Medical Edncation in the United States. An Address delivered before the Section on Pedagogy of the Pan-Ameri- can Medical Congress. J. COLLINS WARREN M.D. Professor of Surgery in Harvard University. President of the Section. THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, REPRINTED FROM SEPTEMBER 9, 1893. PUBLISHED AT THE OFFICE OF THE ASSOCIATION CHICAGO; 1893. MEDICAL EDUCATION IN THE UNITED STATES. Gentlemen :—The work of this Section is of a character which does not usually form a prominent part in the proceedings of medical gatherings. In almost any department of education, pedagogy or the science of teaching is a recognized specialty. The rapid progress which has been made in medi- cal education in this country within the last few years has brought about such profound changes in methods of instruction, and the strides which medi- cal science is making all over the civilized globe are bringing into view so many new fields of work, that the teachers of to-day have a far more complex and difficult task than was presented to their prede- cessors. The art of teaching medicine has not been taught, in this country at least; the time has arrived to take up the subject. In introducing such a subject as this, it seems ap- propriate to take a brief retrospective glance at the history of medical education in this country. There lies before me as I write, a quaint little vol- ume entitled, “A Discourse upon the Institutions of Medical Schools in America,” published in 1765. It bears the following inscription : “To Doctor John Warren, Physician in Boston, This Copy is presented by his respectful and affec- tionate Friend, John Morgan, Philad’a, Feb. 27,1783.” This book may be safely regarded as the first contribu- tion to the subject which we are to discuss to-day and the two dates are memorable; the former indicating the foundation of the medical department of the University of Pennsylvania, and the latter the birth of the medical department of Harvard University. Dr. Morgan justly remarks that “medicine is a science as important in its object as it is difficult in the acquisition. It is very extensive in its researches and presupposes the knowledge of many other sciences. The cultivation of it requires no small abilities, and demands of those who engage in the arduous pursuit an enlarged and benevolent mind.” It is interesting to note that one whom we might justly look upon as the father of medical education in this country and who “had spent five years in Europe under the most celebrated master in every branch of medicine,” should have taken so optimistic a view of the knowledge of medicine at that time as to say : “The industry of many centuries has already been employed to bring Physio to that degree of perfection at which it is now arrived.” Fortunately he adds : “It will still require a long time to remove the obscurities which yet veil manv parts of it.” Three years after this book was written, Pennsyl- vania held her first medical commencement and the provost justly remarked; “This may be considered the birthday of medical honors in America.” The men who started this movement had received much encouragement from across the ocean and the remark of one of their teachers, Dr. John Fothergill of London, is of special interest to those concerned in the work of this congress. Writing to James Pemberton in 1762 he recommends Drs. Shippenand Morgan as men well qualified for the work of teachers, “both of whom,” he says, “will not only be useful to the province in their employment but if suitably countenanced by the legislature will be able to erect a school of physic among you that may draw students from various parts of America and the West Indies.” During the colonial period of our history it was the custom for young men who entered upon the study of medicine to become regularly apprenticed to some practitioner for a term of three or four years during which time the preceptor was entitled to the students’ services in preparing and dispensing med- 3 icine and serving as an assistant in minor surgical operations. As a return for this, the physician was obliged to give the student detailed and thorough instruction in all the branches of medicine. Many of the leading men frequently had several students in their office, constituting a small class, who were drilled as regularly in their studies as they would be in college. In some instances the term of appren- ticeship was extended even to six or seven years.1 When the medical school sprang into existence it was at first intended merely to supplement the ap- prentice system, and as means of communication of one part of the country with another were exceedingly limited it was found desirable to concentrate school work into as small a part of the year as possible. Hence the origin of the short term of four months which has clung so persistently to the American system. I will not undertake to weary you with a detailed account of the history of the development of our system of education. Suffice it to say that the close of the century found schools established not only in Pennsylvania and Massachusetts but in New York, Maryland and Vermont. There were, however, in 1810 only five medical schools in existence with an aggregate number of medical students of about 650, of whom 100 received the degree either of bachelor or doctor of medicine. The bachelor’s degree was given to those who had attended one full course of college instruction. It was hoped that such students after a short period of practice would eventually return to take the higher degree, but as this expec- tation was not fulfilled ,the degree of bachelor of medicine was soon wisely abolished. A noticeable feature of the education of that early period in our medical history were the requirements for a high standard of general education. Those students who did not possess a college degree were expected to pass an examination in Latin, mathe- matics and “Natural and Experimental Philosophy.” i N. S. Davis, Med. Ed. and Med. Institutions in the United States of America. 1877. 4 To obtain the degree of doctor of medicine it was necessary that the applicant should have been a bachelor of medicine for at least three years, should have attained the age of twenty-four years and should write and defend a thesis publicly in the college.2 When we consider how imperfect was the knowl- edge of chemistry, physiology and even anatomy, and many other branches of medical science, and how little of what we now consider the foundation of medical education there was to teach—such a course cannot be regarded as a very complete and exacting one. “Under these influences the first thirty years suf- ficed to cause the bachelor’s degree to be abandoned by all the schools, the number of professors in each school to be double, and the length of the annual college term to be shortened one-third.” (Davis.) Such was the standard of education with which the present century opened. New schools continued to be created, not infrequently in connection with some university, as in 1810 at Yale University, in 1817 in Lexington, Ky., in 1820 at Brunswick, Me., in 1825 at Charlottesville, Virginia, until in 1840 twenty-six new medical colleges had been added to the list, the whole number of students in the country amounting to 2,500, the population in that year being 17,069,453. A glance at the report of a committee to the Med- ical Society of the State of New York in 1833, gives a good idea of the amount of work done by the schools at that period. In the twenty schools mentioned in this report the number of courses of lectures required was two, with one exception—that of the University of Virginia, where three courses were required; and to the credit of this university be it said, the length of each course was ten months, whereas, the almost invariable cus- tom of the other schools was to give a course of four months’ duration only. The time of study purported, however, to be in all cases three years, “including the 2 William Pepper. Higher Medical Education. 1877. 5 time devoted to lectures,” as is stated in most of the reports. This straw indicates that at that time the chief dependence, or nearly so, was placed upon the extra-mural instruction which was given to the student. At Yale University there was this ad- ditional requirement, namely, that the student was required to study four years, “if he had not gradu- ated,” which phrase, I presume, means if he had not already taken the academic degree. This seems to be the first intimation that a longer term than the standard then set was necessary for a complete equip- ment for the practice of medicine. The Medical Institution of the State of Georgia (incorporated in 1828) gave at first the bachelor’s degree with one year of study, but immediately abandoned it for the usual curriculum. In the University of Pennsylvania, to which we look for the standard in these early, as well as later days, two full courses were required, but as in many other schools one course only was demanded from those who had attended a course at some other repu- table school. In addition, a course of clinical instruction in one of the Philadelphia hospitals was required. The course was then three years in length, but as each course of lectures lasted only four months, it was expected that during the remaining portion of the first two years the student should receive private instruction. As the period of the school term was so short, it is interesting to note at what time of the year the var- ious courses of lectures began. This, it will be seen, varied greatly according to the geographical position of the institution. At Dartmouth and the University of Vermont the term began in August. In Bowdoiu College, Maine, how- ever, it began in the middle of July, continuing until the middle of May that is, the term time in the far north was in the summer or spring. At Yale and Harvard and in Philadelphia and New York the term opened at the end of October or the beginning of November, as did also the schools 6 in North Carolina and Kentucky. The University of Virginia, with its long course of ten months, began September 10. Although the term time was exceedingly short in some schools a large amount of work was crowded into the daily routine of the students. Five or six systematic lectures a day, with attendance on clinics and dissections when possible, was considered noth- ing more than a fair amount of work for the medical student to digest properly. This system of teaching remained practically unaltered in 1851, if we may judge from a report to the Committee on Medical Education of the Ameri- can Medical Association.3 In regard to the private instruction which was supposed to continue during the remaining eight months of the year, the report states that a very large proportion of students sim- ply read medicine under the direction of their pre- ceptors. Anything like careful instruction upon the part of the teachers did not exist. The student nei- ther while attending lectures nor while in his precep- tor’s office was encouraged in anything like faithful and rigid study. To remedy the defect, private schools for teaching medicine were founded by enter- prising physicians and surgeons andthese quiz classes which were then inaugurated, became a prominent feature of the national system of teaching. Many a distinguished professor has first won his spurs at these private schools, and many valuable experi- ments in medical education were carried on by these men. As the college term has lengthened, the neces- sity for these accessory courses has diminished, and in many cities the extra-mural instruction, whether by private school or by teacher, has passed into his- tory. No one will, I presume, regret the departure of the year of private teaching, “by some respectable practitioner,” whose certificate, purchased by a hand- some fee, came eventually to have so little meaning. When this custom was first inaugurated it was the sole method of inspection, and during the long period of apprenticeship the student received a large amount 3\V, Hooker, M.D. 1851. 7 of instruction of the most valuable sort. When the medical school came into existence the attempt was made to combine the two systems. The practitioner, relieved from the responsibilities of giving a com- plete course of study to the student, gradually re- laxed his efforts as a teacher until this part of his daily work came to have only a nominal value. According to Davis it consisted in 1877 in little more than the registry of the student’s name in the doctor’s office, permission to read the books of his library or not, as he chose, and the giving of a cer- tificate of time of study for the student to take to the medical college where he expected to graduate. At the beginning of this century the successful practitioner gave a prominent place in his household to the medical student. I have often heard my father and many other practitioners of his day tell stories of the school life of those times. The office in the old homestead where I began the practice of medicine, then a luxurious library, was in those times a plain room with a sanded floor, occupied during the day by a small band of medical students who all boarded in the same house. The old room was the scene of many amusing stories of schoolboy life, and also of thrilling tales of escape from the indignant pursuer, by the hero of some graveyard scrape which was rendered necessary by the peculiar laws of that period. This phase of student life has long since passed away and the equally agreeable and far more profitable experience of hospital life has taken its place. Would that I could add that such hospital experience was now the privilege of every medical student in the land. As we approach the middle of the century, we find the nation growing rapidly in population and pros- perity, and a corresponding increase in the numbers and activity of the medical profession. From 1830 to 1845 the number of medical schools in the United States had more than doubled. At a meeting of the Medical Society of the State of New York in 1839, when the subject of medical education was brought forward, it was proposed to 8 hold a national medical convention the following year in Philadelphia, consisting of representatives from the different schools and State societies. No response was made to the action of this society, but in 1844 Dr. N. S. Davis, then a delegate from Broome county, New York, offered a resolution that a national convention be called in 1846, and the American Med- ical Association thus sprang into existence, the fund- amental idea, which brought about the formation of the association, being the improvement of our sys- tem of medical education. It was high time that some such movement should take place, as the rapid increase of the number of medical schools brought with it a constant increase in the laxity of methods of teaching. The equipment of a new school was sometimes pa- thetic in its meagerness—a mannikin and a few lecture rooms constituting the entire “plant” of the infant institution. It would not do to question the Mean too curiously about the clinical facilities which the school enjoyed; and as for laboratory work there were few teachers sufficiently advanced in their ideas to think of criticising the absence of such instruc- tion. There was, indeed, no time for it. Every avail- able space in the tabular view was filled with lecture hours. Professors were asked to come from neigh- boring towns to assist in teaching, and often gave two lectures in the same day. This cramming pro- cess, which seems so peculiarly American in its hus- tling activity, is perpetuated to the present day in a limited number of schools, chiefly those situated far from medical centers. As Oliver Wendell Holmes has said, life at that time was cheap; medical visits in the country were worth only twenty-five cents apiece, and the ambitious student could not afford to make an expensive outlay for his future work. The American Medical Association therefore justly put on record its opinion, “that the abuses which ex- ist in the modes of medical education pursued in this country demand the serious consideration of the pro- fession.” and at each meeting it continued to sound a note of warning on this all-important subject. 9 One of the principal reforms which it proposed to bring about was the lengthening of the term of each year from four to six months, and you will doubtless be somewhat surprised to hear that at the second meeting of the Association, which was held in Bos- ton, a paper was presented from the faculty of Har- vard University opposing this proposition. Tempora mutantur et nos mutamur in illis. If Harvard was unwilling to lead in the matter of reform at that time, it is not surprising that the other schools should not have been persuaded to change their customs. To the Chicago Medical Col- lege—which was founded in 1859—must be given the credit of having been the first to attempt to lengthen the college course and to establish the sys- tem of teaching upon the so-called graded plan.4 The school was in fact organized for this express pur- pose. Little change was, however, effected by the Asso- ciation in the methods of teaching at that time, al- though the discussions which were constantly held were destined eventually to bring forth good fruit. During the following decade little was done in the way of reform. Graduating from the academic department of Har- vard in 1863, I had an opportunity to study person- ally the methods in vogue at that time and am the more competent to express an opinion as I passed one year of my course of study in Philadelphia. The old system of medical education was then in all its glory and presented a striking contrast to one who had been subjected for four years to the strict disci- pline of a well conducted university. The course of lectures in Philadelphia began about the first of November, and the day was occupied in a bewildering succession of lectures, on all of which the student felt called upon to attend, as he had been obliged to “take out tickets” for the full course. The teachers were able, conscientious, and in many cases brilliant men, and many a lesson then learned has been of value in after life. Clinical teaching was, IN. S. Davis. Contributions to the History of Med. Ed., etc., 1877. 10 however,largely crowded aside by the superabundance of systematic lectures. The course came to an end on the first of March, and the class—which was an enormous one—was allowed to scatter to the four quarters of the country. Many of my classmates re- turned the following autumn, and after attendance on a second course of lectures and having also handed in the certificate of study from the “respectable practitioner” were able to graduate in the following March ; that is, after having been connected with the school less than eighteen months. This may appear to the younger members of this Section an absurdly short curriculum, but there were a considerable num- ber of enterprising young men who did not propose to occupy so long a. time in obtaining their educa- tion. You will remember what has already been said about the period of the year occupied by the school term. At that time there were not only schools who had their college “year” in the winter, but there were spring “years” and summer “years” as well. Several of my friends proposed accordingly, after leaving Philadelphia in March to take a spring “year” at another school, in accordance with a custom which many at that time followed. Such a student was therefore able on July Ist to show to the examining body, tickets for two full courses of lectures and a letter testifying to private instruction. It was no- torious that many students at that time were able to obtain a degree after nine months only of medical study. The custom of short courses of study at dif- ferent periods of the year unfortunately still pre- vails. This zodiacal paradox has not yet been fully eliminated from the medical calendar. The condi- tion of teaching at Harvard was practically the same as at Philadelphia, It is not surprising that the best class of students were dissatisfied with the opportunities, and that the number of those who found it necessary to go to Eu- rope to complete their education was constantly in- creasing. Two and even three years of study was not considered too long a time to occupy in this manner. 11 It is true that spring terms of a supplementary na- ture were organized by most schools, and those stu- dents who chose to remain could receive instruction throughout the year. The majority of students, how- ever, disappeared, many of them employing their time in other occupations to earn sufficient money to pay for a second course of lectures. The class of individuals who studied medicine at that time seemed far inferior to the medical student of to-day in cul- ture and refinement. President Eliot says of the medical students of that period : ‘Tn this university, until the reformation of the school in 1870-71, the medical students were noticeably inferior in bearing, manners and discipline to the students of the other departments; they are now (1888) indistinguishable from other students.” The date which I have just mentioned marks the era of a great change in the history of medical edu- cation. The rising generation of teachers were not content with the antiquated methods of a previous century; they had learned of a new order of things in the centers of medical learning in Europe. As the old generation of teachers went out and a new one came in, the modern ways of teaching grew into a substantial system which had come to stay. Harvard adopted the graded course of three years’ study, but she did also far more than that—and in this respect she stands in advance of almost every other school in the country—she lengthened her course to nine months, so that her two terms corre- spond with those of the other departments of the university and represent a full year’s work. I will not undertake to record the history of the reform in medical education since that time; it is familiar to most of you. The example which has been set to the rest of the country by the University of Pennsylvania and by the College of Physicians and Surgeons of New York is too well known for me to repeat them here. While criticising, as I have done, the work of a previous generation, I ought to remind you that our forefathers accomplished what they did only by 12 individual efforts. There were no governments, and as a rule no liberal benefactors to back them in their undertakings. Their schools had to be conducted on business principles, with a keen eye to the prac- tical success of their venture. During the past twenty years, it is true, a number of State universi- ties have been established. In the University of Michigan, and possibly in one or two other State universities, the medical professorships like those of other departments, are sustained by the income from the general endowment, independent of fees derived from medical students; but, as a rule, the success of the school has depended upon the patron- age which it has received. It may be justly said, therefore, that the whole system of medical educa- tion in this country is the spontaneous outgrowth of the work of the medical profession, and that it is due to their public spirit and disinterestedness that so important a department in the educational devel- opment of a great nation has been brought to its present state of excellence. The good work has, however, but just begun. The reform of medical education is still in its infancy. If we are to believe all the glowing announcements which we read in the annual catalogues of the vari- ous schools, we might be lulled into a sense of calm security for the future; but, unfortunately, the actual practice of many, I might say a majority, of the schools does not come up to the ideals which are here set forth. The essential points in the new scheme of educa- tion have been well stated by our President, Dr. Pepper ;5 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. 4. The introduction of ample clinical and labora- tory instruction. 5. The establishment of fixed salaries for the teachers. 5 Introductory Address, Philadelphia, 1877. 13 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 edu- cational qualifications 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 graduated students at the end of the second course of lectures the present year is less than 10 per cent, of the whole number of schools in the country. There are now in the United States thirty-two ex- amining 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 examina- tion 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 influ- ences of these bodies. The reports on medical edu- cation by the Illinois board, I do not hesitate to say, have exerted a more powerful influence on the move- ment in education than any other publication which our medical literature has produced. The effects of these Medical Practice acts which establish a minimum of time spent at medical lec- tures 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 examinations are required in Minnesota, North 14 Dakota, Montana, Washington, North Carolina, Ala- bama, Florida, Virginia, New Jersey, New York, Nebraska, Maryland and Utah.6 Millard, who has had experience in framing the act of Minnesota, believes that it would be an im- provement upon the Medical Practice acts at present in existence, to separate the two functions of the board, the licensing power and the educational supervision. He thinks that the best interests of the public will be observed by assigning the duties of the State licens- ing 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 regulate all educational institutions granting degrees, together with the power of granting charters and revoking the same; par- ticularly should this apply to all institutions wish- ing to afford the community any of the various forms of higher or special education. Having thus sketched the progress of medical edu- cation 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 im- portance 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 sci- ences 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 6 Millard. “ The Necessity and Best Methods of Regulating the Prac- tice of Medicine,” Journal Amer. Med. Ass’n., July 30,1892. 15 ■clergyman form the nucleus of culture in the community; they are, especially in the country or small towns, the rep- resentatives 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 suppres- sion 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 in- tegral parts of the university, and entrance to the professional schools depends upon the previous com- pletion of the course in philosophy, a course which •corresponds to that of our academic degree. In Dr. Holmes’ suggestive article7 on this subject it is shown that while the increase in the total number -of medical students has been very great during the last decade, the increase in the number of “ college men ” who have entered the profession has been very slight, and in some of the more prominent schools the percentage has even slightly diminished. The author says : “It can not then be doubted that rel- atively a smaller number of medical students have a bachelor’s degree than in 1880, though the educa- tion of the average medical student is superior to the average medical student ten years ago.” Al- though the proportion of medical students to stu- dents 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 during which medicine has become more of a science and the domain of surgery has increased under antiseptic methods, the proportion of medical students to the students of other profes- sions has greatly increased. The reason for this variation in the proportion of students in the two 7 “ xhe Forthcoming Report of the Bureau of Education on Profes- sional Education in the United States,” Jour. Amer. Med. Ass’n., Janu- ary 14,1893. 16 countries is explained by the imperfection of our system of education. Educators have not had proper control and medicine has not been placed upon that dignified scientific basis which it enjoys in Germany. Dr. Holmes complains that the medical department is neglected by every university in the United States. “It is farmed out or left to shift for itself.” Harvard has recently made an attempt to overcome the difficulty by a modification of the academic course. As Welch points out in an article on this subject:8 If a young man choose the medical pro- fession he should devote at least four years to medi- cal studies, including the preliminary sciences. If he supplements this with a year in a hospital and a year or two in study abroad, and all this work has been preceded 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,9 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 ris- ing 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 beginning 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 pro- fessional 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 physician is ready to begin practice before he is 23|- years old. The average age of matriculants at Oxford is 19 years, and it is perfectly possible for an Oxford stu- dent desiring to study medicine to begin his purely professional studies before the end of his second year 8 Some of the advantages of the union of Medical School and Univer- sity. 1888. 9 Remarks made at a meeting of the Academic Council, 1887. 17 of college life. The dean writes me upon this sub- ject as follows: “There are many students in our school who have had one or two years of college life either as special or regular stu- dents, 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.” It seemed, therefore, reasonable to the medical faculty of Harvard to make the following proposi- tion, namely, that the academic council should con- sider the expediency of granting the degree of A.B. to all undergraduates who should subsequently take the longest course of study offered at the professional school after three years’ attendance in the academic department—the professional degree and that of A.B. to be given simultaneously at the end of the profes- sional course. One of the medical studies at least can be obtained in the usual college curriculum, and general chemistry is frequently “anticipated” by stu- dents who enter the medical school. It is hoped, indeed, that this course will soon become one of the “preliminary studies” to medicine. It would be a short step to place one or two more of the scientific medical studies on the list of academic electives, and a whole year could be thus anticipated. The relations of professional schools to the university are not appreciated in the same light that they are in Germany, and the proposition of the medical fac- ulty after much discussion was finally declined. The advantages of a more intimate relation between the medical school and the university are clearly set forth by Welch in the article referred to. The duplication of laboratories is thus avoided, and men of different branches of sciences are brought more intimately together. The important departments of botany, zoology, and comparative anatomy cannot fail to have an elevating influence upon the work done in a medical school. How much more rapidly might not original investigation progress when dif- ferent branches of science work in a common cause. 18 It is here that the great strength of German science- and progress takes its origin. A movement in the same direction is the estab- lishment 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, com- parative anatomy, geology, comparative osteology,, physics, qualitative analysis and themes. It is certainly to be hoped that the medical teach- ers of the United States will not remain content with the very elementary examinations which are now demanded for those students who have not received a college education. The advantage of a previous college training is shown in some statistics given by Billings10 of ex- aminations conducted by the examining boards of the army and navy. Of those candidates who had a college degree 34 per cent, were successful, and of those who had no such degree 28.9 per cent, suc- ceeded. 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, suc- ceeded, 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 education 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 attached to this means of teaching io ideals of Medical Education. 1891. 19 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 received a munificent endowment for its department of hy- giene. The literature of this part of our educational 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, re- spectively, 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 ad- mission. 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 stu- dent 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 comes in the first year. This is a time when the student has more time for laboratory work, and it paves the way for special work in the study of these organisms in con- nection with pathology, which is placed in the second year. I shall leave a more detailed statement to Prof. Ernst, who will have something to say upon this subject later. Bacteriology needs no special plea to-day. It cannot even be regarded as a purely 20 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 dis- ease without a practical knowledge of the demon- stration of certain forms of bacteria, and there is certainly no better school for aseptic surgery than the bacteriological laboratory. The study of pathology at the Harvard Medical School11 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 of material obtained from the hospitals 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 speci- men demonstrated to him. In the course on patho- logical 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 stu- dents who have done well in their studies, and oppor- tunity is given them for special study or original in- vestigation. 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 begin- ning of their second year and is confined to a de- tailed study and drill in the practical part of such 11 Bulletin of tlie Harvard Medical School Association. No. 4. 21 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 bandages. In this way every member of the class learns thor- oughly 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 school became a custom which has continued almost unimpaired to the present day. 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 essen- tial to a medical school.” Would that all teachers of that time had realized sufficiently that fact and had educated the public to recognize the necessity of such a close relation of the two. Many of the older members of this congress can remember the old-fashioned prejudice which resented the intrusion of students into the hospital wards. The theory of the trustee of that time was; This money was given for the cure of patients and not for the education of physicians. They could not be persuaded that the two interests were identical. The change of feeling in more enlightened times was indicated by the benefactor of the great Johns Hopkins hospital. At the opening of that hospital in 1889 Dr. Billings showed the advantage of such a union in the following words: “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 attention 22 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 investiga- tion, and hence it is that those cases which are lectured on receive the best treatment. 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 relation 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.’ ” The reaction in favor of clinical teaching is becom- ing daily stronger, and no school can hope to com- pete with the great schools of the country which does not have control of what is usually called “clin- ical facilities.” This term must unfortunately still be used; for the number of schools which have a hospital of their own is yet exceedingly small. The union between the two is in most of our large cities becoming a more and more intimate one. Another immense advantage which the possession of a hospital gives to a faculty is the control of appointments. Most schools are now obliged to select their teachers from members of the staffs of hospitals in their city who have services at times of the year which enable them to teach. These indi- viduals are appointed by laymen who have no knowl- edge of or regard for the necessities of medical edu- cation. Faculties thus placed are unable to select teachers of national reputation, as there is no ap- pointing powxr which enables them to give such a person the material with which to teach. But, while applauding the movement in favor of clinical teaching it is perhaps well at the present time to consider whether systematic or, as it is usu- ally inaccurately called, “didactic” teaching should be abandoned. The discussion as carried on in med- ical journals, appears to lean in this direction. A course of systematic lectures enables the teacher to cover ground which he would be unable to do, even in a clinic most richly endowed with material. The method of handling the subject differs entirely from that adopted at the bedside, and in a well regulated four years’ course I believe the systematic lecture should still retain a prominent place.’ Clinical in- struction should be abundant and of the most varied kind. Instruction of the class in small sections is a most desirable feature of this department. It in- volves a greater expenditure of time, an increase in the teaching staff and great ability as an organ- izer in the head of the department. It is the squad drill, however, which brings the student in most in- timate contact with disease. 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 conspicu- ous by its absence. I refer to endowments ; the val- uable paper of Dr. Bayard Holmes already referred to gives 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 uni- versities 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 $4,047,618, and the theological schools were accom- modated with buildings and grounds valued at $7,762,095. The medical schools had in 1889, 12,238 students who paid tuitions to the amount of $763,761, while at the same time the theological schools enrolled 6,989 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 schooHpoSsessed buildings and grounds in 1892 valued at $7,507,937, and pro- ductive funds amounting to $611,214. Medical departments of State universities also received State aid in 1892 amount- ing to $40,500, which, if capitalized at 5 per cent., would be equal to an endowment of $810,000; making a total endow- ment of $1,421,214. There were 16,731 medical students in attendance. The theological schools report productive funds amount- ing to $17,599,979, and stated, at the same time, the value of their buildings and grounds was $10,720,860. They had 7,- 672 students in attendance. Technological schools report productive funds amounting to $13,229,940. These institutions received from State ap- propriations or municipal aid in 1891-92, $747,504, which, if 24 capitalized at 5 per cent., would be equivalent to an endow- ment 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 endowment 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.” Probably the available funds possessed by our medical schools are somewhat larger than these sta- tistics show, but they give the proportions which are needed to impress upon us how little financial en- couragement 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 lis- tened to. He does not build railroads or organize society in new lands, but he is in the foremost rank of pioneers, with the complete equipment 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 be- gin 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 teach- ing to realize this, but it can not develop beyond a certain point until it has established its own inde- pendence. I cannot help believing that in this direc- tion lies one of the greatest avenues of development of our system of medical education in the future.