical school because they have felt the necessity of getting started in their life work. These men would have been glad to take the A.B. degree if it could have been procured in a shorter time, but they consider it too dearly purchased when it involves so much delay in beginning their professional life." the number of "college men" who have entered the pro- of college life. The dean writes me upon this subject fession has been very slight, and in some of the more as follows: prominent schools the percentage has even slightly diminished. The author says: "It can not then be doubted that relatively a smaller number of medical students have a bachelor's degree than in 1880, though the education of the average medical student is superior to the average medical student ten years ago." Although the proportion of medical students to students of law and divinity is greater in the United States, the relative proportion has diminished in the last ten years, whereas in Germany in the same period, a period dur- It seemed, therefore, reasonab.e to the medical faculing which medicine has become more of a science and ty of Harvard to make the following proposition, namethe domain of surgery has increased under antiseptic ly, that the academic council should consider the expemethods, the proportion of medical students to the stu-diency of granting the degree of A.B. to all undergraddents of other professions has greatly increased. The uates who should subsequently take the longest course reason for this variation in the proportion of students of study offered at the professional school after three in the two countries is explained by the imperfection of years' attendance in the academic department—the proour system of education. Educators have not had fessional degree and that of A.B. to be given simulta proper control and medicine has not been placed upon neously at the end of the professional course. One of that dignified scientific basis which it enjoys in Ger the medical studies at least can be obtained in the usual many. Dr. Holmes complains that the medical depart- college curriculum, and general chemistry is frequently ment is neglected by every university in the United "anticipated" by students who enter the medical school. States. "It is farmed out or left to shift for itself." It is hoped, indeed, that this course will soon become Harvard has recently made an attempt to overcome one of the "preliminary studies" to medicine. It would the difficulty by a modification of the academic course. be a short step to place one or two more of the scientific As Welch points out in an article on this subject (some medical studies on the list of academic electives, and a of the advantages of the union of Medical School and whole year could be thus anticipated. The relations of University, 1888): If a young man choose the medical professional schools to the university are not appreciatprofession he should devote at least four years to medi-ed in the same light that they are in Germany, and the cal studies, including the preliminary sciences. If he proposition of the medical faculty after much discussupplements this with a year in a hospital and a year or sion was finally declined. The advantages of a more two in study abroad, and all this work has been pre-intimate relation between the medical school and the ceded by a college academic course, he would not be able to enter upon the practice of his profession much before the age of thirty. Dr. H. P. Bowditch (remarks made at a meeting of the Academic Council, 1887), Dean of the Medical Faculty of Harvard, has strongly advocated a change which would overcome this difficulty. The average age of students who enter the Harvard academic department, as President Eliot has shown, has been gradually rising during the whole of this century until it has reached nearly nineteen years. The student who en ters the medical school therefore finds himself just be ginning the preparation of the real work of his life at an age when many of his contemporaries are already engaged in the productive work of their professions. In Germany the best class of students begin their profes. sional studies at a little earlier age than that at which our young men enter Harvard College. As the course of study leading to the degree of doctor of medicine lasts five years, it follows that the German physicia.. is ready to begin practice before he is twenty three and a half years old. The average age of matriculants at Oxford is nine teen years, and it is perfectly possible for an Oxford university are clearly set forth by Welch in the article A movement in the same direction is the establishment in our colleges and scientific schools of courses of tuition, intended specially for the benefit of those who intend ultimately to study medicine. Such a course has been planned by Prof. Shaler in the Scientific School of Harvard, and a similar course is offered by the Institute of Technology. Professor Shaler's course preparatory to medicine consists of two years. In the first year we find physics, zoology, botany, general chemistry rhetoric and elementary French or German, and freehand drawing among the studies required. In the second year there is botany, zoology, compara. student desiring to study medicine to begin his purely tive anatomy, geology, comparative osteology, physics, professional studies before the end of his second year qualitative analysis and themes. It is certainly to be hoped that the medical teachers ogy, which is placed in the second year. I shall leave of the United States will not remain conte t with the very elementary examinations which are now demanded for those students who have not received a college edu ication. The advantage of a previous college training is shown in some statistics given by Billings (Ideals of Medical Education, 1891) of examinations conducted by the examining boards of the army and navy. Of these candidates who had a college degree 34 per cent were suc cessfull, and of those who had no such degree 28 9 per cent succeeded. It is interesting in this connection to note that taking the medical schools of Harvard, Yale, the College of Physicians and Bellevue Hospital of New York, the University of Pennsylvania, and the University of Virginia together, 46.1 per cent succeeded, while for all the rest of the schools in a body 22.3 per cent succeeded. One of the most prominent features of the new edu cation is the character and amount of laboratory work which is now required by our medical school. The new building of the Harvard Medical School, erected twelve years ago, showed the importance which its faculty at tached to this means of teaching the student. Already the large addition of the Sears laboratory has more than doubled the facilities of this department of the school. The University of Pennsylvania has felt the necessity of increasing the facilities of laboratory work and has re ceived a munificent endowment for its department of hygiene. The literature of this part of our educationai system is already becoming voluminous. The recent reports of Vaughan and Holmes in behalf of the work done at the University of Michigan and of the College of Physicians and Surgeons of Chicago, respectively, show the interest which is taken in this subject in some of the Western schools. General chemistry forms so large a part of the first year's work in the Harvard Medical School that it is proposed to make room for other valuable work by making this study one of the requirements of admission. This course is already anticipated by most of the college graduates. The course on embryology and histology is at present a required one, and lasts throughout the year. Students are obliged to keep books in which drawings are made of the specimens studied and these books are examined by the teacher. Those who do not possess microscopes are provided with them by the school, and the equipment of this department enables it to handle classes of 150 students. Prof. Minot, who conducts this course, urges the addition of a course on biology to the work of the first year, as it would not only enable the student to pursue many of his studies more intelligently, but would add greatly to the value of all original work done by the student or physician. The new four years' course has been so arranged that the technique of bacteriology come in the first year. This is a time when the student has more time for lab oratory work, and it paves the way for special work in the study of these organisms in connection with pathol a more detailed statement to Prof. Ernst, who will have something to say upon this subject later. Bacteriology neede no special plea to-day. It cannot even be regarded as a purely scientific study. No practitioner of medicine or surgery who emerges from one of our schools to day should be considered properly equipped for his work unless he has been trained in such a laboratory. No physician can expect to unravel the secrets of disease without a practical knowledge of the demonstration of certain forms of bacteria, and there is cer tainly no better school for aseptic surgery than the bacteriological laboratory. The study of pathology at the Harvard Medical School (Bulletin of the Harvard Medical School Association, No. 4) is conducted by Professor Councilman, not only by lectures, but by demonstrations, recitations and exercises in pathological histology. The latter course, which has hitherto been optional, is now obligatory. The relation of bacteria to disease is taught by the study of certain types of disease, as tuberculosis, suppuration, pneumonia, etc. Demonstrations are given twice a week a material obtained from the hospitais and private practitioners. This is a laboratory exercise. Individual members of the class are called upon to study the specimens. They then carry them around to the other members of the class and demonstrate and explain to them the lesions. Each student in this way has the specimen demonstrated to him. In the course on pathological histology the student is required to make drawings of the sections studied. An opportunity is given to a certain number of men, who have gone through with their course in pathology to act as demonstrators the following year and to assist in teaching. Places are assigned in the pathological laboratory to a certain number of students who have done well in their studies, and opportunity is given them for special study or original investigation. A type of laboratory course, which I think is peculiar to Harvard, is that on the application of bandages and surgical apparatus. It is a purely laboratory course, is given to students at the beginning of their second year and is confined to a detailed study and drill in the prac tical part of such work. Bandaging is taught upon the living subject and upon wooden models. The feature of this course which is perhaps most valuable is the preparation and application of all the forms of stiff ban. dages. In this way every member of the class learns thoroughly the elementary part of this work before he begins to practice upon patients in the hospital, and no student leaves the school without becoming an adept in the application of the stiff bandage. Another subject which is receiving more and more attention yearly is that of clinical instruction. The weakness of this feature of medical education was one of the glaring faults of the old system, and arose out of the fact that hospitals were far less numerous than they are at the present time, and that, from the necessities of the situation, the independent origin of the medical necessities of medical education. Faculties thus placed school became a custom which has continued almost un-are unable to select teachers of national reputation, as impaired to the present day. there is no appointing power which enables them to give such a person the material with which to teach. This is a grave defect in our system, and one which the leaders in medical education should not forget to im press upon the profession and the public. In Boston the medical school flourished for nearly one-third of a century before its teachers realized the importance of this problem. A circular was then issued in 1810, in which the statement was made that "a hospital was an institution absolutely essential to a medical But, while applauding the movement in favor of clinschool." Would that all teachers of that time had ical teaching it is perhaps well at the present time to realized sufficiently that fact and had educated the consider whether systematic or, as it is usually inaccupublic to recognize the necessity of such a close rela rately called, “didactic” teaching should be abandoned. tion of the two. Many of the older-members of this The discussion as carried on in medical journals, appears congress can remember the old-fashioned prejudice to lean in this direction. A course of systematic lecwhich resented the intrusion of students into the hos-tures enables the teacher to cover ground which he pital wards. The theory of the trustee of that time would be unable to do, even in a clinic most richly enThis money was given for the cure of patients dowed with material. The method of handling the and not for the education of physicians. They could subject differs entirely from that adopted at the bedside, not be persuaded that the two interests were identical. and in a well regulated four years' course I believe the The change of feeling in more enlightened times was systematic lecture should still retain a prominent place. indicated by the benefactor of the great Johns Hopkins Clinical instruction should be abundant and of the most hospital. At the opening of that hospital in 1889 Dr. varied kind. Instruction of the class in small sections is Billings showed the advantage of such a union in the a most desirable feature of this department. It infollowing words: volves a greater expenditure of time, an increase in the teaching staff and great ability as an organizer in the head of the department. It is the squad drill, however, which brings the student in most intimate contact with disease. was: "It is well known to those familiar with the subject that the sick in a hospital where medical instruction is given receive more constant, careful and thoughtful at tention than do those in a hospital where no such instruction is given. The clinical teacher must do his best; keen eyes will note every error in diagnosis, every failure in results of treatment. Moreover, the very act of teaching clarifies and crystalizes his own knowledge in attempting to explain, the dark places become prominent and demand investigation, and hence it is that those cases which are lectured on receive the best treat ment. I need say nothing here on the other side of the question; the value of properly trained physicians to the community and the necessity for hospital instruction in such training. Johns Hopkins understood all this, and especially directed that in all your arrangements in re lation to this hospital you will bear constantly in view that it is my wish and purpose that the institution shall ultimately form a part of the medical school of the University.' To carry out these ideals necessitates a "plant" far in advance of that which the average school now possesses. No such enterprise can be undertaken without that aid which has hitherto been conspicuous by its absence. I refer to endowments; the valuable paper of Dr. Bayard Holmes already referred to give some interesting data on this subject. He says: "The productive funds in the hands of medical schools, both those connected with and those independent of universities in the United States was in 1889, $249,200, while at the same time there was in the hands of schools of theology productive funds to the amount of $11,939,631. The value of buildings and grounds used by medical schools at the same time was $4,047,614, and the theological schools were accommo dated with buildings and grounds valued at $7,662,095, The medical schoois had in 1889, 12,238 students who paid tuitions to the amount of $763,761, while at the same time the theological schools enrolled 6,98€ students. I am able to reinforce these figures by an abstract of the statistics for medicine, theology and technology as reported to the Bureau in June, 1892. The medical schools possessed buildings and grounds in 1892 valued at $7,507,937, and productive funds amounting to $611,214. Medical departments of State universitie also received State aid in 1892 amounting to $40,500 which, if capitalized at 5 per cent, would be equal to ar eneowment of $810,000; making a total endowment o $1,421,214. There were 16,731 medical students in attendance. The theological schools report productive fund amounting to $17,599,979, and stated, at the same time, conducted by St. Louis Surgeons who will select the the value of their buildings and grounds was $10,720, 860. They had 7,672 students in attendance. Technological schools report productive funds amount ing to $13,229,940 These institutions received from State appropriations or municipal aid in 1891-92, $747,504, which, if capitalized at 5 per cent, would be equivalent to an encowment of $14,950,080; making a total endowment for schools of technology of $28,180, 020. There were enrolled in the schools of technology 10,921 students, about one third of whom were in preparatory courses. It will thus be seen that the endow. ment of theology is increasing at the rate of about two million dollars a year. The technological schools are well provided for, but medicine has scarcely raised its endowment, even at the most liberal estimate, to a million and a half." most instructive material at their disposal, will be held at the Alexian Brothers Hospital, the City Hospital and the Sisters Hospital and will add materially to the usefulness and success of the meeting. The following papers have so far been annouuced. Fractures and the Plaster of-Paris Dressing. A General Practitioners View, Robert F. Brooks, M.D., Carthage, Mo. Concealed Injuries of the Abdomen. H. D. Hill, M.D., Augusta, Kas. Are Immediate Amputations, after Crushing Injuries always Justifiable? Willis P. King, M.D., Kansas City, Missouri. Amputations in Railway Surgery, B. A. Wilkes M.D., Bowling Green, Mo. Traumatic Neurosis in Court, L. Bremer, M.D., Louis. St. Treatment of Injuries to the Cranial Vault, Emory Injuries to Back without Psychic Elements, W. B. An Anomalous Case of Appendicitis, W. N. Yates, M.D., Fayetteville, Ark. Probably the available funds possessed by our medical schools are somewhat larger than these statistics show, but they give the proportions which are needed to impress upon us how little financial encouragement medicine receives. When we realize what a valuable factor the medical man is in the rapidly increasing development of the territory of a vast and prosperous country like ours, it seems as if his claims to receive encouragement should be listened to. He does not build railroads or organize society in new lands, but he is in the foremost rank of pioneers, with the complete equip-field, Mo. ment which our teachers can give him to day, and he becomes a most valuable member of society. He protects the young colony from epidemics; without him State medicine could not exist, and States could not be provided on a basis which could ensure prosperity. These ideas should be impressed upon our men of wealth and upon the State governments as well. In the meantime it is important that we should adopt as a principle in our new departure in education that the medical faculty should have personal control of hospital wards and management. Let this work begin in a small way at first, but with a view to future development. Such a change can only be brought about by a slow process of evolution. The sooner, therefore, the principle is recognized and adopted, the better. It is difficult for a prosperous school which has abundant opportunities for bedside teaching to realize this, but it can not develop beyond a certain point until it has established its own independence. I cannot help believing that in this direction lies one of the greatest avenues of development of our system of medical education in the future. South-Western Association of Railway Surgeons.-As may be seen from the titles of papers to be read and their authors the meeting of this asso ciation, which will take place October 26 and 27 in this city, promises to be one of great interest. In addition to the reading of papers and their discussion, the scientific part of the meeting will consist in the holding of Clinics, These clinics which will be Compression of the Brain, J. E. Tefft, M.D., Spring Cases from Practice, W. B. Rogers, M.D., Memphis, Tennesee. A Method of Applying Plaster-of Paris Jackets, Wm. A. McCandless, M.D., St. Louis. Symptoms Caused by the Electric Light. Freeland has reported the case of an electrician, who was suddenly seized with intense pain in both eyes and severe headache. The eyes were suffused and the conjunctivæ congested. There was marked photophobia and partial blepharospasm. The skin was hot and dry. The temperature was 102°. The free instillation of a five per cent. solution of cocain was soon followed by a subsidence of pain and a desire to sleep. After little more than an hour, however, the man became wildly delirious. The administration of fifteen grains each of potassium bromid and chloral was followed in half an hour by quietness and sleep. An ice bag was applied to the head. The man slept for several hours, meanwhile perspiring quite freely, and on awaking felt much refreshed and was quite rational, although somewhat shaky The pain in the eyes and head had gone, but the eyes were still suffused and injected and intolerante of light. The temperature was normal and the skin moist. The man was kept in a dark room for the remainder of the day, and on the following morning was able to resume his usual occupation. It was learned that he had had charge of a powerful electric search-light and had neglected to wear protective goggles. -Brit. Med. Jurn. |