REVIEW OF PROGRESS IN MEDICAL EDUCATION.*

IN his recent report the Commissioner of Education, the Hon. JOHN EATON, takes occasion to say that, in view of the overcrowded state of the medical profession, the time has now come when the medical student pays to the medical college money for which he receives no calculable equivalent. He asks for bread and receives a stone. The really capable graduate is jostled, crowded, shouted down and trampled upon by a horde of unwieldy behemoths, who not only intercept most of the work that he only is able to do satisfactorily, but who supplement their scant incomes by arts and devices that his nature and training forbid him to join in. Having overcrowded all other departments of medical employment, many of these physicians, by the grace of a diploma, have lately taken up the work of opening and conducting medical colleges, much to the wrath and confusion of the older schools, who would dearly like to retain their monopoly of oversupplying the market with medical "spring chickens."

INADEQUATE REQUIREMENTS FOR PRACTICING MEDICINE.

The position assumed by these older schools is exquisitely illogical; they do not like to establish effectual entrance examinations (which might force some candidates to defer the study of anatomy and chemistry until they had mastered the simpler mysteries of reading and writing) because they do not want to limit the number of doctors by artificial regulations." This phrase, quoted from a recent address by a widely known and much respected medical teacher and author, teaches us that "artificial regulations" mean. all rules or usages that may or can hinder any young white man from paying money twice over for the privilege of hearing the same course of lectures during two courses of instruction. The "regulations that forbid the faculty from receiving the money of a white woman or that of a black man, we learn by inference, are not "artificial."

This same medical professor and author says that "the law of supply and demand will properly control the professional expansion." Assuming that this is true, let the same rule be applied to the schools that supply the human integers of "the professional expansion" the establishments that do not try "to limit the number of doctors" by long, complicated, and difficult courses of study obviously should become the most frequented and best attended, because the law of prompt and cheap supply is as much an axiom as the one quoted by the learned professor and author. When, however, "the law of supply and demand" is thus supplied, the professor expresses his disapproval of the result in the following words:

Many of the new colleges which have sprung up so abundantly over the country have really no right to exist. They are unprovided with the materials for teaching, and the fees are insufficient to procure them; they have no hospitals or dispensaries to which they can resort for clinical instruction; the faculties are without reputation or experience; the building in which the college has its habitat is some temporary structure little suited to the purpose. The lectures are mere recitals of text books, which the student could better read for himself. *

* See pp. CLXV-CLXXIX, Report of the Commissioner of Education for the Year 1882-83. Washington: 1884.

These medical schools get into such desperate pecuniary straits that they must employ every possible expedient to obtain students. One hears of personal solicitations, of promises, of sending out drammers to intercept students on the trains and at hotels, of practices in short which seem to touch at the lowest point of degradation. The "advantages of these institutions, besides their proximity to the homes of students, are the Such institutions low fees, or no fees a all, how high soever the nominal price, and the certainty that a diploma may be obtained on a minimum of attendance on lectures. are, indeed, little more than "diploma mills." These medical shops hurt our position before the public immensely. They unite with the reputable medical schools to form a national association of medical colleges. After a time they put on a severely virtuous air, and are disposed to snub newer colleges organizing in their vicinity, stigmatizing them as unnecessary, crude, and inferior. Having thus acquired a quasi-position and assuming a tone of lofty pretension, they carry on a traffic in medical diplomas the profits of which enable them to maintain a baleful existence. The most beneficent reform which can now be undertaken is to close the doors of these institutions engaged in flooding the country with unqualified doctors.*

Denunciations like the foregoing are of little value, for they accomplish nothing. When analyzed dispassionately they are reduced. to complaints that newer competitors are underselling "the old and well known stands." Of course the customers at the cheaper shops will get an article of inferior quality; that also is a "law" of trade. Even if the respected professor could have his wish and he could "close the doors of these institutions engaged in flooding the country with unqualified doctors," the evil, so injurious to the profession. at large and to the guild of higher-priced medical colleges in particular, would not be corrected. If the cheaper schools are closed their clients "will enter some diploma shop and secure such training as its meagre resources afford," together with the coveted diploma. In this direction there is no hope of relief. Gazing on the prospect before him, the professor can well adopt Satan's melancholy words:

In the lowest deep, a lower deep,

Still threatening to devour me, opens wide.

Some medical schools and many medical educators have chosen a much better expedient: they have adopted a preliminary exami nation to test the would-be medical student's general intelligence and knowledge. Commissioner EATON is sorry to say that in several cases this preliminary test is a "humbug," but in most of the colleges that have adopted the expedient it has been applied in good faith. Into these schools a person styling himself in writing "a Nachural Practishuner't can no longer enter for the purpose of being crammed with medical lore. There is little doubt that, either by general consent or the passing of State laws, it will not be many before an entrance examination will be required of all persons years desiring a medical training.

Another antiquated and obsolescent practice in American medical education is also doomed to an early death, to-wit: the practice of requiring less than the usual exertion in order to obtain a diploma. from the man who, without previous lecture-courses, has dared to trifle with the lives and health of his fellow creatures during some "years of reputable practice," so called. Formerly it was quite common to offer a man of this kind a degree at the end of one course of lectures, while young men whose records and consciences were entirely clear of professional manslaughter were obliged to pay for two courses, exactly like each other in subject, length, and cost.

*See the Maryland Medical Journal, vol. VIII, pp. 505-512. Also pp. 39, 60 and 61, Abstract of Pro†See the Boston Advertiser of July 1, 1882. ceedings, Sixth Annual Report, ILLINOIS STATE BOARD OF HEALTH.

This practice of selling the same article twice is also falling into deserved disrepute, although still followed and defended by many flourishing medical schools and "demanded" by the large body of young men who always want to become physicians in the easiest way that is considered respectable. These clients crowd the amphitheatres of the schools alluded to, well knowing that. if public sentiment were once thoroughly informed as to their unwritten bargain with the schools they attend, such haste and imperfect preparation for their solemn responsibilities would not long be tolerated in a civilized community. Does this language seem harsh and ill-natured? Let us relieve its effect by quoting the following wise and witty remarks of Surgeon John S. Billings, U. S. A., at a recent medical college commencement:

Being unable, as I have just explained, to remember what was said to me by way of valedictory, and never having been present at a similar ceremony from that day to this, I thought it would be prudent to consult the literature of the subject and find out what is usually said upon such occasions. For this purpose I have examined about a hundred valedictory addresses, and have obtained from them a vast amount of instruction and some little amusement. From them I gather that this is an epoch in your lives, that you are entering & remarkable age of the world's history (it is customsry here to allude to steam and electricity), that you live in the most wonderful country under the sun, and that the eyes of the world are upon you. All are agreed upon these points, and also as to the importance and dignity of the science and art of medicine and the necessity of continued study on your part to keep pace with its advances. But the addresses are not equally harmonious on all points. Some of them assert that the condition of medical education in this country is not altogether satisfactory; that there are some medical colleges (not, of course, the college of the graduates, but some other medical college) which might be spared; that there are too many doctors now and more coming, and that some of these not only have not as clear ideas about the precession of the equinoxes or the authorship of the book of Job as a member of one of the learned professions should have, but that there are even graduates in medicine (of other schools of course) to whom the addition of vulgar fractions is a stumbling block and correct spelling a vexation of spirit. On the other hand, I find some who assert, first, that the above statements are unfounded; second, that it is not necessary to know how to spell correctly in order to cure the chills or set a broken leg; and, third, that the demand for higher medical education is essentially a pernicious, aristocratic movement, calculated to oppress the poor and prevent them from obtaining the sheepskins so desirable to cover their nakedness. As, however. I am sure that all of you are just now strongly in favor of higher medical education (without regard to what you may have thought about it a few weeks ago, or what you may think about it a few years hence, when you get a little steam-hatching machine of your own), I feel that I shall most contribute to the harmony which this occasion demands by- entirely agreeing with you.*

NEED OF IMPROVED STANDARDS IN MEDICAL INSTRUCTION.

The more thoughtful and less self-seeking members of the medical profession unite with Dr. Billings in his desire for a higher and better medical training than has hitherto been common in America. The venerable American Medical Association has, almost since its foundation, tried to produce a better condition of sentiment on this. subject in the profession, and learned committees of its members have reported at different times important recommendations. General EATON's first annual report, fourteen years ago, contained an article on medical education as it was and as its writer, Charles Warren, M. D., thought it should be. Some of the recommendations in that paper have been almost literally carried out by the recent reforms instituted; others, which the Commissioner believes to be as useful and indispensable to both public and professional well-being, are not accomplished yet, but soon may be. The special form that reformed medical education should assume was pointed out in that article and it was recommended that the lecture courses be graded and extended through three years, preceded by an entrance examination and terminated by an examination conducted under the

*The Medical News, March 18, 1883.

auspices of the State. When that article was published only two medical colleges in the country provided a graded course of lectures occupying three winter sessions, the Chicago Medical College and the Woman's Medical College of the New York Infirmary. Now, although the Chicago school has not yet made such a course compulsory, many others have done so under the leadership of the medical departments of Harvard University and of the University of Pennsylvania.

Harvard, for 1871-72, announced an extended and graded course of instruction. The University of Pennsylvania, laboring beside a formidable and vigorous rival school, was obliged to proceed more slowly a university hospital was opened in 1874; three professors of the medical faculty and three lecturers appointed by that faculty, together with five professors appointed by the trustees, became the teaching staff of the hospital. April 4, 1876, four of the hospital teaching corps became permanent members of the medical faculty in the university. In 1877-78 a compulsory graded course of instruction comprised three lecture-courses, each five months long. Early in 1878 a generous woman endowed the university chair of surgery with a gift of $50,000, and a like endowment of the other chairs in the medical faculty is progressing, so that in time the pay of the faculty will not depend on the size of the attending class or the number graduated. The entrance examination, still of a rudimentary character, was instituted in 1881. The lecture-term was lengthened from five to six months in 1882, and a further prolonging to seven months is announced for the session of 1883-84. Moreover, a fourth year of more advanced study, recommended and advised, but not as yet required, has been arranged to begin at the same time. The graded scheme has thus been tried for six annual sessions, at which the attendance of students has varied from 378 to 363, with an average of 367.5 per session. The graduates from 1878 to 1883, six years, have been 670, an average of 111.66 annually. For the six years before the adoption of the graded course the annual attendance was 388.33, and the average number of graduates was 108.33. Thus, while the university has substantially preserved its attendance, the quality, character and attainments of the students have improved immensely. The longer time, more thorough teaching, harder work and greater expense have attracted a better class of men, while frightening the superficial, the lazy, the badly prepared and the crammers." The advance in general intelligence and education is very manifest, and the proportion of students possessing literary and scientific diplomas has doubled in six years.

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Harvard, as already said, adopted an excellent scheme of three lecture-courses properly graded in 1871, and candidates for degrees. were required to spend at least the last entire year under its instruction, besides passing the oral and written examinations in the studies of the two previous years. Of late, like the University of Pennsylvania, a graded course of four years has been provided and is strongly recommended by the faculty, though it is not yet obligatory. Men graduating in three years at Harvard receive the degree of M. D.; those who study the fourth year and pass the examination with credit receive the degree cum laude, and, on proper application to the university authorities, may also receive the degree of