The Future of Medical Colleges 
in the Smaller Cities of 
the United States. 
BY 
DANIEL MORTON, M. D., 
ST. JOSEPH, MO. 
REPRINTED FROM THE 
Neto York journal 
for July If 1896. Reprinted from the New York Medical Journal 
for July 11, 1896. 
THE FUTURE OF MEDICAL COLLEGES 
IN THE SMALLER CITIES OF THE UNITED STATES* 
By DANIEL MORTON, M. D., 
ST. JOSEPH, MO. 
There are two marked principles that are governing 
the medical profession to-day, in dealing with the sub- 
ject of medical education. They are as follows: First, 
a diploma should confer no right to practise medicine. 
Second, every student entering upon the study of medi- 
cine should have a thorough preliminary education. 
What effect will the enforcement of these principles have 
upon the smaller medical colleges of the Union? This 
is the question proposed for discussion in this paper. 
A backward glance at the beginning of a movement 
and a little study of its subsequent progress will often 
enable one to forecast its future with a considerable de- 
gree of certainty. 
In the early history of America, medical aid was 
often rendered by men who had never attended a medi- 
cal college. Graduates from the mother country were 
* Read before the Kansas State Medical Society, May 14, 1896, at 
Topeka, Kansas. 
Copyright, 1896, by D. Appleton and Company. 2 
medical colleges in small cities 
not sufficient to supply the demand. The first school 
in America, the College of Medicine of Philadelphia, 
now the Medical Department of the University of Penn- 
sylvania, was not founded until 1765. 
From this institution was graduated, in 1768, Dr. 
John Archer with the degree of Bachelor of Medicine, 
the first medical degree ever conferred in America. In 
the same year in New York city was organized the 
Medical Department of King's College, now the College 
of Physicians and Surgeons, the Medical Department 
of Columbia University. It has been estimated by Dr. 
Noah Davis that at the time of the Declaration of Inde- 
pendence there were in the thirteen colonies three or 
four thousand practitioners of medicine supplying the 
three million inhabitants with medical aid. About four 
hundred only of these practitioners had received the de- 
gree of M. D. In 1810 there were five medical colleges in 
the United States. Students were apprenticed to a regu- 
lar practitioner for two or four years, the degree of M. D. 
being conferred after attendance at two subsequent col- 
lege terms. Some entered practice at the end of one 
college term, and some at the end of their apprentice- 
ship without having attended college at all. And now 
medical colleges in America began to multiply with in- 
creasing rapidity as the years went on, until their num- 
ber greatly exceeded the actual demands of the situation. 
From 1840 to 1890 there was a perfect craze for estab- 
lishing medical colleges, and the competition for stu- 
dents became so severe that entrance and graduation re- 
quirements were reduced to a minimum. 
During the fifty years between 1830 and 1880 medi- 
cal education in the United States failed to keep pace 
with the advance made in the same line of work in other MEDICAL colleges in small cities. 
3 
countries. Although a vast quantity of knowledge had 
been accumulated since the beginning of the century, 
two years of instruction still remained the length of the 
medical course, just as it had been in 1810, and this too 
at a time when European countries were requiring four, 
five, and six years' study of their medical graduates. 
This statement should be modified by mentioning the 
adoption by the Chicago Medical College, in 1868, of a 
three years' graded course. 
The diploma opened the door to practice; and as long 
as it did this, it remained a commodity to be first manu- 
factured at the lowest possible cost by the manufacturer 
(the medical college), and then to be purchased in the 
open market by the consumer (the medical student) 
at the least outlay in money and time. At the end 
of our first century of existence Dr. Noah Davis thus 
describes the American medical educational system as it 
had grown up under the principle of giving to the 
diploma a licensing power. (See quotation at end of 
paper.) 
Having now sketched the condition of affairs as they 
have existed in the past, we are prepared to appreciate 
the efforts made to correct the abuses which had grown 
up as a result of this " freest rivalry " among medical 
colleges. 
All laws governing medical practice are based, first, 
upon the recognition of the diploma as a legal license; 
and second, upon denying this right to the diploma, and 
requiring an examination of every applicant at the hands 
of a civil board of medical examiners. 
The first-named law, known as the " Diploma law," 
gives the right of college supervision to the State Board 
of Health. This supervision is exercised by establish- 4 
MEDICAL COLLEGES IN SMALL CITIES. 
ing a " Schedule of Minimum Requirements/' which 
schedule requires all medical colleges, large or small, 
to make the course of lectures extend through a speci- 
fied number of months, to furnish specified laboratory 
facilities, to furnish a specified amount of dissecting 
material to each student, etc. 
In this way are the medical colleges made amenable 
to the civil authorities. With the teaching requirements 
thus laid down every college must comply to secure rec- 
ognition of its diploma. About the year 1880, for the 
first time in the history of the country, the Illinois board, 
under the leadership of Dr. John H. Rauch, began to 
vigorously use this power. It published a series of re- 
ports that have been the basis of all subsequent work 
having for its object the legal control of medical prac- 
tice in the United States. I can not enter into a detailed 
history of the good accomplished by the " Diploma 
law." Suffice it to say that its effect has been most 
salutary. In my own State it is this law which is in force, 
and it is executed by a board of fearless men who are 
doing a great work in checking the abuses which have so 
long run riot in our midst. The great flaw in it is the 
fact that it after all delegates the licensing power to the 
faculties of the medical colleges. This is not true of a 
law requiring every applicant for license to stand an 
examination conducted by a board of medical examin- 
ers. Let us not digress, however, but return to the 
minimum requirements and discuss the effect of the 
enforcement of some of them upon the smaller medical 
colleges, and the ability of the medical colleges to com- 
ply with others. 
Preliminary Education.-The great tendency of 
the profession to-day is to demand a thorough prelimina- MEDICAL COLLEGES IN SMALL CITIES. 
5 
ry education of every student entering upon the study of 
medicine and to permit none to matriculate who do not 
have it. For many years any one who so desired could 
enter a medical college without regard to preliminary 
English education. Many matriculates had the merest 
rudiments of a common school education, and many 
more were lacking even in this. This statement can be 
easily substantiated by looking for a few minutes at the 
prescriptions on file in the drug stores, or by the revela- 
tions of one day's mail at the office of any State medical 
officer like that of the secretary of the board of health. 
Men who could not enter other callings in life because 
of their lack of education found the doors of medicine 
wide open, with no obstacles thrown in the way to those 
desiring to enter. Engineers, harness makers, hostlers, 
and men of like station in life desiring to become doc- 
tors were readily accommodated by medical colleges. 
I would not cast a slur upon these occupations, for I be- 
lieve that work is honorable in all, and laziness is a re- 
proach wherever found. But no one has a right to as- 
sume the grave responsibilities of a physician's calling 
unless he has qualified himself to do so. Granting for 
argument's sake that there was at one time a warrant 
for such a custom, it is certainly true that that time has 
passed, never to return. The advance of science has been 
too great to be appreciated by one who can barely put 
himself in communication with the everyday affairs of 
life as published in the daily papers. What can such a 
man do with a scientific treatise on physiology or thera- 
peutics, studies involving a presumption of knowledge 
of physics and chemistry and the ability to think and 
reason accurately, to properly observe phenomena, and 
to draw therefrom the proper conclusions? One must 6 
MEDICAL COLLEGES IN SMALL CITIES. 
know addition and subtraction before one can solve prob- 
lems in multiplication and division. On account of the 
uneducated students who flock to the medical colleges, 
the latter have, in some instances, established chairs for 
teaching Latin and elementary chemistry and physics. 
They thus convert themselves into a sort of medico- 
literary college, and I have wondered sometimes why they 
did not at the same time confer both the degree of M. D. 
and the degree of A. M. The uneducated student goes 
to the college in the smaller city or to the low grade one 
in the large city. There he often finds teachers as igno- 
rant as he. I have known graduates of a medical school 
to become in a few months professors in their Alma 
Mater. When a high, uniform standard is established 
for preliminary education this class will be unable to 
measure up to it. They will then either give up the study 
of medicine and take a station in life commensurate 
with their attainments, or they will set about correct- 
ing the defects of their education so that they may, when 
this is done, enter a medical college. 
Students who have received a good literary education 
seek a good medical college. Knowing what a good lit- 
erary education is, they will not be content with a poor 
medical one. So that either way the knife cuts into the 
medical college of the small city. The uneducated stu- 
dent can not matriculate and the educated one will not. 
The result is inevitable-lessened attendance and lessened 
income. In Missouri the State board ruled out about a 
hundred students in the various colleges of the State be- 
cause of lack of preliminary education. This was for the 
session of 1895 and 1896, acting under the ruling of an 
examination by the county superintendents of public 
instruction. This method has proved unsatisfactory, MEDICAL COLLEGES IN SMALL CITIES. 
7 
for nearly all of this number have since been reinstated. 
For the session of 1896 to 1897 matriculates must have 
diplomas of graduation from a literary or scientific col- 
lege or high school;, or in lieu thereof pass an examina- 
tion before the State superintendent of public schools. 
Dissection.-It is with the greatest difficulty that 
the smaller colleges secure subjects for dissection. If 
there were not more students than necessary the anatomi- 
cal law would supply the demand. It was never intended 
that every city of fifty or sixty thousand people should 
have two or three medical colleges. But the colleges 
must have the subjects or the State board won't recog- 
nize them. What is the result? The anatomical boards 
can't supply them, and we see a Topeka Medical College 
close its doors temporarily; we see a widow suing a St. 
Joseph Medical College, charging the school with the 
theft of her husband's body; we see nineteen medical 
students arrested at Des Moines, Iowa, on the charge of 
grave-robbing. There is little encouragement to smaller 
schools if the teaching of the very foundation study of 
medicine is attended with such hazard. 
Length of Term.-By establishing a uniform length 
of term another blow has been struck at the smaller 
schools. They have heretofore said to the student: 
" Come to us; a diploma is what you want. We will 
graduate you in two years. Why go to a school that re- 
quires three? Our term is only five months long; why 
do you want to study six? Our fees are one third those 
of the larger schools. You can board in our town for 
three dollars a week; why go elsewhere and pay five? " 
But when every school in every city must give a course 
of equal duration one of the great inducements of the 
smaller medical college is gone. 8 
MEDICAL COLLEGES IN SMALL CITIES. 
Clinics and Hospital Attendance.-In a recent 
article entitled The Necessities of a Modern Medical Col- 
lege, Dr. Ingals says: " The advantages that were consid- 
ered ample until recently can not now be accepted. Every 
college must therefore be provided with dispensary 
rooms and hospital accommodations. I am familiar with 
the fact that fifty years ago a first-class medical college 
could be conducted with very little clinical material, but 
it does not seem practicable to give the instruction requi- 
site at the present time with less than four or five thou- 
sand outdoor patients annually, and hospital facilities 
of less than seventy-five or a hundred beds." How many 
of the smaller colleges can measure up to this minimum 
requirement? How many cases of obstetrics do their 
graduates attend before receiving a diploma? Do their 
graduates have sufficient hospital experience to acquire 
a knowledge of the grave diseases affecting men? If 
they have all these things, why in the name of Heaven 
do their graduates pack their grips and start for a large 
school in a large city? 
And thus I might go on enumerating many other 
points in which the smaller school works at a great 
disadvantage, under a uniform standard of requirements; 
but I will not weary you; I merely mention chemical, 
bacteriological, histological, and pathological laboratories 
and the expense of their proper equipment and main- 
tenance, which can not be obtained from the tuition fees. 
Let us now consider the effect upon these schools 
of a law requiring a State examination of every graduate 
from every school. Will this examination be more diffi- 
cult than the school examination? Undoubtedly it will. 
The examinee when at school has opportunities to be- 
come acquainted with the hobbies of each teacher. It is MEDICAL COLLEGES IN SMALL CITIES. 
9 
a well-established fact that every teacher has special 
questions and special subjects that play an important 
role in his examination. These individual preferences 
are handed down by tradition from one class of students 
to the succeeding one. Special stress laid upon certain 
subjects during the winter's course by the teacher are 
sure pointers of future examination questions. Stu- 
dents and quiz masters are quick to pick up these hints. 
How common it is toward the end of a session for stu- 
dents, with or without the help of a quiz master,to " bone 
up" on studies for examination! When the final test 
is made, many of the questions asked in the trying ordeal 
are found to be the ones expected and looked for. In 
fact, one of the strongest inducements held out to stu- 
dents by quiz masters is the knowledge which the latter 
possess of the individual peculiarities of the teacher's 
views on medical subjects taught by him, and a list of 
the questions which have been asked on examinations 
for many years perhaps. Any one who has looked over 
such a list has been struck with the striking similarity 
of the questions asked and with the appearance at certain 
intervals of well-known ones. The disadvantage under 
which a student labors who takes the senior year in an- 
other college from that in which his first courses were 
taken is thoroughly well understood, and is only another 
proof of the truth of the above assertions. In other 
words, each college has an examination that in char- 
acter, questions asked, standard required, and other char- 
acteristics is sui generis. These things are not true of a 
State examination. The questions are broader in scope, 
because they are prepared from a study not only of medi- 
cal college examination papers, but of many State exam- 
ination papers. Go to the students who must pass a 10 
MEDICAL COLLEGES IN SMALL CITIES. 
State as well as a college examination and ask them 
which they fear the most. They will answer, the State 
examination, and cite as a basis of their dread the rea- 
sons mentioned above, or others of a like character. 
There is every inducement on the part of a State board 
to keep the grade of its examinations high, so that in- 
competent men may be kept out of the State. If it estab- 
lishes a grade lower than that of its neighboring States 
the State over which it has jurisdiction at once becomes 
the dumping ground of those who have failed to obtain 
a license elsewhere. 
There is every inducement for the medical college 
to make its examinations easy, especially if it be an un- 
endowed institution, dependent upon students' fees for 
existence. The tendency of one is up, the tendency of 
the other is down. When a student knows that after 
his medical college life is ended there is an examination 
to be passed at which he has no " under holds," at which 
he must prove the possession of medical knowledge suffi- 
cient in amount to entitle him to be trusted with the 
lives of his fellow beings, and that, too, before a tribunal 
impartial and impersonal, what will be his course? He 
will at once see that nothing but the possession cf sheer 
knowledge will be of avail, and he will set about seeking 
a place where this can be best obtained. Will he find it 
in the medical college of the small city? I believe not. 
A diploma carrying with it the licensing power is the 
stock in trade of these medical colleges. Do away with 
licensing power and you have done away with the only 
inducement it has to offer, and students desiring a medi- 
cal education will go elsewhere. Do away with students 
and you do away with the food which gives the college 
life. Inanition and death follow. The diploma law is MEDICAL COLLEGES IN SMALL CITIES. 
11 
gradually being replaced with the State examination law. 
There are now twenty-two medical examining boards in 
the United States recognizing no diploma as a license. 
When all the States shall have fallen into line the smaller 
medical college as a degree-conferring body will become 
a thing of the past. 
Having to compete with the superior advantages of 
the larger colleges on the one hand and constantly sub- 
jected to the prodding of the State board on the other, 
deserted by those students who recognize that such a 
college can not fit them for a State examination, draw- 
ing their supply of students from a territory ever dimin- 
ishing in size because of the encroachments of medical 
practice laws upon States heretofore having none, so 
situated that it is absolutely impossible for them to 
comply with the ever-increasing demands of the profes- 
sion for a higher education, and having to meet these 
demands with an ever-diminishing income produced by 
the lessened number of students, it does look as though 
the future of the medical college in the smaller city is 
dark and dreary. 
If, then, all these things are true, what will be the 
future of the medical college in the smaller city? The 
handwriting is on the wall, and Mene, Mene, Tekel, 
Upharsin does not require the aid of a prophet for inter- 
pretation. At no far distant day a diploma will have one 
significance and one significance only. It will indicate 
that the holder has complied with the prescribed course 
of the institution granting it, and it will be a preliminary 
to the State license. The medical college of the future 
will be compelled to regulate its teaching by require- 
ments of the civil licensing power. It will stop trying 
to do something it can not do. We have reached the high 12 
MEDICAL COLLEGES IN SMALL CITIES. 
tide in medical college creation. There will never again 
be as many medical colleges. They will lessen in num- 
ber but improve in quality with every succeeding year. 
Cities that are capable of sustaining one good medical 
college will see the three or four now existing merged 
into one institution capable of doing good, thorough, 
honest work. Others still will cease to be degree-con- 
ferring institutions, but will correlate themselves with 
colleges in larger cities where ample facilities for teach- 
ing the senior classes are found. They will find a legiti- 
mate sphere of usefulness in teaching the primary 
branches of medicine and then passing the student on 
for final instructions and for the degree to a degree-con- 
ferring school in a large city. 
Colleges so situated as to be unable to comply with 
the ever-increasing demands of the civil medical authori- 
ties will become extinct. When this condition of affairs 
is brought about we shall see medical colleges receiving 
endowments. With these endowments will come larger 
teaching facilities and larger facilities for original re- 
search. As a result of the former will come a highly 
educated profession who will use the discoveries of the 
latter to lessen the woes and sufferings of the human race. 
I trust that this paper will leave upon your minds 
the abiding conviction that a medical examining law is 
superior to every other form of enactment having for its 
object the legal control of medical practice. I hope that 
Kansas in this, as in everything else, will prove herself 
in the line of progress. I hope that she will place no 
" mossback " law upon her statute books. 
" Under these conditions and tendencies, by the end 
of the second thirty years of our history the number of 
medical colleges had increased from five to forty-one; the MEDICAL COLLEGES IN SMALL CITIES. 
13 
number of students attending them, from six hundred 
and fifty to twenty-five hundred; and the ratio of those 
graduating each year, from less than one in six to one in 
three. 
" Here we see a system of medical colleges originat- 
ing spontaneously to supply the wants of a free and rap- 
idly increasing people, and open to the most unrestrict- 
ed rivalry, actively developing two apparently opposite 
results. In one direction the schools properly vie with 
each other in increasing the number of their professors, 
in full consonance with the rapid advancement of the 
medical sciences; they sagaciously seek out and enlist 
the services, as teachers, of the most learned, eloquent, 
and industrious men to be found in the profession; they 
spend time and money freely in filling laboratories, ana- 
tomical rooms, and museums with all the means for effi- 
cient teaching and illustration. So far their free rivalry 
has reference only to their office as teaching bodies, insti- 
tutions for imparting instruction, and is productive of 
nothing but good to the profession and the people. But 
the anomaly consists in the fact that, at the same time 
they were increasing their professors, the same institu- 
tions were rapidly shortening their annual courses; cut- 
ting off all collateral requirements; failing to grade the 
branches of medical study as they increased in number 
and extent, so as to adapt them to the several years of 
pupilage; and even reducing the final examination to 
the simple process of asking a few oral questions in the 
mysterious ' greenroom.' 
" This most unfortunate tendency of our experiment 
in permitting the freest rivalry in the establishment 
of medical schools results directly and necessarily from 
the fact that the degrees they confer and the diplomas 
they give have been permitted throughout the whole 
country, with only a few temporary exceptions, to have 
all the force and effect of a license to practise medicine. 
It requires but a moderate familiarity with the motives 
that govern human actions to see clearly that in a coun- 
try where there are no entailments of estates, and where 
the great body of young men who seek the professions 14 
MEDICAL COLLEGES IN SMALL CITIES. 
are without pecuniary fortunes, and largely dependent 
on their own industry for the means of education as well 
as reputation and fortune in after life, the question, 
' Where can I get the degree of doctor, which is equiva- 
lent to a license to practise and a full admission into 
the ranks of the medical profession, in the shortest time, 
and consequently with the least expenditure of time and 
money?' exerts a very great if not controlling influ- 
ence in determining where the student shall attend his 
college instruction. Not that medical students are a 
whit less conscientious in their desire to fully qualify 
themselves for the responsible duties of our profession 
than those who seek any other calling in life; but pres- 
ent necessity, or even convenience, easily controls when 
there comes with it the flattering thought that, at an- 
other time, after having earned a little money by prac- 
tice, all deficiencies can be supplied by a season of re- 
viewing in a school of the largest facilities. 
" Just on this half-unconscious delusion, hundreds 
are induced to go where the requirements in time and 
money are least, regardless of all other advantages. The 
medical college in a country village, remote from all 
facilities for clinical instruction in hospital or dispen- 
sary, and but scantily supplied with subjects for dissec- 
tion, can issue to its graduates just as large a diploma, 
couched in just as unintelligible Latin, and having 
much the same influence with the people as the school 
in a metropolitan city whose students can have the 
largest facilities for clinical and practical study. Hence 
it is not strange that, before the end of the seventh 
decade of the past century of our existence as a nation, 
about forty medical colleges had been organized, only 
sixteen of which were so situated as to afford their stu- 
dents any proper facilities for clinical instruction; and 
that those sixteen were resorted to by a little more than 
one third of the whole number of those who attended 
medical colleges. 
" The general- acceptance of the college diploma as 
full admission into the profession, thereby uniting in the 
hands of the same men the business of teaching and the MEDICAL COLLEGES IN SMALL CITIES. 
15 
power of licensing, has continued to the present day. 
It is wholly responsible for the fact that, while we have 
sixty-four medical colleges to-day (1876), one third of 
them are so located that they can afford their students 
no advantages for clinical instruction worthy of men- 
tion; and all except three or four still attempt to crowd 
instruction in all the departments of medicine upon the 
attention of mixed or ungraded classes, in annual col- 
lege terms of from sixteen to twenty weeks, and exact 
only two such strictly repetitional courses for gradua- 
tion. 
" This state of things, in regard to our medical 
schools, is made still worse by the fact that, during the 
century under consideration, the system of private medi- 
cal pupilage has undergone a complete change. At the 
beginning of that period, as we have already seen, the 
private study under a master was a protracted and seri- 
ous work, and the resort to the college was simply to 
review and more fully illustrate that work; but steadily, 
as medical colleges increased in number, as population 
became more dense, and as steamboats and railroads 
increased a thousandfold the facilities for travel, the 
work of private pupilage relaxed. Indentures of medi- 
cal students, as pupils, to the more noted practitioners 
long since ceased, and the relations of student and pre- 
ceptor have become merely nominal in practice; in nine 
cases out of ten consisting in little more than the regis- 
try of the student's name in the doctor's office, permis- 
sion to read the books of his library or not, as he chooses, 
and the giving of a certificate of time of study for the 
student to take to the medical college where he expects 
to graduate."-Contributions to the History of Medical 
Education and Medical Institutions in the United States 
of America, 1776-1876. Bureau of Education, Wash- 
ington, D. C. The New York Medical Journal. 
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