Address before the Harvard Medical Alumni Association June 27, 1893 BY J. M. DA COSTA, M.D., LL.D. ADDRESS BEFORE the Harvard medical alumni ASSOCIATION June 27, 1893 BY J. M. DA COSTA, M.D., LL.D. BOSTON Geo. H. Ellis, Printer, 141 Franklin Street 1893 ADDRESS. Mr. President,- When I last had the pleasure of sitting next to you at dinner, I observed that there was at times a little nervousness in your manner. I did not quite understand what was disturbing your equanimity until you were called upon for a speech. However it be, my feelings of self-congratulation that I was not to be other than a listener did not remain unalloyed; for, with your usual persuasiveness and earnestness, I found myself by the end of the enter- tainment pledged to address this meeting to-day. Yet let me thank you for having done so; for it gives me a pleasure which, indeed, is great. But I cannot thank you for the subject you allotted to me, Medical Education; for if there be a subject which has been talked over again and again, if there be a subject which, wherever broached, calls to its feet the old and the young, if there be a subject that is sure to arouse antagonism, it is the subject of medical education. I have often asked myself why it is that medical educa- tion is so discussed by the profession, why this never- ceasing upheaval. We do not see the education in law, we do not see the education in theology, a matter of constant dispute and agitation. And I have con- 4 eluded that the keen interest, the deep feeling, which it engenders, is really due to the state of medicine it- self. The agitation is but a sign of the unrest in medicine we see everywhere. It is but a recognition of the spirit of research and investigation that is so conspicuous now, of the enthusiasm that is constantly adding- new facts, almost new sciences. Medical edu- cation must be discussed, must be recast, since the groundwork on which medicine stands is being from day to day enlarged and strengthened. Let us be, therefore, after all, glad that the subject attracts so much attention. It attracts attention because medi- cine itself is a most progressive science. We cannot congratulate ourselves on the state of medical education as it existed in this country some years since. There were, as there are now, many earnest and eloquent teachers; but the wretched sys- tem of going over the same ground year by year, the total inadequacy of the time allowed for prepara- tion, the utter lack of laboratory and hospital facili- ties, made the condition of medical education a re- proach instead of a subject of honest pride. Now it is becoming vastly different. There is, indeed, no self- respecting medical school which can stand the press- ure of public opinion and go on in the forefatherly ways. The sacrifices, the struggles, of Harvard and of those great schools that stood by her side in honest rivalry, schools that appreciated the inherited wants of the past and the needs of the present, have not 5 been in vain. They have done what the profession of medicine wanted them to do, and have done it splendidly. The chief difficulty in making a high standard uni- versal lies in the number of the medical colleges. It is, indeed, a sorry admission that the medical schools in this country are the greatest enemy to medical progress, not in themselves, but in their number. Some years ago there were nearly three hundred. Now there are not far from one hundred and fifty; and they are dying at about the rate of three a year, without, it must be said, many mourners. A further re- duction would be a national benefit. The reason they constitute in their number a bar to medical education is not only that in their struggle for existence the feebler ones tend to keep the general standard down, but that it is utterly impossible that all can keep pace with the requirements of modern medicine. How can all have well-equipped laboratories ? Where can the clinical work be done on which the medicine of the day depends ? The remedy lies in their amalgamation. Let the absurdity cease of small towns having three, four, six, of these struggling institutions, no one of which can have a vigorous life. The remedy also lies in the profession,- in the stand taken by potent repre- sentative bodies and their authoritative action, in public opinion discountenancing the establishment of medical schools except where the development of the country proves them to be imperatively needed in 6 fresh growing centres. Thus in time the preposter- ous disproportion of medical schools as compared with schools of law, of divinity, of engineering, will cease; and it will come to be recognized that there is nothing about medicine that calls for such a profusion of teachers. There is now all over the country a growing dis- position for the universities to take charge of medical teaching, and to develop their medical departments with all the zeal they give to the others. We see it in Michigan, we see it in California and Colorado, we see it in Louisiana and in Texas, as strikingly as in our Eastern States. There is nothing but good in this. The power, the means, the spirit, of the uni- versity, go out to its branch. The university, in turn, gains by the reputation of its medical faculty, and by the recognition that medicine is an essential part of the new learning which leads on to the highest attainable civilization. Thus both are benefited. The future of medical education certainly lies in the universities, and in such great schools as can vie with them in clinical and other facilities. But, as this state of things becomes more and more general and the weak colleges disappear, the university has increased obligations. It must en- courage, it must satisfy, the legitimate ambition of those who wish to become teachers, and who prove their aptitude. Throw open the doors as widely as possible, grant the use of the lecture-rooms, attach 7 men of rising prominence to the university, accustom them to look upon her as their true mother. You need not fear. You will not have too many. Stu- dents are keen critics. It will be a survival of the fittest at the end. You have in this great School adopted a four years' course. I observed a rivalry here between you, Mr. President, and you, Mr. Chairman of the Committee on the Medical School, who should be the one to announce its success to this Association. I am sure that there is not a member present who would not like to be in either of your places, and make this an- nouncement; for it is one of great gratification to every member of Harvard, to every member of the whole profession in the United States. I am equally sure that, should the time come when Harvard calls for a fifth year, its loyal alumni would at once re- spond. Do not, however, understand me as thinking this necessary or even desirable. I believe that for the present you have done enough, and that the cur- riculum is sufficiently extended. I hope to see the advance in medicine, or rather, I should say, in medi- cal education, going on at the other end. I want to see trained minds enter on the study of medicine. It is so much easier for a teacher to speak to and to in- struct those who have had good mental training. It is frightful to talk in an uphill manner to men - fortunately, now a diminishing proportion in medical classes-who are unaccustomed to thinking, and 8 who show in their faces that they have to labor to understand. Therefore, I say again that it is to the beginnings that we must look. Let us have pre- liminary standards of sufficient kind, and the curricu- lum will, in process of time, and with growing sub- jects, and with the wealth of the country aiding, take care of itself. It is gratifying to know that the medical colleges are, with almost unanimity, moving in the direction of exacting certain educational requirements for matric- ulation. In the Report of 1891 of the Illinois State Board of Health it is stated that 129 colleges out of 148 in the United States and Canada have adopted some standard of general qualifications. It will soon be the universal rule. Even if the requirements are with many of the most shadowy kind, still they are requirements. They aim at securing mental training as a preliminary, and the whole means progress. The most desirable state of things would certainly be if, as a prerequisite to the study of medicine, a degree in arts or science be demanded. But the country is not ready for this. It would exclude many who are fully competent to study and to profit by their studies. All we can now ask for is proof of sufficient mental training, and it would be best if this proof were forthcoming from bodies unconnected with medi- cal teaching. But, if we are to get our students of medicine from the universities and colleges of the country, we must 9 be sure that these give us help. Here I fear I am treading on ground which has been gone over thoroughly; but I wish to record at least my individ- ual opinion that, if you want medicine in its higher branches to flourish, if you want it to flourish through university influence and university support, especially if the universities are to become the general medical educators, the university must meet you more than half-way. You must have not simply a shorter course of preliminary study at these universities,- and I am an advocate of the three years' course for the degree in arts and in science,- but you must also have them in every way giving facilities to those who are desirous of choosing medicine as a profession. • The assertion that the medical classes show a smaller proportion of college graduates than was formerly the case I know to be true. I have fol- lowed the matter for some years; and the reduction, I find, is general. The Dean of the Harvard Medical School states that in 1884 the per cent, of college graduates in the Medical Department at Harvard was 53.9, and that in 1892 it was 28.2. At Columbia it rose from peculiar causes to 34.7 in 1891, and was 32.5 in 1892. At the University of Pennsylvania, the Medical Department of which is solving the same problems as Harvard in the same spirit, the college graduates were, at the session of 1890-91, 152 out of 582, or 26 per cent.; in 1891-92, 167 out of 693, or 24 per cent.; in 1892-93, 168 out of 835, or 20 per 10 cent. In some of the medical departments of uni- versities in which the proportion has not been very high there is much less difference to be noted. For instance, in the well-known University of Michigan, in 1882-83, in a class of 378, 40 were college graduates, or 10.6 per cent.; in 1890-91, in a class of 369, 39, or 10.5 per cent.; in 1892-93, in a class of 370, 35, or 9.4 per cent. There are sixteen medical colleges, as I learn from a recent instructive paper by Dr. Bayard Holmes, in the Journal of the American Medical Association, with no student enrolled who had obtained a literary or a scientific degree. Yet I am quite certain that, while the number who complete their academic studies is less, the general average of those of mental training is much higher, and the number much greater who have been for a year or two at some of the higher educational estab- lishments, but have left without graduating. I made it a point for years, while actively connected with a medical school, to inquire into this matter, and kept records that were convincing. This is, I think, only an additional argument for the universities and col- leges to consider. The age at which they graduate young men is certainly too high for the professions, especially that of medicine, which requires a long period of special study. It is, undoubtedly, the chief cause why the graduates of colleges are diminishing in the medical schools. Why should the age be so high ? Why, here, in a young, rapidly developing 11 country, where men want to, and mostly have to, get to work early, should we require this long prepara- tion ? I have taken some trouble to go over the re- ports of the universities of France and of Germany, and I am astonished to see the difference. The men who enter the professions, with their academic course completed, are, as a rule, nineteen years of age. In a work " On the German Universities for the Last Fifty Years," by Professor Conrad of Halle, he states that during a long term of years there were but 23 per cent., or, to speak accurately, 23.1 per cent, of men who were over twenty. We must attain the same here if we want to have college-bred men enter the professions. The colleges must recognize and take into account that professional work is itself a continu- ance of mental training and culture. But this subject is too wide a one to follow further here. Let me return to the aims and results of medical education in this country. Vast good has been accomplished by the methods now gaining. It educates those who are trained by it before they see their patients; formerly they educated themselves largely off their patients. I need scarcely say that I am heartily in sympathy with the advance that is going on,- the advance as to time required for the course, the advance as regards the subjects taught. But there are in all great movements periods of ebb and flow, of advance and retrogression. We are in risk of retrogression in trying to put too many sub- I 2 jects into the curriculum. The medical student can- not master them all. You cannot turn him out a finished article. The thing is impossible. Let him keep some of his angles. They will be worn off quickly enough when he gets into practice. Teach some subjects thoroughly, and let the rest alone. Treat him less as a school-boy, and more as a member of a university; develop in him the university idea. Allow him after the first year to choose for himself much more than he is now permitted to, with full knowledge of the subjects required at the final examination. And there is another matter allied to this on which I feel strongly,- the constantly re- curring examinations. I am utterly opposed to the everlasting examination of the poor medical student. Why cannot you take it for granted that he is devel- oping? Why must you always pull him up by the roots, to satisfy yourself that he is growing? We all know that the knowledge of examinations and real knowledge, knowledge that from training and use has become part of the man, are not always the same thing; and, after all, you do not want to turn out medical prize oxen stuffed and fattened for examina- tion, but medical men with thought, with power, with intelligence, and with love of work and of original in- vestigation. Let us act on the belief that the medical graduate is a compound to be made by synthesis, not by analysis. Mr. President and gentlemen,-A good deal has 13 been said here, and well said, about the desirability of endowing universities. I am sure I sympathize deeply. I think that, if Dante is still at work on his " Inferno," he ought to add a chapter on the tortures that shall await rich men who do not give large sums to universities and colleges. But, after all, it is not simply by endowments that institutions flourish. It is also by appreciating the great teachers they have, doing them every honor, treasuring them. A great teacher in medicine, as a great teacher in anything else, is rare. Hold him dear when you have got him. Show him every honor. Advance him. He is a potent influence in life: his memory is a power. Who goes to Paris without thinking of Laennec, Andral, Trousseau, and Nelaton ? Who visits Vienna and does not have before him Rokitansky, Skoda, and Oppolzer? Who can go to Berlin and not think of Langenbeck and Frerichs; or to London and be un- mindful of Hunter and Cooper and Bright? Who comes to Harvard and does not remember the Jack- sons and Bowditch and Bigelow and Clark and Ellis and Storer and Shattuck and many others of fame ? Their memories go to make up the School, and con- tinue from generation to generation. In these mem- ories they have left much behind them. Some have left also, from their very households, worthy succes- sors; but all have left that great influence which, like the unseen subtle ether, goes to form the rays of light that illuminate a great university. I have made 14 it a rule in these remarks not to speak of the living; but I must make one exception. In the list of those in whose memories Harvard is rich - I find myself speaking almost as if he had passed to another world, and bequeathed his immortal name - there is also Holmes. Who has struck a straighter, a keener, blow for medical rights, for honesty in the profession, and against shams than Holmes? He reminds me of one of those Eastern knights whose blade was so skilful that it severed the head of an adversary or cut him down to the saddle, yet he would keep together until he was touched, when he fell asunder. But I must not be tempted by the interest of the occasion and the kindly warmth of your reception to say more. As I look around me and see the earnest faces of those who are fighting together life's battle in the same cause; as I see side by side the veteran whose name is honored everywhere and the young man who is still to win his laurels, united in one desire, eager all for helpful aid and to promote useful endeavor,- it is not teacher and pupil I think of, but brother joined to brother, intent on upholding the beneficent influence, the traditions, the fame, of Har- vard, and joyfully ranged around the glorious old banner that on its crimson folds shows victories in all science, literature, learning, progress.