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Full text of "Medical education in the United States and Canada; a report to the Carnegie Foundation for the Advancement of Teaching"

MEDICAL EDUCATION 

IN THE 
UNITED STATES AND CANADA// 

A REPORT TO 

(THE CARNEGIE FOUNDATION 
FOR THE ADVANCEMENT OF TEACHING. 8cA-W- "* 



ABRAHAM FLEXNER 



WITH AN INTRODUCTION BY 

HENRY S. PRITCHETT 

PRESIDENT OF THE FOUNDATION 



BULLETIN NUMBER FOUR 



576 FIFTH AVENUE 
NEW YORK CITY 



COPYRIGHT 1910 

BY 

THE CARNEGIE FOUNDATION 
FOR THE ADVANCEMENT OF TEACHING 



D. B. UPDIKE, THE MERRYMOUNT PRESS, BOSTON 



Library 



TABLE OF CONTENTS 

PAGE 

Introduction . vii 



PART I 

CHAPTER 

I. Historical and General 8 

II. The Proper Basis of Medical Education .20 

III. The Actual Basis of Medical Education 28 

IV. The Course of Study : The Laboratory Branches. (A) First and Second 

Years 52 

V. The Course of Study: The Laboratory Branches. (B) First and Second 

Years (continued) ......... 71 

VI. The Course of Study : The Hospital and the Medical School. (A) Third 

and Fourth Years 91 

VH. The Course of Study : The Hospital and the Medical School. (B) Third 

and Fourth Years (continued) . . . . . . 105 

VIII. The Financial Aspects of Medical Education 126 

IX. Reconstruction . . . 143 

X. Medical Sects . . 156 

XL The State Boards . . 167 

XII. The Postgraduate School . . 174 

XIII. The Medical Education of Women 178 

XIV. The Medical Education of the Negro ' 180 

PART II 
The Medical Schools of 

Alabama 185 

Arkansas ............ 187 

California 188 

Colorado 197 

Connecticut 199 

District of Columbia 201 



iv CONTENTS 

Georgia 203 

Illinois 207 

Indiana 220 

Iowa ............. 222 

Kansas . . . . . .. . . . . . 225 

Kentucky 229 

Louisiana 231 

Maine 233 

Maryland . 234 

Massachusetts 239 

Michigan 243 

Minnesota 247 

Mississippi 249 

Missouri ............ 251 

Nebraska 259 

New England 261 

New Hampshire 263 

New York 265 

North Carolina 279 

North Dakota 282 

Ohio 283 

Oklahoma 289 

Oregon 291 

Pennsylvania 293 

South Carolina 300 

South Dakota 301 

Tennessee 302 

Texas 309 

Utah 313 

Vermont 313 

Virginia 314 



CONTENTS v 

West Virginia 317 

Wisconsin 317 

Canada 320 

APPENDIX 

Table showing number in Faculty, Enrolment, Fee Income, Budget of Schools 

by States 327 



INDEX 337 



INTRODUCTION 

THE present report on medical education forms the first of a series of papers on pro- 
fessional schools to be issued by the Carnegie Foundation. The preparation of these 
papers has grown naturally out of the situation with which the trustees of the Founda- 
tion were confronted when they took up the trust committed to them. 

When the work of the Foundation began five years ago the trustees found them- 
selves intrusted with an endowment to be expended for the benefit of teachers in 
the colleges and universities of the United States, Canada, and Newfoundland. It 
required but the briefest examination to show that amongst the thousand institu- 
tions in English-speaking North America which bore the name college or university 
there was little unity of purpose or of standards. A large majority of all the insti- 
tutions in the United States bearing the name college were really concerned with 
secondary education. 

Under these conditions the trustees felt themselves compelled to begin a critical 
study of the work of the college and of the university in different parts of this wide 
area, and to commend to colleges and universities the adoption of such standards as 
would intelligently relate the college to the secondary school and to the university. 
While the Foundation has carefully refrained from attempting to become a stan- 
dardizing agency, its influence has been thrown in the direction of a differentiation 
between the secondary school and the college, and between the college and the uni- 
versity. It is indeed only one of a number of agencies, including the stronger colleges 
and universities, seeking to bring about in American education some fair conception 
of unity and the attainment ultimately of a system of schools intelligently related 
to each other and to the ambitions and needs of a democracy. 

At the beginning, the Foundation naturally turned its study to the college, as 
that part of our educational system most directly to be benefited by its endowment. 
Inevitably, however, the scrutiny of the college led to the consideration of the re- 
lations between the college or university and the professional schools which had 
gathered about it or were included in it. The confusion found here was quite as great as 
that which exists between the field of the college and that of the secondary school. Col- 1 
leges and universities were discovered to have all sorts of relations to their professional \ 
schools of law, of medicine, and of theology. In some cases these relations were of the 
frailest texture, constituting practically only a license from the college by which a 
proprietary p^ipal gffrnnl 9^ lavy school was enabled to live under its name. In other 
cases the medical school was incorporated into the college or university, but remained 
an imperium in imperio, the college assuming no responsibility for its standards or 
its support. In yet other cases the college or university assumed partial obligation of 
support, but no responsibility for the standards of the professional school, while in 
only a relatively small number of cases was the school of law or of medicine an in- 
tegral part of the university, receiving from it university standards and adequate 



viii INTRODUCTION 

maintenance. For the past two decades there has been a marked tendency to set up 
some connection between universities and detached medical schools, but under the 
very loose construction just referred to. 

Meanwhile the requirements of medical education have enormously increased. The 
fundamental sciences upon which medicine depends have been greatly extended. 
The laboratory has come to furnish alike to the physician and to the surgeon a new 
means for diagnosing and combating disease. The education of the medical practi- 
tioner under these changed conditions makes entirely different demands in respect to 
both preliminary and professional training. 

Under these conditions and in the face of the advancing standards of the best 
medical schools it was clear that the time had come when the relation of professional 
education in medicine to the general system of education should be clearly defined. 
The first step towards such a clear understanding was to ascertain the facts concern- 
ing medical education and the medical schools themselves at the present time. In ac- 
cordance, therefore, with the recommendation of the president and the executive com- 
mittee, the trustees of the Carnegie Foundation at their meeting in November, 1908, 
authorized a study and report upon the schools of medicine and law in the United 
States and appropriated the money necessary for this undertaking. The present report 
upon medical education, prepared, under the direction of the Foundation, by Mr. 
Abraham Flexner, is the first result of that action. 

No effort has been spared to procure accurate and detailed information as to the 
facilities, resources, and methods of instruction of the medical schools. They have 
not only been separately visited, but every statement made in regard to each detail 
has been carefully checked with the data in possession of the American Medical Asso- 
ciation, likewise obtained by personal inspection, and with the records of the Asso- 
ciation of American Medical Colleges, so far as its membership extends. The details 
as stated go forth with the sanction of at least two, and frequently more, independent 
observers. 

In making this study the schools of all medical sects have been included. It is clear 
that so long as a man is to practise medicine, the public is equally concerned in his 
right preparation for that profession, whatever he call himself, allopath, homeo- 
path, eclectic, osteopath, or whatnot. It is equally clear that he should be grounded 
in the fundamental sciences upon which medicine rests, whether he practises under 
one name or under another. 

It will be readily understood that the labor involved in visiting 150 such schools 
is great, and that in the immense number of details dealt with it is altogether im- 
possible to be sure that every minute fact concerning these institutions has been 
ascertained and set down. While the Foundation cannot hope to obtain in so great 
an undertaking absolute completeness in every particular, such care has been exer- 
cised, and the work has been so thoroughly reviewed by independent authorities, 
that the statements which are given here may be confidently accepted as setting 



INTRODUCTION ix 

forth the essential facts respecting medical education and respecting the institutions 
which deal with it. 

In this connection it is perhaps desirable to add one further word. Educational 
institutions, particularly those which are connected with a college or a university, 
are peculiarly sensitive to outside criticism, and particularly to any statement of 
the circumstances of their own conduct or equipment which seems to them unfavor- 
able in comparison with that of other institutions. As a rule, the only knowledge 
which the public has concerning an institution of learning is derived from the state- 
ments given out by the institution itself, information which, even under the best cir- 
cumstances, is colored by local hopes, ambitions, and points of view. A considerable 
number of colleges and universities take the unfortunate position that they are private 
institutions and that the public is entitled to only such knowledge of their operations 
as they choose to communicate. In the case of many medical schools the aversion to 
publicity is quite as marked as it is reputed to be in the case of certain large indus- 
trial trusts. A few institutions questioned the right of any outside agency to collect and 
publish the facts concerning their medical schools. The Foundation was called upon to 
answer the question : Shall such an agency as the Foundation, dedicated to the bet- 
terment of American education, make public the facts concerning the medical schools 
of the United States and Canada? 

The attitude of the Foundation is that all colleges and universities, whether sup- 
ported by taxation or by private endowment, are in truth public service corporations, 
and that the public is entitled to know the facts concerning their administration and 
development, whether those facts pertain to the financial or to the educational side. 
We believe, therefore, that in seeking to present an accurate and fair statement of 
the work and the facilities of the medical schools of this country, we are serving the 
best possible purpose which such an agency as the Foundation can serve; and, further- 
more, that only by such publicity can the true interests of education and of the 
uni versities themselves be subserved. In such a reasonable publicity lies the hope 
for progress in medical education. 

I wish to add with pleasure that notwithstanding reluctance in some quarters to 
furnish information, the medical schools of the colleges and universities, as well 
as proprietary and independent medical schools, have generally accepted the view 
just stated and have seconded the work of the Foundation by offering to those who 
were engaged in this study every facility to learn their opportunities and resources; 
and I beg to express the thanks of the trustees of the Foundation to each of these 
institutions for the cooperation which it has given to a study which, in the very nature 
of the case, was to bear sharply in the way of criticism upon many of those called 
on for cooperation. 

The report which follows is divided into two parts. In the first half the history of 
medical education in this country and its present status are set forth. The story is 
there told of the gradual development of the commercial medical school, distinctly 



x INTRODUCTION 

an American product, of the mo4ern movement for the transfer of medical education 
to university surroundings, and of the effort to procure stricter scrutiny of those seek- 
ing to enter the profession. The present status of medical education is then fully 
described and a forecast of possible progress in the future is attempted. The second 
part of the report gives in detail a description of the schools in existence in each 
state of the Union and in each province of Canada. 

It is the purpose of the Foundation to proceed at once with a similar study of medi- 
cal education in Great Britain, Germany, and France, in order that those charged 
with the reconstruction of medical education in America may profit by the experi- 
ence of other countries. 

The striking and significant facts which are here brought out are of enormous con- 
sequence not only to the medical practitioner, but to every citizen of the United 
States and Canada; for it is a singular fact that the organization of medical educa- 
tion in this country has hitherto been such as not only to commercialize the process 
of education itself, but also to obscure in the minds of the public any discrimination 
between the well trained physician and the physician who has had no adequate train- 
ing whatsoever. As a rule, Americans, when they avail themselves of the services of 
a physician, make only the slightest inquiry as to what his previous training and 
preparation have been. One of the problems of the future is to educate the public 
itself to appreciate the fact that very seldom, under existing conditions, does a patient 
receive the best aid which it is possible to give him in the present state of medicine, 
and that this is due mainly to the fact that a vast army of men is admitted to the 
practice of medicine who are untrained in sciences fundamental to the profession and 
quite without a sufficient experience with disease. A right education of public opinion 
is one of the problems of future medical education. 

The significant facts revealed by this study are these: 

(1) For twenty-five years past there has been an enormous over-production of un- 
educated and ill trained medical practitioners. This has been in absolute disregard 
of the public welfare and without any serious thought of the interests of the public. 
Taking the United States as a whole, physicians are four or five times as numerous in 
proportion to population as in older countries like Germany. 

(2) Over-production of ill trained men is due in the main to the existence of a 
very large number of commercial schools, sustained in many cases by advertising 
methods through which a mass of unprepared youth is drawn out of industrial occu- 
pations into the study of medicine. 

(3) Until recently the conduct of a medical school was a profitable business, for 
the methods of instruction were mainly didactic. As the need for laboratories has be- 
come more keenly felt, the expenses of an efficient medical school have been greatly 
increased. The inadequacy of many of these schools may be judged from the fact that 
nearly half of all our medical schools have incomes below $10,000, and these incomes 
determine the quality of instruction that they can and do offer. 



INTRODUCTION xi 

Colleges and universities have in large measure failed in the past twenty-five years 
to appreciate the great advance in medical education and the increased cost of teach- 
ing it along modern lines. Many universities desirous of apparent educational com- 
pleteness have annexed medical schools without making themselves responsible either 
for the standards of the professional schools or for their support. 

(4) The existence of many of these unnecessary and inadequate medical schools has 
been defended by the argument that a poor medical school is justified in the interest 
of the poor boy. It is clear that the poor boy has no right to go into any profession 
for which he is not willing to obtain adequate preparation; but the facts set forth in 
this report make it evident that this argument is insincere, and that the excuse 
which has hitherto been put forward in the name of the poor boy is in reality an ar- 
gument in behalf of the poor medical school. 

(5) A hospital under complete educational control is as necessary to a medical school 
as is a laboratory of chemistry or pathology. High grade teaching within a hospital 
introduces a most wholesome and beneficial influence into its routine. Trustees of hos- 
pitals, public and private, should therefore go to the limit of their authority in open- 
ing hospital wards to teaching, provided only that the universities secure sufficient 
funds on their side to employ as teachers men who are devoted to clinical science. 

In view of these facts, progress for the future would seem to require a very much 
smaller number of medical schools, better equipped and better conducted than our 
schools now as a rule are; and the needs of the public would equally require that we 
have fewer physicians graduated each year, but that these should be better educated 
and better trained. With this idea accepted, it necessarily follows that the medical 
school will, if rightly conducted, articulate not only with the university, but with 
the general system of education. Just what form that articulation must take will 
vary in the immediate future in different parts of the country. Throughout the east- 
ern and central states the movement under which the medical school articulates with 
the second year of the college has already gained such impetus that it can be regarded 
as practically accepted. In the southern states for the present it would seem that 
articulation with the four-year high school would be a reasonable starting-point for 
the future. In time the development of secondary education in the south and the 
growth of the colleges will make it possible for southern medical schools to accept 
the two-year college basis of preparation. With reasonable prophecy the time is not 
far distant when, with fair respect for the interests of the public and the need for 
physicians, the articulation of the medical school with the university may be the 
same throughout the entire country. For in the future the college or the university 
which accepts a medical school must make itself responsible for university standards 
in the medical school and for adequate support for medical education. The day has 
gone by when any university can retain the respect of educated men, or when it can 
fulfil its duty to education, by retaining a low grade professional school for the sake 
of its own institutional completeness. 



xii INTRODUCTION 

If these fundamental principles can be made clear to the people of the United 
States and of Canada, and to those who govern the colleges and the universities, we 
may confidently expect that the next ten years will see a very much smaller number 
of medical schools in this country, but a greatly increased efficiency in medical edu- 
cation, and that during the same period medical education will become rightly articu- 
lated with, and rightly related to, the general educational system of the whole country. 

In the suggestions which are made in this report looking toward the future de- 
velopment of medicine, it ought to be pointed out that no visionary or impossible 
achievement is contemplated. It is not expected that a Johns Hopkins Medical School 
can be erected immediately in cities where public support of education has hitherto 
been meager. Nevertheless, it is quite true that there is a certain minimum of equip- 
ment and a minimum of educational requirement without which no attempt ought 
to be made to teach medicine. Hitherto not only proprietary medical schools, but 
colleges and universities, have paid scant attention to this fact. They have been ready 
to assume the responsibility of turning loose upon a helpless community men licensed 
to the practice of medicine without any serious thought as to whether they had re- 
ceived a fair training or not. To-day, under the methods pursued in modern medi- 
cine, we know with certainty that a medical school cannot be conducted without a 
certain minimum of expense and without a certain minimum of facilities. The insti- 
tution which attempts to conduct a school below this plane is clearly injuring, not 
helping, civilization. In the suggestions which are made in this report as to what 
constitutes a reasonable minimum no visionary ideal has been pursued, but only such 
things have been insisted upon as in the present light of our American civilization 
every community has a right to demand of its medical school, if medicine is to be 
taught at all. 

It seems desirable also in connection with both the medical school and the uni- 
versity or college to add one word further concerning the relation of financial sup- 
port to efficiency and sincerity. Where any criticism is attempted of inadequate 
methods or inadequate facilities, no reply is more common than this: "Our insti- 
tution cannot be judged from its financial support. It depends upon the enthusiasm 
and the devotion of its teachers and its supporters, and such devotion cannot be 
measured by financial standards. " 

Such an answer contains so fine a sentiment and so pregnant a truth that it often- 
times serves to turn aside the most just criticism. It is true that every college must 
ultimately depend upon the spirit and devotion of those who work in it, but behind 
this noble statement hides most of the insincerity, sham, and pretense not only of the 
American medical school, but of the American college. The answer quoted is com- 
monly made by the so-called university that, with an income insufficient to support 
a decent college, is trying to cover the whole field of university education. It is the 
same answer that one receives from the medical school which, with wholly inade- 
quate facilities, is turning out upon an innocent and long-suffering community men 



INTRODUCTION xiii 

who must get their medical education after they get out of the institution. In 
many of these ill manned and poorly equipped institutions there is to be found a 
large measure of devotion, but the fact remains that such devotion is usually ill 
placed, and the individual who gives it loses sight of the interests of education and 
of the general public in his desire to keep alive an institution without reason or 
right to exist. 

It will, however, be urged by weak schools that the fact that an institution is ill 
manned and poorly equipped is inconclusive; that in the time devoted to the ex- 
amination of a single school it is impossible to do it justice. Objection of this kind 
is apt to come from schools of two types, ineffective institutions in large cities, 
and schools attached to colleges in small towns in which clinical material is scarce. 
In my opinion the objection is without force. A trained observer of wide experience 
can go directly to the heart of a problem of this character. The spirit, ideals, and 
facilities of a professional or technical school can be quickly grasped. In every in- 
stance in which further inquiry has been made, the conclusions reached by the au- 
thor of the report have been sustained. 

The development which is here suggested for medical education is conditioned 
largely upon three factors: first, upon the creation of a public opinion which shall 
discriminate between the ill trained and the rightly trained physician, and which will 
also insist upon the enactment of such laws as will require all practitioners of medi- 
cine, whether they belong to one sect or another, to ground themselves in the funda- 
mentals upon which medical science rests ; secondly, upon the universities and their 
attitude towards medical standards and medical support; finally, upon the attitude 
of the members of the medical profession towards the standards of their own practice 
and upon their sense of honor with respect to their own profession. 

These last two factors are moral rather than educational. They call for an educa- 
tional patriotism on the part of the institutions of learning and a medical patriotism 
on the part of the physician. 

By educational patriotism I mean this : a university has a mission greater than the 
formation of a large student body or the attainment of institutional completeness, 
namely, the duty of loyalty to the standards of common honesty, of intellectual sin- 
cerity, of scientific accuracy. A university with educational patriotism will not take 
up the work of medical education unless it can discharge its duty by it; or if, 
in the days of ignorance once winked at, a university became entangled in a medi- 
cal school alliance, it will frankly and courageously deal with a situation which is 
no longer tenable. It will either demand of its medical school university ideals and 
give it university support, or else it will drop the effort to do what it can only do 
badly. 

By professional patriotism amongst medical men I mean that sort of regard for 
the honor of the profession and that sense of responsibility for its efficiency which 
will enable a member of that profession to rise above the consideration of personal 



xiv INTRODUCTION 

or of professional gain. As Bacon truly wrote, "Every man owes a duty to his pro- 
fession," and in no profession is this obligation more clear than in that of the mod- 
ern physician. Perhaps in no other of the great professions does one find greater dis- 
crepancies between the ideals of those who represent it. No members of the social 
order are more self-sacrificing than the true physicians and surgeons, and of this 
fine group none deserve so much of society as those who have taken upon their 
shoulders the burden of medical education. On the other hand, the profession has 
been diluted by the presence of a great number of men who have come from weak 
schools with low ideals both of education and of professional honor. If the medical 
education of our country is in the immediate future to go upon a plane of efficiency 
and of credit, those who represent the higher ideals of the medical profession must 
make a stand for that form of medical education which is calculated to advance the 
true interests of the whole people and to better the ideals of medicine itself. 

There is raised in the discussion of this question a far-reaching economic pro- 
blem to which society has as yet given little attention ; that is to say, What safeguards 
may society and the law throw about admission to a profession like that of law or 
of medicine in order that a sufficient number of men may be induced to enter it and 
yet the unfit and the undesirable may be excluded? 

It is evident that in a society constituted as are our modern states, the interests of 
the social order will be served best when the number of men entering a given pro- 
fession reaches and does not exceed a certain ratio. For example, in law and medi- 
cine one sees best in a small village the situation created by the over-production of 
inadequately trained men. In a town of two thousand people one will find in most 
of our states from five to eight physicians where two well trained men could do the 
work efficiently and make a competent livelihood. When, however, six or eight ill 
trained physicians undertake to gain a living in a town which can support only two, 
the whole plane of professional conduct is lowered in the struggle which ensues, each 
man becomes intent upon his own practice, public health and sanitation are neglected, 
and the ideals and standards of the profession tend to demoralization. 

A similar state of affairs comes from the presence of too large a number of ill 
trained lawyers in a community. When six or eight men seek to gain their living from 
the practice of the law in a community in which, at the most, two good lawyers 
could do all the work, the demoralization to society becomes acute. Not only is the 
process of the law unduly lengthened, but the temptation is great to create busi- 
ness. No small proportion of the American lack of respect for the law grows out of 
the presence of this large number of ill trained men seeking to gain a livelihood 
from the business which ought in the nature of the case to support only a much 
smaller number. It seems clear that as nations advance in civilization, they will be 
driven to throw around the admission to these great professions such safeguards as 
will limit the number of those who enter them to some reasonable estimate of the 
number who are actually needed. It goes without saying that no system of stan- 



INTRODUCTION xv 

dards of admission to a profession can exclude all the unfit or furnish a perfect 
body of practitioners, but a reasonable enforcement of such standards will at least 
relieve the body politic of a large part of the difficulty which comes from over- 
production, and will safeguard the right of society to the service of trained men in 
the great callings which touch so closely our physical and political life. 

The object of the Foundation in undertaking studies of this character is to serve 
a constructive purpose, not a critical one. Unless the information here brought to- 
gether leads to constructive work, it will fail of its purpose. The very disappearance 
of many existing schools is part of the reconstructive process. Indeed, in the course 
of preparing the report a number of results have already come about which are 
of the highest interest from the constructive point of view. Several colleges, finding 
themselves unable to carry on a medical school upon right lines, have, frankly facing 
the situation, discontinued their medical departments, the result being a real gain to 
medical education. Elsewhere, competing medical schools which were dividing the stu- 
dents and the hospital facilities have united into a single school. In still other instances 
large sums of money have been raised to place medical education on a firmer basis. 

In the preparation of this report the Foundation has kept steadily in view the 
interests of two classes, which in the over-multiplication of medical schools have 
usually been forgotten, first, the youths who are to study medicine and to become 
the future practitioners, and, secondly, the general public, which is to live and die 
under their ministrations. 

No one can become familiar with this situation without acquiring a hearty sym- 
pathy for the American youth who, too often the prey of commercial advertising 
methods, is steered into the practice of medicine with almost no opportunity to 
learn the difference between an efficient medical school and a hopelessly inadequate 
one. A clerk who is receiving $50 a month in the country store gets an alluring 
brochure which paints the life of the physician as an easy road to wealth. He has 
no realization of the difference between medicine as a profession and medicine as a 
business, nor as a rule has he any adviser at hand to show him that the first requi- 
site for the modern practitioner of medicine is a good general education. Such a boy 
falls an easy victim to the commercial medical school, whether operating under the 
name of a university or college, or alone. 

The interests of the general public have been so generally lost sight of in this 
matter that the public has in large measure forgot that it has any interests to pro- 
tect. And yet in no other way does education more closely touch the individual than 
in the quality of medical training which the institutions of the country provide. 
Not only the personal well-being of each citizen, but national, state, and municipal 
sanitation rests upon the quality of the training which the medical graduate has re- 
ceived. The interest of the public is to have well trained practitioners in sufficient 
number for the needs of society. The source whence these practitioners are to come 
is of far less consequence. 



xvi INTRODUCTION 

In view of this fact, the argument advanced for the retention of medical schools in 
places where good clinical instruction is impossible is directly against the public 
interest. If the argument were valid, it would mean that the sick man is better off 
in the hands of an incompetent home-grown practitioner than in those of one well 
trained in an outside school. Such an argument ought no longer to blind the eyes 
of intelligent men to the actual situation. Any state of the Union or any province 
of Canada is better off without a medical school than with one conducted in a com- 
mercial spirit and below a reasonable plane of efficiency. No state and no section of 
a state capable of supporting a good practitioner will suffer by following this policy. 
The state of Washington, which has no medical school within its borders, is doubt- 
less supplied with as capable and well trained a body of medical practitioners as is 
Missouri with its eleven medical schools or Illinois with its fourteen. 

The point of view which keeps in mind the needs and qualifications of the medi- 
cal student and the interests of the great public is quite a different one from that 
which the institution which conducts a medical department ordinarily occupies. The 
questions which look largest to the institutions are : Can we add a medical school to 
our other departments? and if so, where can we find the students? The questions 
which the other point of view suggest are : Is a medical school needed ? Cannot those 
qualified to study medicine find opportunities in existing schools? If not, are the 
means and the facilities at hand for teaching medicine on a right basis? 

While the aim of the Foundation has throughout been constructive, its attitude 
towards the difficulties and problems of the situation is distinctly sympathetic. The 
report indeed turns the light upon conditions which, instead of being fruitful and 
inspiring, are in many instances commonplace, in other places bad, and in still others, 
scandalous. It is nevertheless true that no one set of men or no one school of medi- 
cine is responsible for what still remains in the form of commercial medical educa- 
tion. Our hope is that this report will make plain once for all that the day of the 
commercial medical school has passed. It will be observed that, except for a brief his- 
torical introduction, intended to show how present conditions have come about, no 
account is given of the past of any institution. The situation is described as it exists to- 
day in the hope that out of it, quite regardless of the past, a new order may be speedily 
developed. There is no need now of recriminations over what has been, or of apolo- 
gies by way of defending a regime practically obsolete. Let us address ourselves re- 
solutely to the task of reconstructing the American medical school on the lines of the 
highest modern ideals of efficiency and in accordance with the finest conceptions of 
public service. 

It is hoped that both the purpose of the Foundation and its point of view as thus 
stated may be remembered in any consideration of the report which follows, and that 
this publication may serve as a starting-point both for the intelligent citizen and for 
the medical practitioner in a new national effort to strengthen the medical profession 
and rightly to relate medical education to the general system of schools of our nation. 



INTRODUCTION xvii 

The Foundation is under the greatest obligation in the preparation of this report 
to leading representatives of medicine and surgery in this country for their coopera- 
tion and advice. The officers of the various medical associations and of the Associa- 
tion of American Medical Colleges have furnished information which was invaluable 
and have given aid in the most cordial way. We are particularly indebted for con- 
stant and generous assistance to Dr. William H. Welch of Johns Hopkins Uni- 
versity, Dr. Simon Flexner of the Rockefeller Institute, and Dr. Arthur D. Bevan, 
chairman of the Council on Education of the American Medical Association. In ad- 
dition, our acknowledgments are due to Dr. N. P. Colwell, secretary of the Council on 
Education of the American Medical Association, and to Dr. F. C. Zapffe, secretary 
of the Association of American Medical Colleges, for most helpful cooperation. I wish 
to acknowledge also our indebtedness to a number of eminent men connected with 
various schools of medicine who have been kind enough to read the proof of this 
report and to give us the benefit of their comment and criticism. 

HENRY S. PRITCHETT. 
April 16, 1910. 



PART I 
MEDICAL EDUCATION 

IN THE UNITED STATES AND CANADA 



CHAPTER I 

HISTORICAL AND GENERAL 

THE American medical school is now well along in the second century of its history. 1 
It began, and for many years continued to exist, as a supplement to the apprentice- 
ship system still in vogue during the seventeenth and eighteenth centuries. The 
likely youth of that period, destined to a medical career, was at an early age inden- 
tured to some reputable practitioner; to whom his service was successively menial, 
pharmaceutical, and professional: he ran his master's errands, washed the bottles, 
mixed the drugs, spread the plasters, and finally, as the stipulated term drew towards 
its close, actually took part in the daily practice of his preceptor, bleeding his 
patients, pulling their teeth, and obeying a hurried summons in the night. The 
quality of the training varied within large limits with the capacity and conscientious- 
ness of the master. Ambitious spirits sought, therefore, a more assured and inspiring 
discipline. Beginning early in the eighteenth century, having served their time at 
home, they resorted in rapidly increasing numbers to the hospitals and lecture-halls 
of Leyden, Paris, London, and Edinburgh. The difficulty of the undertaking proved 
admirably selective ; for the students who crossed the Atlantic gave a good account 
of themselves. Returning to their native land, they sought opportunities to share 
with their less fortunate or less adventurous fellows the rich experience gained as 
they "walked the hospitals" of the old world in the footsteps of Cullen, Munro, and 
the Hunters. The voices of the great masters of that day thus reechoed in the recent 
western wilderness. High scientific and professional ideals impelled the youthful 
enthusiasts, who bore their lighted torches safely back across the waters. 

Out of these early essays in medical teaching, the American medical school devel- 
oped. As far back as 1750 informal classes and demonstrations, mainly in anatomy, 
are matters of record. Philadelphia was then the chief center of medical interest. 
There, in 1762, William Shippen the younger, after a sojourn of five years abroad, 
began in the very year of his return home, a course of lectures on midwifery. In the 
following autumn he announced a series of anatomical lectures " for the advantage 
of the young gentlemen now engaged in the study of physic in this and the neighbor- 
ing provinces, whose circumstances and connections will not admit of their going 
abroad for improvement to the anatomical schools in Europe; and also for the en- 
tertainment of any gentlemen who may have the curiosity to understand the anatomy 
of the Human Frame." From these detached courses the step to an organized medi- 
cal school was taken at the instigation of Shippen's friend and fellow student abroad, 

1 This statement has reference only to the United States and Canada, with which the present account 
alone deals. As a matter of fact, a chair of medicine was established at the University of Mexico 
towards the close of the sixteenth century. A complete medical school was there developed. James J. 
Walsh : "First American Medical School," in New York Medical Journal, Oct. 10, 1908 (based on 
Historia de la medicina en Mexico des de la epoca de los Iiulios, hasta la present*. Por Francisco 
Flores. Mexico, 1886). 



4 MEDICAL EDUCATION 

John Morgan, who in 1765 proposed to the trustees of the College of Philadelphia 
the creation of a professorship in the theory and practice of medicine. At the ensuing 
Commencement, Morgan delivered a noble and prophetic discourse, still pertinent, 
upon the institution of medical schools in America. The trustees were favorable to 
the suggestion ; the chair was established, and Morgan himself was its first occupant. 
Soon afterwards Shippen became professor of anatomy and surgery. Thirteen years 
previously the Pennsylvania Hospital, conceived by Thomas Bond, had been estab- 
lished through the joint efforts of Bond himself and Benjamin Franklin. Realizing 
that the student "must Join Examples with Study, before he can be sufficiently 
qualified to prescribe for the sick, for Language and Books alone can never give him 
Adequate Ideas of Diseases and the best methods of Treating them," Bond now 
argued successfully in behalf of bedside training for the medical students. " There 
the Clinical professor comes in to the Aid of Speculation and demonstrates the Truth 
of Theory by Facts," he declared in words that a century and a half later still warrant 
repetition; "he meets his pupils at stated times in the Hospital, and when a case 
presents adapted to his purpose, he asks all those Questions which lead to a certain 
knowledge of the Disease and parts Affected; and if the Disease baffles the power of 
Art and the Patient falls a Sacrifice to it, he then brings his Knowledge to the Test, 
and fixes Honour or discredit on his Reputation by exposing all the Morbid parts 
to View, and Demonstrates by what means it produced Death, and if perchance he 
finds something unexpected, which Betrays an Error in Judgement, he like a great 
and good man immediately acknowledges the mistake, and, for the benefit of sur- 
vivors, points out other methods by which it might have been more happily treated."" 1 
The writer of these sensible words fitly became our first professor of clinical medi- 
cine, 1 with unobstructed access to the one hundred and thirty patients then in the 
hospital wards. Subsequently the faculty of the new school was increased and greatly 
strengthened when Adam Kuhn, trained by Linnaeus, was made professor of materia 
medica, and Benjamin Rush, already at twenty-four on the threshold of his brilliant 
career, became professor of chemistry. 

Our first medical school was thus soundly conceived as organically part of an in- 
stitution of learning and intimately connected with a large public hospital. The 
instruction aimed, as already pointed out, not to supplant, but to supplement ap- 
prenticeship. A year's additional training, carrying the bachelor's degree, was offered 
to students who, having demonstrated a competent knowledge of Latin, mathema- 
tics, natural and experimental philosophy, and having served a sufficient apprentice- 
ship to some reputable practitioner in physic, now completed a prescribed lecture 
curriculum, with attendance upon the practice of the Pennsylvania Hospital for one 

1 An essay on Th Utility of Clinical Lecturgt, by Thomas Bond, 1766. 

2 There is no record of Dr. Bond's appointment, but in the minutes of the Hospital trustees he "is 
rcouested by the Trustees and Professors to continue his Clinical Lectures at the Hospital as a Branch 
of Medical Education." Quoted by Packard: Hittory of Medicine in tht United State*, p. 201. 



HISTORICAL AND GENERAL 5 

year. This course was well calculated to round off the young doctor's preparation, 
reviewing and systematizing his theoretical acquisitions, while considerably extend- 
ing his practical experience. 

Before the outbreak of the Revolution, the young medical school was prosperously 
started on its career. The war of course brought interruption and confusion. More 
unfortunate still, for the time being, was the local rivalry ominous as the first of 
its kind of the newly established medical department of the University of Penn- 
sylvania; but wise counsels averted disaster, and in 1791 the two institutions joined 
to form a single faculty, bearing, as it still bears, the name of the university, the 
earliest of a long and yet incomplete series of medical school mergers. Before the 
close of the century three more " medical institutes," similar in style, had been started : 
one in 1768 in New York, as the medical department of King's College, which, how- 
ever, temporarily collapsed on the British occupation and was only indirectly restored 
to vigor by union in 1814 with the College of Physicians and Surgeons, begun by 
the Regents in 1807; another, the medical department of Harvard College, opened 
in Cambridge in 1783, and twenty-seven years later removed to Boston so as to 
gain access to the hospitals there; 1 last of the group, the medical department of 
Dartmouth College, started in 1798 by a Harvard graduate, Dr. Nathan Smith, who 
was himself for twelve years practically its entire faculty and a very able faculty at 
that. 

The sound start of these early schools was not long maintained. Their scholarly 
ideals were soon compromised and then forgotten. True enough, from time to time 
seats of learning continued to create medical departments, Yale in 1810, Transyl- 
vania in 1817, among others. But with the foundation early in the nineteenth cen- 
tury at Baltimore of a proprietary school, the so-called medical department of the 
so-called University of Maryland, 2 a harmful precedent was established. 3 Before that 
a college of medicine had been a branch growing out of the living university trunk. 

1 The removal took place in 1810. But definite arrangements for clinical teaching long remained vague. 
Dr. R. C. Cabot quotes.the Harvard Catalogue of 1833 as follows : " The lectures for medical students 
are delivered in Boston. . . . During lectures the students may find in the city various opportunities 
for practical instruction." A hospital is first mentioned in 1835, " when it is stated that students may 
attend the medical visits at the Massachusetts General Hospital." R. C. Cabot: "Sketch of the De- 
velopment of the Department of Clinical Medicine," in Harvard Medical Alumni Quarterly, Jan., 1904, 
p. 666. 

2 In recent years an effort has been made to fill out the non-existent university by an affiliation with 
St. John's College (Annapolis), whereby it becomes nominally the department of arts of the Univer- 
sity of Maryland. This is, of course, a makeshift. A university begins with a school of arts and 
sciences ; it cannot be formed of loosely associated schools of dentistry, pharmacy, and even law, 
whether with or without still looser connection with a remote college of arts. Analogous in type are 
the so-called medical departments of the Universities of Buffalo, Toledo, and Memphis, which at this 
writing still lack academic affiliation. Their titles cannot disguise the fact that they are in essence in- 
dependent medical schools, nor does a university charter make a university. 

3 This was in imitation of London, as against the Edinburgh or the Leyden example, followed by the 
four earlier schools. But the London schools never conferred the degree or gave the right to practise : 
for the bestowal of degrees is the function of a university, the qualification for practice is determined 
by the state. The American departure in both these respects developed evils from which England has 
never suffered. 



6 MEDICAL EDUCATION 

This organic connection guaranteed certain standards and ideals, modest enough at 
that time, but destined to a development which medical education could, as experi- 
ence proved, ill afford to forego. Even had the university relation been preserved, 
the precise requirements of the Philadelphia College would not indeed have been 
permanently tenable. The rapid expansion of the country, with the inevitable decay 
of the apprentice system in consequence, must necessarily have lowered the terms of 
entrance upon the study. But for a time only : the requirements of medical educa- 
tion would then have slowly risen with the general increase in our educational re- 
sources. Medical education would have been part of the entire movement instead of 
an exception to it. The number of schools would have been well within the number 
of actual universities, in whose development as respects endowments, laboratories, 
and libraries they would have partaken; and the country would have been spared 
the demoralizing experience in medical education from which it is but now painfully 
awakening. 

Quite aside from the history, achievements, or present merits of any particular in- 
dependent medical school, the creation of the type was the fertile source of unfore- 
seen harm to medical education and to medical practice. Since that day medical col- 
leges have multiplied without restraint, now by fission, now by sheer spontaneous 
generation. Between 1810 and 1840, twenty-six new medical schools sprang up; be- 
tween 1840 and 1876, forty-seven more; 1 and the number actually surviving in 1876 
has been since then much more than doubled. First and last, the United States and 
Canada have in little more than a century produced four hundred and fifty-seven 
medical schools, many, of course, short-lived, and perhaps fifty still-born. 2 One 
hundred and fifty-five survive to-day. 5 Of these, Illinois, prolific mother of thirty- 
nine medical colleges, still harbors in the city of Chicago fourteen ; forty-two sprang 
from the fertile soil of Missouri, twelve of them still "going" concerns; the Empire 
State produced forty -three, with eleven survivors; 4 Indiana, twenty-seven, with two 
survivors; Pennsylvania, twenty, with eight survivors; Tennessee, eighteen, with 
nine survivors. The city of Cincinnati brought forth about twenty, the city of 
Louisville eleven. These enterprises for the most part they can be called schools 
or institutions only by courtesy were frequently set up regardless of opportunity 
or need: in small towns as readily as in large, and at times almost in the heart of the 
wilderness. No field, however limited, was ever effectually preempted. Wherever and 
whenever the roster of untitled practitioners rose above half a dozen, a medical 
school was likely at any moment to be precipitated. Nothing was really essential but 

l Contrib. to Hittory ofMed. Educat., N. S. Davis (Washington, 1877, p. 41). 

These were usually frauds, suppressed by police or by post-office departments. Postgraduate and 
osteopathic schools are not included in these figures. 

1 Including osteopathic schools, of which there are eight, but not including postgraduate schools, of 
which there are thirteen, one of them in Kansas City without students at present. The last-named 
institution retains its organization in order to obtain staff recognition at the Kansas City Hospital. 

* Not including four postgraduate schools. 



HISTORICAL AND GENERAL 7 

professors. The laboratory movement is comparatively recent; and Thomas Bond's 
wise words about clinical teaching were long since out of print. Little or no invest- 
ment was therefore involved. A hall could be cheaply rented and rude benches were 
inexpensive. Janitor service was unknown and is even now relatively rare. Occasional 
dissections in time supplied a skeleton in whole or in part and a box of odd 
bones. Other equipment there was practically none. The teaching was, except for a 
little anatomy, wholly didactic. The schools were essentially private ventures, money- 
making in spirit and object. A school that began in October would graduate a class the 
next spring; it mattered not that the course of study was two or three years ; immigra- 
tion recruited a senior class at the start. 1 Income was simply divided among the lec- 
turers, who reaped a rich harvest, besides, through the consultations which the loyalty 
of their former students threw into their hands. " Chairs " were therefore valuable pieces 
of property, their prices varying with what was termed their "reflex" value: only re- 
cently a professor in a now defunct Louisville school, who had agreed to pay $3000 
for the combined chair of physiology and gynecology, objected strenuously to a di- 
vision of the professorship assigning him physiology, on the ground of "failure of 
consideration;" for the "reflex" which constituted the inducement to purchase went 
obviously with the other subject. 2 No applicant for instruction who could pay his 
fees or sign his note was turned down/ State boards were not as yet in existence. The 
school diploma was itself a license to practise. The examinations, brief, oral, and se- 
cret, plucked almost none at all; even at Harvard, a student for whom a majority 
of nine professors "voted" was passed. 3 The man who had settled his tuition bill was 
thus practically assured of his degree, whether he had regularly attended lectures or 
not. Accordingly, the business throve. Rivalry between different so-called medical 
centers was ludicrously bitter. Still more acrid were and occasionally are the local 
animosities bound to arise in dividing or endeavoring to monopolize the spoils. Sud- 
den and violent feuds thus frequently disrupted the faculties. But a split was rarely 
fatal: it was more likely to result in one more school. Occasionally, a single too 
masterful individual became the strategic object of a hostile faculty combination. 
Daniel Drake, indomitable pioneer in medical education up and down the Ohio Val- 
ley, thus tasted the ingratitude of his colleagues. As presiding officer of the faculty 
of the Medical College of Ohio, at Cincinnati, cornered by a cabal of men, only a 
year since indebted to him for their professorial titles and profits, he was compelled 
to put a motion for his own expulsion and to announce to his enemies a large major- 

1 This is recent as well as ancient history, e.g. : 

Tufts College Medical School opened 1893 first class graduated 1894 

Illinois Medical College 184 1885 

Birmingham Medical College 1894 1895 

College of Physjcians and Surgeons, Little Rock 1906 1907 

College of Physicians and Surgeons, Memphis 1900 1907 

2 The sale of chairs is not even now wholly unknown. At the North Carolina Medical College (Char- 
lotte, N. C.) the faculty owns the stock, and the sale of one's stock carries with it one's chair. 

3 There were at Harvard at one time only seven professors and an examination was conducted even 
if only a majority was present. 



8 MEDICAL EDUCATION 

ity in its favor. It is pleasant to record that the indefatigable man was not daunted. 
He continued from time to time to found schools and to fill professorships at Lex- 
ington, at Philadelphia, at Oxford in Ohio, at Louisville, and finally again in that 
beloved Cincinnati, where he had been so hardly served. In the course of a busy 
and fruitful career, he had occupied eleven different chairs in six different schools, 
several of which he had himself founded ; and he had besides traversed the whole 
country, as it then was, from Canada and the Great Lakes to the Gulf, and as far 
westward as Iowa, collecting material for his great work, historically a classic, The 
Diseases of the Interior Valley of North America. 

In the wave of commercial exploitation which swept the entire profession so far 
as medical education is concerned, the original university departments were practi- 
cally torn from their moorings. The medical schools of Harvard, Yale, Pennsylvania, 
became, as they expanded, virtually independent of the institutions with which they 
were legally united, and have had in our own day to be painfully won back to their 
former status. 1 For years they managed their own affairs, disposing of professor- 
ships by common agreement, segregating and dividing fees, along proprietary lines. 
In general, these indiscriminate and irresponsible conditions continued at their 
worst until well into the eighties. To this day it is as easy to establish a medical 
school as a business college, 1 though the inducement and tendency to do so have 
greatly weakened. Meanwhile, the entire situation had fundamentally altered. The 
preceptorial system, soon moribund, had become nominal. The student registered in 
the office of a physician whom he never saw again. He no longer read his master's 
books, submitted to his quizzing, or rode with him the countryside in the enjoy- 
ment of valuable bedside opportunities. All the training that a young doctor got 
before beginning his practice had now to be procured within the medical school. The 
school was no longer a supplement; it was everything. Meanwhile, the practice of 
medicine was itself becoming quite another thing. Progress in chemical, biological, 
and physical science was increasing the physician's resources, both diagnostic and 
remedial. Medicine, hitherto empirical, was beginning to develop a scientific basis 
and method. The medical schools had thus a different function to perform : it took 
them upwards of half a century to wake up to the fact. The stethoscope had been 
in use for over thirty years before, as Dr. Cabot notes, 3 its first mention in the cata- 
logue of the Harvard Medical School in 1868-9; the microscope is first mentioned 

1 The first step towards depriving the medical school of virtual autonomy was taken when the univer- 
sity undertook to collect the fees and thenceforward to administer the finances of the department by 
means of an annual budget. This took place at Harvard in 1871, at Yale in 1880, at the University 
of Pennsylvania in 1896. The scope of the medical faculty has gradually shrunk since. Columbia, 
which gave up its medical department to the College of Physicians and Surgeons in 1814, contracted 
a nominal relation with that school in I860; in 1891 the connection became organic. 

* In New York, however, the chartering of educational institutions is in the hands of the Regents, 
who have large powers. Nevertheless, they have recently given a limited charter to the Brooklyn 
Postgraduate School, a corporation practically without resources and relying on hospital and student 
fee income (the latter thus far small) to carry it through. 
Cabot, loc. cit., p. 673. 



HISTORICAL AND GENERAL 9 

the following year. The schools had not noticed at all when the vital features of 
the apprentice system dropped out. They continued along the old channel, their 
ancient methods aggravated by rapid growth in the number of students and by the 
lowering in the general level of their education and intelligence. Didactic lectures 
were given in huge, badly lighted amphitheaters, and in these discourses the instruc- 
tion almost wholly consisted. Personal contact between teacher and student, be- 
tween student and patient, was lost. No consistent effort was made to adapt medical 
training to changed circumstances. Many of the schools had no clinical facilities 
whatsoever, and the absence of adequate clinical facilities is to this day not prohibi- 
tive. The school session had indeed been lengthened to two sessions; but they were 
of only sixteen to twenty weeks each. Moreover, the course was not graded and the 
two classes were not separated. The student had two chances to hear one set of lec- 
tures and for the privilege paid two sets of fees. To this traffic many of the ablest 
practitioners in the country were parties, and with little or no realization of its 
enormity at that! "It is safe to say," said Henry J. Bigelow, professor of surgery 
at Harvard in 1871, "that no successful school has thought proper to risk large 
existing classes and large receipts in attempting a more thorough education." 1 A 
minority successfully wrung a measure of good from the vicious system which they 
were powerless to destroy. They contrived to reach and to inspire the most capable 
of their hearers. The best products of the system are thus hard to reconcile with the 
system itself. Competent and humane physicians the country came to have, at 
whose and at what cost, one shudders to reflect; for the early patients of the rapidly 
made doctors must have played an unduly large part in their practical training. An 
annual and increasing exodus to Europe also did much to repair the deficiencies of 
students who would not have neglected better opportunities at home. The Edin- 
burgh and London tradition, maintained by John Bell, Abernethy, and Sir Astley 
Cooper, persisted well into the century. In the thirties, Paris became the medical 
student's Mecca, and the statistical and analytical study of disease, which is the dis- 
criminating mark of modern scientific medicine, was thence introduced into America 
by the pupils of Louis, 2 the younger Jackson, "dead ere his prime," Gerhard, and 
their successors. With the generation succeeding the civil war, the tide turned decisively 
towards Germany, and thither continues to set. These men subsequently became 
teachers in the colleges at Philadelphia, New York, Boston, Charleston, and else- 
where; and from them the really capable and energetic students got much. One 
of the latter, who in recent years has wielded perhaps the greatest single influence in 
the country towards the reconstruction of medical education, says of his own school, 
the College of Physicians and Surgeons of New York, in the early seventies: "One 
can decry the system of those days, the inadequate preliminary requirements, the 
short courses, the dominance of the didactic lecture, the meager appliances for 

1 Medical Education in America, by Henry J. Bigelow, Cambridge, the University Press, 1871, p. 79. 
a Osier : ' Influence of Louis on Modern Medicine, " Bulletin Johns Hopkins Hospital, vol. iii. , nos. 77, 78. 



10 MEDICAL EDUCATION 

demonstrative and practical instruction, but the results were better than the system. 
Our teachers were men of fine character, devoted to the duties of their chairs; they 
inspired us with enthusiasm, interest in our studies and hard work, and they imparted 
to us sound traditions of our profession ; nor did they send us forth so utterly igno- 
rant and unfitted for professional work as those born of the present greatly improved 
methods of training and opportunities for practical studies are sometimes wont to 
suppose. Clinical and demonstrative teaching for undergraduates already existed. Of 
laboratory training there was none. 1 " l As much could perhaps be said of a half-dozen 
other institutions. The century was therefore never without brilliant names in ana- 
tomy, medicine, and surgery; but they can hardly be cited in extenuation of condi- 
tions over which unusual gifts and perseverance alone could triumph. Those con- 
ditions made uniform and thorough teaching impossible; and they utterly forbade 
the conscientious elimination of the incompetent and the unfit. 

From time to time, of course, the voice of protest was heard, but it was for years 
a voice crying in the wilderness. Delegates from medical schools and societies met at 
Northampton, Massachusetts, in 1827, and agreed upon certain recommendations 
lengthening the term of medical study and establishing a knowledge of Latin and 
natural philosophy as preliminary thereto. The Yale Medical School actually went 
so far as to procure legislation to this end. But it subsequently beat a retreat when 
it found itself isolated in its advanced position, its quondam allies having failed to 
march. 2 As far back as 1835, the Medical College of Georgia had vainly suggested 
concerted action looking to more decent methods; but no step was taken until, eleven 
years later, an agitation set up by Nathan Smith Davis resulted in the formation of 
the American Medical Association, committed to two propositions, viz.) that it is 
desirable "that young men received as students of medicine should have acquired a 
suitable preliminary education," and "that a uniform elevated standard of require- 
ments for the degree of M.D. should be adopted by all the medical schools in the 
United States." This was in 1846; much water has flowed under the bridge since 
then; and though neither of these propositions has even yet been realized, there is no 
denying that, especially in the last fifteen years, substantial progress has been made. 

In the first place, the course has now at length been generally graded * and ex- 

1 Wm. H. Welch: "Development of American Medicine," Columbia Unwerrity Quarterly Supple- 
ment, Dec., 1907. 

1 Wm. H. Welch : " The Relation of Yale to Medicine " (reprinted from Yale Medical Journal for Nov., 
1901), p. 20, and note 28, pp. 30, 31. 

A certain amount of ungraded teaching is still to be found, especially in the south and west. For 
example, at Chattanooga, no examinations are held at the close of the first year ; the examinations at 
the close of the second year are supposed to cover two years' work, the practical outcome of which 
is obvious. More frequently, clinical lectures are delivered to the juniors and seniors together, at 
least, as far as a single amphitheater is capable of containing the combined classes. This is the case 
at the University of Louisville. At certain other schools, the work is only partially graded, e.g., the 
Memphis Hospital Medical College, Tennessee Medical College, University of Arkansas, Birmingham 
Medical College, Ensworth Medical College (St. Joseph. Mo.), Hahnemann, San Francisco, Kansas 
Medical (Topeka), Woman's Medical (Baltimore), Maryland Medical, Mississippi Medical, American 



HISTORICAL AND GENERAL 11 

tended to four years, still varying, however, from six l to nine months each in du- 
ration. Didactic teaching has been much mitigated. Almost without exception the 
schools furnish some clinical teaching; many of them provide a fair amount, though 
it is still only rarely used to the best teaching advantage; a few are quite adequately 
equipped in this respect. Relatively quicker and greater progress has been made on 
the laboratory side since, in 1878, 2 Dr. Francis Delafield established the laboratory 
of the Alumni Association of the College of Physicians and Surgeons of New York ; 3 
in the same autumn Dr. William H. Welch opened the pathological laboratory of 
the Bellevue Hospital Medical College, from which, six years later, he was called to 
organize the Johns Hopkins Medical School in Baltimore. It is at length everywhere 
conceded that the prospective student of medicine should prove his fitness for the 
undertaking. Not a few schools rest on a substantial admission basis ; the others have 
not yet abandoned the impossible endeavor at one and the same time to pay their own 
way and to live up to standards whose reasonableness they cannot deny. Finally, the 
creation of state boards has compelled a greater degree of conscientiousness in teach- 
ing, though in many places, unfortunately, far too largely the conscientiousness of 
the drillmaster. 

In consequence of the various changes thus briefly recounted, the number of med- 
ical schools has latterly declined. Within a twelvemonth a dozen have closed their 
doors. Many more are obviously gasping for breath. Practically without exception, 
the independent schools are scanning the horizon in search of an unoccupied univer- 
sity harbor. It has, in fact, become virtually impossible for a medical school to com- 
ply even in a perfunctory manner with statutory, not to say scientific, requirements 
and show a profit. The medical school that distributes a dividend to its professors 
or pays for buildings out of fees must cut far below the standards which its own 
catalogue probably alleges. Nothing has perhaps done more to complete the dis- 
credit of commercialism than the fact that it has ceased to pay. It is but a short 
step from an annual deficit to the conclusion that the whole thing is wrong anyway. 

In the first place, however, the motive power towards better conditions came from 
genuine professional and scientific conviction. The credit for the actual initiative 
belongs fairly to the institutions that had the courage and the virtue to make 
the start. The first of these was the Chicago school, which is now the medical de- 
Medical (St. Louis), St. Louis College of Physicians and Surgeons, Barnes Medical, Western Eclec- 
tic (Kansas City), Eclectic Medical (New York), Eclectic Institute (Cincinnati). 
1 The low-grade southern schools have a nominal seven months' course; but as they allow students 
to enter without penalty several weeks later and have liberal Christmas holidays besides, the course 
is actually less than six months. 

2 Prior to this date Drs. Francis Delafield, E. G. Janeway, and others had given courses at Bellevue 
Hospital and elsewhere in histology, pathology, etc. See George C. Freeborn : History of the Associa- 
tion of the Alumni of the College of Physicians and Surgeons, New York, p. 10, etc. Instruction in 
pathological anatomy in the Harvard Medical School had begun in 1870 with the appointment of 
Dr. R. H. Fitz to an instructorship in that subject. 

5 This laboratory was at first independent of the faculty of the College of Physicians and Surgeons. 



12 MEDICAL EDUCATION 

partment of Northwestern University, and which in 1859 initiated a three-year 
graded course. Early in the seventies the new president of Harvard College startled 
the bewildered faculty of its medical school into the first of a series of reforms that 
began with the grading of the existing course and ended in 1901 with the require- 
ment of an academic degree for admission. 1 In the process, the university obtained 
the same sort of control over its medical department that it exercises elsewhere. 2 
Towards this consummation President Eliot had aimed from the start; but he was 
destined to be anticipated by the establishment in 1893 of the Johns Hopkins Med- 
ical School on the basis of a bachelors degree, from which, with quite unprecedented 
academic virtue, no single exception has ever been made. 8 This was the first medical 
school in America of genuine university type, with something approaching adequate 
endowment, well equipped laboratories conducted by modern teachers, devoting them- 
selves unreservedly to medical investigation and instruction, and with its own hospital, 
in which the training of physicians and the healing of the sick harmoniously combine 
to the infinite advantage of both. The influence of this new foundation can hardly 
be overstated. It has finally cleared up the problem of standards and ideals; and its 
graduates have gone forth in small bands to found new establishments or to recon- 
struct old ones. In the sixteen years that have since elapsed, fourteen more institu- 
tions have actually advanced to the basis of two or more years of college work ; others 
have undertaken shortly to do so. Besides these, there are perhaps a dozen other 
more or less efficient schools whose entrance requirements hover hazily about high 
school graduation. In point of organization, the thirty-odd schools now supplying 
the distinctly better quality of medical training are not as yet all of university type. 
Thither they are unquestionably tending; for the moment, however, the very best 
and some of the very worst* are alike known as university departments. Not a few 
so-called university medical departments are such in name only. They are practically 
independent enterprises, to which some university has good-naturedly lent its pres- 
tige. The College of Physicians and Surgeons of Chicago is the medical department 
of the University of Illinois, but the relation between them is purely contractual ; 
the state university contributes nothing to its support The Southwestern University 
of Texas possesses a medical department at Dallas, but the university is legally 
protected against all responsibility for its debts. 5 These fictitious alignments retard 

1 Seepage28. 

1 A vein of unmistakable uneasiness runs through Bigelow's address on Medical Education in America, 
previously referred to: "Most American medical colleges are virtually close corporations, . . . ad- 
ministered by their professors, who receive the students' fees, and upon whose tact and ability the 
success of these institutions depends. A university possesses over all its departments a legal jurisdic- 
tion ; but it may be a question of expediency how far this shall be enforced" (p. 59). 

See, however, p. 28. 

*.a.. University of Arkansas, Willamette University, Cotner University (Lincoln, Nebraska), West- 
ern University (London, Ontario), Epworth University, Fort Worth University, etc. 

Other university departments of this nominal character are: medical department of the University 
of Arkansas (Little Rock); College of Physicians and Surgeons (Los Angeles), which is nominally 
the medical department of the University of Southern California; Denver and Gross College of 



HISTORICAL AND GENERAL 13 

the readjustment of medical education through further reduction in the number of 
schools, because the institutions involved are enabled to live on hope for perhaps 
another decade or more. It is important that our universities realize that medical 
education is a serious and costly venture; and that they should reject or terminate 
all connection with a medical school unless prepared to foot its bills and to pitch its 
instruction on a university plane. In Canada conditions have never become so badly 
demoralized as in the United States. There the best features of English clinical 
teaching had never been wholly forgotten. Convalescence from a relatively mild over- 
indulgence in commercial medical schools set in earlier and is more nearly completed. 

With the creation of the heterogeneous situation thus bequeathed to us, it is clear 
that consideration for the public good has had on the whole little to do; nor is it to 
be expected that this situation will very readily readjust itself in response to public 
need. A powerful and profitable vested interest tenaciously resists criticism from that 
point of view; not, of course, openly. It is too obvious that if the sick are to reap 
the full benefit of recent progress in medicine, a more uniformly arduous and expen- 
sive medical education is demanded. But it is speciously argued that improvements 
thus accomplished will do more harm than good: for whatever makes medical edu- 
cation more difficult and more costly will deplete the profession and thus deprive 
large numbers of all medical attention whatsoever, in order that a fortunate minority 
may get the best possible care. It is important to forestall the issue thus raised; 
otherwise it will crop out at every turn of the following discussion, in the effort to 
justify the existing situation and to break the force of constructive suggestion. It 
seems, therefore, necessary to refer briefly at this point to the statistical aspects of 
medical education in America, so far as they are immediately pertinent to the ques- 
tion of improvement and reform. 

The problem is of course practical and not academic. Pending the homogeneous 
filling up of the whole country, inequalities must be tolerated. Man has been not in- 
aptly differentiated as the animal with "the desire to take medicine." 1 When sick, 
he craves the comfort of the doctor, any doctor rather than none at all, and in this 
he will not be denied. The question is, then, not merely to define the ideal training 
of the physician; it is just as much, at this particular juncture, to strike the solution 
that, economic and social factors being what they are, will distribute as widely as 
possible the best type of physician so distributable. Doubtless the chaos above char- 
acterized is in part accounted for by crude conditions that laughed at regular me- 
thods of procedure. But this stage of our national existence has gone by. What with 
widely ramifying railroad and trolley service, improving roads, automobiles, and 

Medicine, which is nominally the medical department of the University of Denver; School of Medi- 
cine of the University of Georgia; Albany (New York) Medical College, which is nominally the 
medical department of Union TJniversity; medical department of Western University (London, 
Ont.), etc. For none of these alliances is there a valid reason; on the contrary, there is in every 
instance a good reason why the university concerned should break off the connection. 

1 Osier: Aequanimitas, p. 131. 



14 



MEDICAL EDUCATION 



rural telephones, we have measurably attained some of the practical consequences of 
homogeneity. The experience of older countries is therefore suggestive, even if not 
altogether conclusive. 

Professor Paulsen, describing in his book on the German Universities the increased 
importance of the medical profession, reports with some astonishment that "the 
number of physicians has increased with great rapidity so that now there is, in Ger- 
many, one doctor for every 2000 souls, and in the large cities one for every 1000." 1 
What would the amazed philosopher have said had he known that in the entire 
United States there is already on the average one doctor for every 568 persons, that 
in our large cities there is frequently one doctor for every 400 a or less, that many 
small towns with less than 200 inhabitants each have two or three physicians apiece! 8 

Over-production is stamped on the face of these facts ; and if, in its despite, there 
are localities without a physician, it is clear that even long-continued over-produc- 
tion of cheaply made doctors cannot force distribution beyond a well marked point. 
In our towns health is as good and physicians probably as alert as in Prussia; there 
is, then, no reason to fear an unheeded call or a too tardy response, if urban commu- 
nities support one doctor for every 2000 inhabitants. On that showing, the towns 
have now four or more doctors for every one that they actually require, something 
worse than waste, for the superfluous doctor is usually a poor doctor. So enormous 
an overcrowding with low-grade material both relatively and absolutely decreases 
the number of well trained men who can count on the profession for a livelihood. 
According to Gresham's law, which, as has been shrewdly remarked, is as valid in edu- 
cation as in finance, the inferior medium tends to displace the superior. If then, by 
having in cities one doctor for every 2000 persons, we got four times as good a doc- 
tor as now when we provide one doctor for every 500 or less, the apothecaries would 
find time hanging somewhat more heavily on their hands. Clearly, low standards 
and poor training are not now needed in order to supply physicians to the towns. 

1 Thilly's translation, p. 400. 

2 New York, 1 : 460 ; Chicago, 1 : 580 ; Washington, 1 : 270 ; San Francisco, 1 : 370. These ratios are 
calculated on the basis of figures obtained from Folk's Medical Register, the American Medical Direc- 
tory, and estimates prepared by the U. S. Census Bureau. The force of the figures as to the number 
of physicians cannot be broken by urging that many physicians no longer practise. Such have been 
carefully excluded by the compilers of the American Medical Directory. Figures used throughout 
this report were obtained from these sources. 

3 Examples may be cited at random from every section of the country in proof of the fact that over- 
crowding is general, not merely local or exceptional, e.g. : 



Ohio: 



Killbrook, population 807. has three doctors 



Houston 


227 





Texas: Wellington 


87 


five 


Whitt 


378 


four 


Whitney 


7M 


ix 


Massachusetts: Colerain 


80 


two 


Harding 


100 


U 


Nebraska: Eustin 


292 


* 


Crofton 


40 


u 


Oregon: K..-,il 


870 


U. 


Oaston 


182 






(Prom the American Medical Directory. 1000.) 



HISTORICAL AND GENERAL 15 

In the country the situation follows one of two types. Assuming that a thousand 
people in an accessible area will support a competent physician, one of two things 
will happen if the district contains many less. In a growing country, like Canada 
or our own middle west, the young graduate will not hesitate to pitch his tent in a 
sparsely settled neighborhood, if it promises a future. A high-grade and comparatively 
expensive education will not alter his inclination to do this. The more exacting 
Canadian laws rouse no objection on this score. The graduates of McGill and Toronto 
have passed through a scientific and clinical discipline of high quality ; but one finds 
them every year draining off into the freshly opened Northwest Territory. In truth, 
it is an old story. McDowell left the Kentucky backwoods to spend two years under 
Bell in Edinburgh; and when they were over, returned contentedly to the wilderness, 
where he originated the operation for ovarian tumor in the course of a surgical 
practice that carried him back and forth through Kentucky, Ohio, and Tennessee. 
Benjamin Dudley, son of a poor Baptist preacher, dissatisfied with the results first of 
his apprenticeship, then of his Philadelphia training, hoarded his first fees, and with 
them subsequently embarked temporarily in trade ; he loaded a flat-boat with sun- 
dries, which he disposed of to good advantage at New Orleans, there investing in a 
cargo of flour, which he sold to the hungry soldiers of Wellington in the Spanish 
peninsula. The profits kept Dudley in the hospitals of Paris for four years, after 
which he came back to Lexington, and for a generation was the great surgeon and 
teacher of surgery in the rough country across the Alleghanies. The pioneer is not 
yet dead within us. The self-supporting students of Ann Arbor and Toronto prove 
this. For a region which holds out hope, there is no need to make poor doctors, 
still less to make too many of them. 

In the case of stranded small groups in an unpromising environment the thing 
works out differently. A century of reckless over-production of cheap doctors has re- 
sulted in general overcrowding; but it has not forced doctors into these hopeless 
spots. It has simply huddled them thickly at points on the extreme margin. Certain 
rural communities of New England may, for example, have no physician in their 
midst, though they are in most instances not inaccessible to one. But let never so 
many low-grade doctors be turned out, whether in Boston or in smaller places like 
Burlington or Brunswick, that are supposed not to spoil the young man for a 
country practice, these unpromising places, destined perhaps to disappear from the 
map, will not attract them. They prefer competition in some already over-occupied 
field. Thus, in Vermont, Burlington, the seat of the medical department of the Uni- 
versity of Vermont, with a population of less than 21,000, has 60 physicians, one for 
every 333 inhabitants; 1 nor can these figures be explained away on the ground that 
the largest city in the state is a vortex which absorbs more than its proper share; 
for the state abounds in small towns in which several doctors compete in the service 
of less than a thousand persons: Post Mills, with 105 inhabitants, has two doctors ; 
1 American Medical Directory; Polk (1908) gives 75 active physicians, a ratio of 1 :280. 



16 MEDICAL EDUCATION 

Jeffersonville, with 400, has two; Plainfield, with 341, has three. Other New England 
states are in the same case. It would appear, then, that over-production on a low 
basis does not effectually overcome the social or economic obstacles to spontaneous 
dispersion. Perhaps the salvation of these districts might, under existing circum- 
stances, be better worked out by a different method. A large area would support one 
good man, where its separate fragments are each unable to support even one poor 
man. A physician's range, actual and virtual, increases with his competency. A well 
qualified doctor may perhaps at a central point set up a small hospital, where the 
seriously ill of the entire district may receive good care. The region is thus better 
served by one well trained man than it could possibly be even if over-production on 
a low basis ultimately succeeded in forcing an incompetent into every hamlet of five 
and twenty souls. This it cannot compel. It cannot keep even the cheap man in a 
place without a "chance;" it can only demoralize the smaller places which are ca- 
pable of supporting a better trained man whose energies may also reach out into the 
more thinly settled surrounding country. As a last resort, it might conceivedly be- 
come the duty of the several states to salary district physicians in thinly settled or 
remote regions, surely a sounder policy than the demoralization of the entire pro- 
fession for the purpose of enticing ill trained men where they will not go. 1 We may 
safely conclude that our methods of carrying on medical education have resulted in 
enormous over-production at a low level, and that, whatever the justification in the 
past, the present situation in town and country alike can be more effectively met by a 
reduced output of well trained men than by further inflation with an inferior product. 
The improvement of medical education cannot therefore be resisted on the ground 
that it will destroy schools and restrict output : that is precisely what is needed. The 
illustrations already given in support of this position may be reinforced by further 
examples from every section of the Union, from Pennsylvania with one doctor for 
every 636 inhabitants, Maryland with one for every 658, Nebraska with one for every 
602, Colorado with one for every 328, Oregon with one for every 646. It is frequently 
urged that, however applicable to other sections, this argument does not for the pre- 
sent touch the south, where continued tolerance of commercial methods is required 
by local conditions. Let us briefly consider the point. The section as a whole contains 
one doctor for every 760 persons. In the year 1908, twelve states 2 showed a gain in 
population of 358,837. If now we allow in cities one additional physician for every 
increase of 2000, and outside cities an additional one for every increase of 1000 in 
population, an ample allowance in any event, we may in general figure on one more 
physician for every gain of 1500 in total population. We are not now arguing that 
a ratio of 1 : 1500 is correct; we are under no necessity of proving that. Our conten- 

1 These officials would combine the duties of county health officer with those now assigned in large 
towns to the city physician. 

'This includes Kentucky, Virginia, Tennessee, North Carolina, South Carolina, Georgia, Florida, 
Alabama, Mississippi, Louisiana, Texas, Arkansas. 



HISTORICAL AND GENERAL 17 

tion is simply that, starting with our present overcrowded condition, production 
henceforth at the ratio of one physician to every increase of 1500 in population will 
prevent a shortage, for the next generation at least. In 1908 the south, then, needed 
240 more doctors to take care of its increase in population. In the course of the same 
year, it is estimated that 500 vacancies in the profession were due to death. 1 If every 
vacancy thus arising must be filled, conditions will never improve. Let us agree to work 
towards a more normal adjustment by filling two vacancies due to death with one new 
physician, once more, a decidedly liberal provision. This will prove sufficiently de- 
liberate; it would have called for 250 more doctors by the close of the year. In all, 
490 new men would have amply cared for the increase in population and the vacancies 
due to death. As a matter of fact, the southern medical schools turned out in that year 
1144 doctors; 78 more southerners were graduated from the schools of Baltimore and 
Philadelphia. The grand total would probably reach 1300, 1300 southern doctors to 
compete in a field in which one- third of the number would find the making of a decent 
living already difficult. Clearly, the south has no cause to be apprehensive inconsequence 
of a reduced output of higher quality. 2 Its requirements in the matter of a fresh sup- 
ply are not such as to make it necessary to pitch their training excessively low. 

The rest of the country may be rapidly surveyed from the same point of view. 
The total gain in population, outside the southern states already considered, was 
975,008, requiring on the basis of one more doctor for every 1500 more people, 
650 doctors. By death, in the course of the year there were in the same area 1730 
vacancies. Replacing two vacancies by one doctor, 865 men would have been re- 
quired ; in most sections public interest would be better cared for if they all remained 
unfilled for a decade to come. On the most liberal calculation, 1500 graduates would 
be called for, and 1000 would be better still. There were actually produced in that 
year, outside the south, 3497, i.e., between two and three times as many as the country 
could possibly assimilate; and this goes on, and has been going on, every year. 

It appears, then, that the country needs fewer and better doctors; and that the 
way to get them better is to produce fewer. To support all or most present schools 
at the higher level would be wasteful, even if it were not impracticable; for they can- 

1 Based on figures collected by the American Medical Association. 

2 As Kentucky is one of the largest producers of low-grade doctors in the entire Union, it is interest- 
ing to observe conditions there. The following is the result of a careful study of Henderson County 
made for me by one thoroughly acquainted with it. 

Total population, 35,000 ; number of doctors, 56 ; ratio, 1 : 624. 

DISTRIBUTION 
Place 

City of Henderson 
Anthaston 
Baskett 
Cairo 
Corydon 
Dixie 
Geneva 
Hebardsville 

Throughout the county there are doctors within five miles everywhere. 



Population 


No. Drs. 1 


tatio 


Place 


Population 


No. Drs. J 


*tatio 


17,500 


27 1 


1:644 


Zion 


250 


S 


:84 


24 


1 ] 


1:24 


Robards 


500 


9 1 


: 187 


200 


2 


:100 


Niagara 


100 


9 


:94 


200 


1 


:200 


McDonald's Landing 


25 






1,000 


4 


:250 


Alzey 


25 


1 


:25 


900 


1 


:300 


Smith Mills 


200 


9 


:7 


100 


2 


:50 


Spottsville 


700 


9 


:294 


400 


2 


:200 











i 



18 MEDICAL EDUCATION 

not be manned. Some day, doubtless, posterity may reestablish a school in some 
place where a struggling enterprise ought now to be discontinued. Towards that 
remote contingency nothing will, however, be gained by prolonging the life of the 
existent institution. 

The statistics just given have never been compiled or studied by the average 
medical educator. His stout asseveration that "the country needs more doctors" is 
based on "the letters on file in the dean's office," or on some hazy notion respecting 
conditions in neighboring states. As to the begging letters: selecting a thinly set- 
tled region, I obtained from the dean of the medical department of the University 
of Minnesota a list of the localities whence requests for a physician have recently 
come. With few exceptions, they represent five states: 1 fifty-nine towns in Minne- 
sota want a doctor ; but investigation shows that these fifty-nine towns have already 
one hundred and forty-nine doctors between them ! 2 Forty-one places in North Dakota 
apply ; they have already one hundred and twenty-one doctors. Twenty-one applica- 
tions come from South Dakota, from towns having already forty-nine doctors; seven 
from Wisconsin, from places that had twenty -one physicians before their prayer for 
more was made; six from Iowa, from towns that had seventeen doctors at the time. 
It is clear that the files of the deans will not invalidate the conclusion which a study 
of the figures suggests. They are more apt to sustain it: for the requests in question 
are less likely to mean "no doctor" than poor doctors, 3 a distemper which con- 
tinued over-production on the same basis can only aggravate, and which a change to 
another of the same type will not cure. As to general conditions, no case has been 
found in which a single medical educator contended that his own vicinity or state 
is in need of more doctors: it is always the "next neighbor." Thus the District of 
Columbia, with one doctor for every two hundred and sixty-two souls, maintains 
two low-grade medical schools. "Do you need more doctors in the District?" was 
asked of one of the deans. "Oh, no, we are making doctors for Maryland, Virginia, 
and Pennsylvania," for Maryland, with seven medical schools of its own and one 
doctor for every six hundred and fifty-eight inhabitants; for Virginia, with three 
medical schools of its own and one doctor for every nine hundred and eighteen; for 
Pennsylvania, with its eight schools and one doctor for every six hundred and thirty- 
six persons. 

With the over-production thus demonstrated, the commercial treatment of medi- 
cal education is intimately connected. Low standards give the medical schools ac- 
cess to a large clientele open to successful exploitation by commercial methods. The 

1 The general distribution in these states shows that over-production prevails in new states as in old 
ones : Minnesota 1 : 981 ; South Dakota 1 : 821 ; Iowa 1 : 605; North Dakota 1 : 971 ; Wisconsin 1 : 936. 

* Ten of the fifty-nine were without registered physicians ; but of these ten, two are not to be found 
on the map, two more are not in the Postal Guide; of the other six, four are in easy reach of doctors ; 
two, with a combined population of one hundred and fifty, are out of reach. 

8 Occasionally these applications, which create the impression of a dearth, come from apothecaries 
who have a rear office to rent, a physician with a practice to sell, etc. 



HISTORICAL AND GENERAL 19 

crude boy or the jaded clerk who goes into medicine at this level has not been moved 
by a significant prompting from within; nor has he as a rule shown any forethought 
in the matter of making himself ready. He is more likely to have been caught drift- 
ing at a vacant moment by an alluring advertisement or announcement, quite com- 
monly an exaggeration, not infrequently an outright misrepresentation. Indeed, the 
advertising methods of the commercially successful schools are amazing. 1 Not infre- 
quently advertising costs more than laboratories. The school catalogues abound in 
exaggeration, misstatement, and half-truths. 3 The deans of these institutions occasion- 
ally know more about modern advertising than about modern medical teaching. They 
may be uncertain about the relation of the clinical laboratory to bedside instruction ; 
but they have calculated to a nicety which "medium" brings the largest "return." 
Their dispensary records may be in hopeless disorder; but the card system by which 
they keep track of possible students is admirable. Such exploitation of medical edu- 
cation, confined to schools that admit students below the level of actual high school 
graduation, is strangely inconsistent with the social aspects of medical practice. The 
overwhelming importance of preventive medicine, sanitation, and public health 
indicates that in modern life the medical profession is an organ differentiated by so- 
ciety for its own highest purposes, not a business to be exploited by individuals ac- 
cording to their own fancy. There would be no vigorous campaigns led by enlight- 
ened practitioners against tuberculosis, malaria, and diphtheria, if the commercial 
point of view were tolerable in practice. And if not in practice, then not in educa- 
tion. The theory of state regulation covers that point. In the act of granting the 
right to confer degrees, the state vouches for them ; through protective boards it still 
further seeks to safeguard the people. The public interest is then paramount, and 
when public interest, professional ideals, and sound educational procedure concur 
in the recommendation of the same policy, the time is surely ripe for decisive action. 



1 One school offers any graduate who shall have been in attendance three years a European trip. 

2 See chapter viii., " Financial Aspects of Medical Education," especially p. 135. 

3 A few instances may be cited at random : 

Medical Department, University of Buffalo: "The dispensary is conducted in a manner unlike that 
usually seen. . . . Each one will secure unusually thorough training in taking and recording of his- 
tories (p. 25). There are no dispensary records worthy the name. 

Halifax Medical College: "First-class laboratory accommodation is provided for histology, bacte- 
riology and practical pathology" (p. 9). One utterly wretched room is provided for all three. 

Medical Department, University of Illinois: "The University Hospital ... contains one hundred 
beds, and its clinical advantages are used exclusively for the students of this college " (p. 56). Over 
half of these beds are private, and the rest are of but limited use. 

Western University (London, Ontario): Clinical instruction. "The Victoria Hospital . . . now con- 
tains two hundred and fifty beds, and is the official hospital of the City of London," etc. (p. 14). On 
the average, less than thirty of these beds are available for teaching. 

The Medical Department of the University of Chattanooga : "The latest advances" are taught "in 
the most entertaining and instructive manner;" professors are "chosen for their proficiency ;' "spec- 
ulative research pertains " to the department of physiology ; the department of pathology is " pro- 
vided with a costly collection of specimens and generous supply of the best microscopes (one, as a 
matter of fact); " the hospitals afford numerous cases of labor' ! 



CHAPTER II 

THE PROPER BASIS OF MEDICAL EDUCATION 

WE have in the preceding chapter briefly indicated three stages in the develop- 
ment of medical education in America, the preceptorship, the didactic school, 
the scientific discipline. We have seen how an empirical training of varying 
excellence, secured through attendance on a preceptor, gave way to the didactic 
method, which simply communicated a set body of doctrines of very uneven value; 
how in our own day this didactic school has capitulated to a procedure that seeks, 
as far as may be, to escape empiricism in order to base the practice of medicine on 
observed facts of the same order and cogency as pass muster in other fields of pure 
and applied science. The apprentice saw disease; the didactic pupil heard and read 
about it; now once more the medical student returns to the patient, whom in the 
main he left when he parted with his preceptor. But he returns, relying no longer 
altogether on the senses with which nature endowed him, but with those senses made 
infinitely more acute, more accurate, and more helpful by the processes and the in- 
struments which the last half-century's progress has placed at his disposal. This is 
the meaning of the altered aspect of medical training : the old preceptor, be he never 
so able, could at best feel, see, smell, listen, with his unaided senses. His achieve- 
ments are not indeed to be lightly dismissed; for his sole reliance upon his senses 
greatly augmented their power. Succeed as he might, however, his possibilities in the 
way of reducing, differentiating, and interpreting phenomena, or significant aspects 
of phenomena, were abruptly limited by his natural powers. These powers are nowa- 
days easily enough transcended. The self-registering thermometer, the stethoscope, the 
microscope, the correlation of observed symptoms with the outgivings of chemical 
analysis and biological experimentation, enormously extend the physician's range. 
He perceives more speedily and more accurately what he is actually dealing with; 
he knows with far greater assurance the merits or the limitations of the agents which 
he is in position to invoke. Though the field of knowledge and certainty is even yet 
far from coextensive with the field of disease and injury, it is, as far as it goes, open 
to quick, intelligent, and effective action. 

Provided, of course, the physician is himself competent to use the instrumentali- 
ties that have been developed! There is just now the rub. Society reaps at this mo- 
ment but a small fraction of the advantage which current knowledge has the power 
to confer. That sick man is relatively rare for whom actually all is done that is at 
this day humanly feasible, as feasible in the small hamlet as in the large city, in 
the public hospital as in the private sanatorium. We have indeed in America medi- 
cal practitioners not inferior to the best elsewhere; but there is probably no other 
country in the world in which there is so great a distance and so fatal a difference 
between the best, the average, and the worst. 



PROPER BASIS OF MEDICAL EDUCATION 21 

The attempt will be made in this chapter and the next to account for these dis- 
crepancies in so far as they are traceable to circumstances that antedate the formal 
beginning of medical education itself. The mastery of the resources of the profession 
in the modern sense is conditioned upon certain definite assumptions, touching the 
medical student's education and intelligence. Under the apprentice system, it was not 
necessary to establish any such general or uniform basis. The single student was in 
personal contact with his preceptor. If he were young or immature, the preceptor 
could wait upon his development, initiating him in simple matters as they arose, 
postponing more difficult ones to a more propitious season ; meanwhile, there were 
always the horses to be curried and the saddle-bags to be replenished. In the end, if 
the boy proved incorrigibly dull, the perceptor might ignore him till a convenient 
excuse discontinued the relation. During the ascendancy of the didactic school, it was 
indeed essential to good results that lecturers and quizmasters should be able to 
gauge the general level of their huge classes ; but this level might well be low, and 
in the common absence of conscientiousness usually fell far below the allowable 
minimum. In any event, the student's part was, parrot-like, to absorb. His medical 
education consisted largely in getting by heart a prearranged system of correspon- 
dences, an array of symptoms so set off against a parallel array of doses that, 
if he noticed the one, he had only to write down the other: a coated tongue a 
course of calomel; a shivery back a round of quinine. What the student did not 
readily apprehend could be drilled 1 into him towards examination time by 
those who had themselves recently passed through the ordeal which he was now 
approaching; and an efficient apparatus that spared his senses and his intellect as 
entirely as the drillmaster spared his industry was readily accessible at tempt- 
ingly low prices in the shape of "essentials" and "quiz-compends." Thus he got, and 
in places still gets, his materia medica, anatomy, obstetrics, and surgery. The med- 
ical schools accepted the situation with so little reluctance that these compends 
were and occasionally still are written by the professors 2 and sold on the pre- 

1 "A reiteration of undisputed facts in their simplest expression," is Bigelow's way of putting it. Loe. 
cit., p. 11. 

2 From the last catalogues of certain medical publishers : 

" QUIZ-COMPENDS : " 

Physiology, by A. P. Brubaker, Professor of Physiology, Jefferson Medical College, Philadelphia. 

Oynecology, by Wm. H. Wells, Demonstrator of Clinical Obstetrics, Jefferson Medical College, 

Philadelphia. 

Surgery, by Orville Horwitz, Prof, of Genito-Urinary Surgery, Jefferson Medical College, Philadelphia. 

Diseases of Children, by Marcus P. Hatfield, Professor of Diseases of Children, Chicago Medical College. 

Special Pathology, by A. E. Thayer, Professor of Pathology, University of Texas. 

"ESSENTIALS:" 

Surgery, by Edward Martin, Professor of Clinical Surgery, University of Pennsylvania. 

Anatomy, by C. B. Nancrede, Professor of Surgery, University of Michigan. 

Obstetrics, by W. E. Ashton, Professor of Gynecology, Medico-Chirurgical College, Philadelphia. 

Oynecology, by E. B. Cragin, Professor of Obstetrics, Columbia University. 

Histology, by Louis Leroy, Professor of Medicine, College of Physicians and Surgeons, Memphis. 

Diseases of the Skin, by H. W. Stelwagon, Prof, of Dermatology, Jefferson Medical College, Phila. 

Diseases of the Eye, by Edward Jackson, Professor of Ophthalmology, University of Colorado. 



22 MEDICAL EDUCATION 

raises. 1 Under such a regime anybody could, as President Eliot remarked, "walk into 
a medical school from the street," and small wonder that of those who did walk in, 
many "could barely read and write." 2 But with the advent of the laboratory, in which 
every student possesses a locker where his individual microscope, reagents, and other 
paraphernalia are stored for his personal use; with the advent of the small group bed- 
side clinic, in which every student is responsible for a patient's history and for a trial 
diagnosis, suggested, confirmed, or modified by his own microscopical and chemical 
examination of blood, urine, sputum, and other tissues, the privileges of the medical 
school can no longer be open to casual strollers from the highway. It is necessary to 
install a doorkeeper who will, by critical scrutiny, ascertain the fitness of the appli- 
cant: a necessity suggested in the first place by consideration for the candidate, 
whose time and talents will serve him better in some other vocation, if he be unfit 
for this; and in the second, by consideration for a public entitled to protection from 
those whom the very boldness of modern medical strategy equips with instruments 
that, tremendously effective for good when rightly used, are all the more terrible 
for harm if ignorantly or incompetently employed. 

A distinct issue is here presented. A medical school may, the law permitting, eschew 
clinics and laboratories, cling to the didactic type of instruction, and arrange its 
dates so as not to conflict with seedtime and harvest ; or it may equip laboratories, 
develop a dispensary, and annex a hospital, pitching its entrance requirements on a 
basis in keeping with its opportunities and pretensions. But it cannot consistently 
open the latter type of school to the former type of student. It cannot provide 
laboratory and bedside instruction on the one hand, and admit crude, untrained boys 
on the other. The combination is at once illogical and futile. The funds of the school 
may indeed procure facilities; but the intelligence of the students can alone ensure 
their proper use. Nor can the dilemma be evaded by alleging that a small amount 
of laboratory instruction administered to an unprepared medical student makes a 
"practitioner," while the more thorough training of a competent man makes a "sci- 
entist."* At the level at which under the most favorable circumstances the medical 
student gets his education, it is absurd to speak of an inherent conflict between science 
and practice. We shall have occasion later to touch on the relation of teaching and 

1 For example, in the Atlanta College of Physicians and Surgeons ; Medical Department, University 
of Nashville ; North Carolina Medical College (Charlotte); Medical Department, University of Pitts- 
burgh; John A. Creighton Medical College (Omaha, Nebraska); Starling-Ohio Medical College 
(Columbus); George Washington University (D. C.). 

2 The American Medical Asiociation Bulletin, vol. iii., no. 5, p. 262. 

* At a medical convention recently held, a professor in an institution on the basis of a "high school 
education or its equivalent," made this point in a speech, as against the medical department of 
a university, which requires for entrance college work: TTie lower-grade institution made "doctors," it 
was averred; the higher made only " scientists." Now it chances that for the last two years both sets 
of students have submitted to a practical examination in subjects like urinalysis, which assuredly it 
behooves the "doctor" as well as the "scientist" to master. At these examinations the "doctors" 
show an average of 59 percent; the "scientists," 77 per cent. On the combined written and practical 
examinations this year, the "doctors" in question averaged 65.2 per cent, the "scientists" averaged 
83.1 percent. 



PROPER BASIS OF MEDICAL EDUCATION 23 

research, 1 between which it is necessary to establish a modus Vivendi. But that pro- 
blem has nothing to do with the point now under discussion, viz., as to how much 
education or intelligence it requires to establish a reasonable presumption of fitness 
to undertake the study of medicine under present conditions. 

Taking, then, modern medicine as an attempt to fight the battle against disease 
most advantageously to the patient, what shall we require of those who propose to 
enlist in the service? To get a somewhat surer perspective in dealing with a ques- 
tion around which huge clouds of dust have been beaten up, let us for a moment 
look elsewhere. A college education is not in these days a very severe or serious dis- -4 
cipline. It is compounded in varying proportions of work and play; it scatters I 
whatever effort it requires, so that at no point need the student stand the strain of 
prolonged intensive exertion. Further, the relation of college education to specific 
professional or vocational competency is still under dispute. It is clear, then, that a 
college education is less difficult, less trying, less responsible, than a professional edu- 
cation in medicine. It is therefore worth remarking that the lowest terms upon which 
a college education is now regularly accessible are an actual four-year high school 
training, scholastically determined, whether by examination of the candidate or by 
appraisement of the school. 

Technical schools of engineering and the mechanic arts afford perhaps an even 
more illuminating comparison. These institutions began, like the college, at a low 
level; but they did not long rest there. Their instruction was too heavily handicapped 
by ignorance and immaturity. To their graduates, tasks involving human life and 
welfare were committed : the building of bridges, the installation of power plants, 
the construction of sewage systems. The technical school was thus driven to seek stu- 
dents of greater maturity, of more thorough preliminary schooling, and strictly to 
confine its opportunities to them. Now it is noteworthy that, though in point of in- 
tensive strain the discipline of the modern engineer equals the discipline of the mod- 
ern physician, in one important respect, at least, it is less complex and exacting. 
The engineer deals mainly with measurable factors. His factor of uncertainty is within 
fairly narrow limits. The reasoning of the medical student is much more complicated. 
He handles at one and the same time elements belonging to vastly different cate- 
gories : physical, biological, psychological elements are involved in each other. More- 
over, the recent graduate in engineering is not at once exposed to a decisive respon- 
sibility ; to that he rises slowly through a lengthy series of subordinate positions that 
search out and complete his education. 2 Between the young graduate in medicine 
and his ultimate responsibility human life nothing interposes. He cannot now- 
adays begin with easy tasks under the surveillance of a superior; the issues of life 

1 See page 55. 

2 It is interesting to observe the tendency towards conferring only a bachelor's degree in engineering 
at graduation instead of the degree of C.E., etc. The bachelor in engineering usually goes to work 
at laborer's wages ; he is years reaching the degree of responsibility with which the graduate in med- 
icine usually begins. 



24 MEDICAL EDUCATION 

and death are all in the day's work for him from the very first. The training of the 
doctor is therefore more complex and more directly momentous than that of the 
technician. Be rt noted, then, that the minimum basis upon which a good school of 
engineering to-day accepts students is, once more, an actual high school education, 
and that the movement towards elongating the technical course to five years con- 
fesses the urgent need of something more. 

There is another aspect of the problem equally significant. The curriculum of the 
up-to-date technical school is heavily weighted, to be sure; but except for mathema- 
tics, the essential subjects with which it starts are separate sciences that presuppose 
no prior mastery of contributory sciences. Take at random the College of Engi- 
neering of the University of Wisconsin. In the first year the science work is chem- 
istry, and though the course is difficult, it demands no preceding acquaintance with 
chemistry itself or with any other science; second-year physics is in the same case, 
and the mechanics of the second semester looks back no further than to the physics 
of the first. 

Very different is the plight of the medical school. There the earliest topics of the 
curriculum proper anatomy, physiology, physiological chemistry already hark 
back to a previous scientific discipline. Every one of them involves already acquired 
knowledge and manipulative skill. They are laboratory sciences at the second, not 
the primary, stage. Consider, for example, anatomy, the simplest and most funda- 
mental of them all. It used to begin and end with the dissection of the adult cada- 
ver. It can neither begin nor end there to-day ; for it must provide the basis upon 
which experimental physiology, pathology, and bacteriology may intelligently be built 
up. Mere dissection does not accomplish this; in addition to gross anatomy, the stu- 
dent must make out under the microscope the normal cellular structure of organ, 
muscle, nerve, and blood-vessel; he must grasp the whole process of structural de- 
velopment. Histology and embryology are thus essential aspects of anatomical study. 
No treatment of the subject including these is possible within the time-limits of the 
modern medical curriculum unless previous training in general biology has equipped 
the student with the necessary fundamental conceptions, knowledge, and technical 
dexterity. It has just been stated that physiology presupposes anatomy on lines involv- 
ing antecedent training in biology; it leans just as hard on chemistry and physics. 
The functional activities of the body propound questions in applied chemistry and 
applied physics. Nutrition and waste what are these but chemical problems within 
the realm of biology? The mechanism of circulation, of seeing, or hearing what 
are these but physical problems under the same qualifications? The normal rhythm 
of physiological function must then remain a riddle to students who cannot think 
and speak in biological, chemical, and physical language. 

All this is, however, only preliminary. The physician's concern with normal pro- 
cess is not disinterested curiosity; it is the starting-point of his effort to comprehend 
and to master the abnormal. Pathology and bacteriology are the sciences concerned 



PROPER BASIS OF MEDICAL EDUCATION 25 

with abnormalities of structure and function and their causation. Now the agents and 
forces which invade the body to its disadvantage play their game, too, according to 
law. And to learn that law one goes once more to the same fundamental sciences 
upon which the anatomist and the physiologist have already freely drawn, viz., bi- 
ology, physics, and chemistry. 

Nor do these apparently recondite matters concern only the experimenting investi- 
gator, eager to convert patiently acquired knowledge of bacterial and other foes into 
a rational system of defense against them. For the practical outcome of such investiga- 
tion is not communicable by rote; it cannot be reduced to prescriptions for mechan- 
ical use by the unenlightened practitioner. Modern medicine cannot be formulated 
in quiz-compends; those who would employ it must trouble to understand it. More- 
over, medicine is developing with beneficent rapidity along these same biological 
and chemical lines. Is our fresh young graduate of five and twenty to keep abreast 
of its progress? If so, he must, once more, understand; not otherwise can he adopt 
the new agents and new methods issuing at intervals from each of a dozen fertile 
laboratories; for rote has no future: it stops where it is. "There can be no doubt," 
said Huxley, "that the future of pathology and of therapeutics, and therefore of 
practical medicine, depends upon the extent to which those who occupy themselves 
with these subjects are trained in the methods and impregnated with the funda- 
mental truths of biology." 1 Now the medical sciences proper anatomy, physiology, 
pathology, pharmacology already crowd the two years of the curriculum that can 
be assigned to them ; and in so doing, take for granted the more fundamental sci- 
ences biology, physics, and chemistry for which there is thus no adequate op- 
portunity within the medical school proper. Only at the sacrifice of some essential 
part of the medical curriculum and for every such sacrifice the future patients pay 
can this curriculum be made to include the preliminary subjects upon which it 
presumes. 

From the foregoing discussion, these conclusions emerge: By the very nature of 
the case, admission to a really modern medical school must at the very least depend 
on a competent knowledge of chemistry, biology, 2 and physics. Every departure from 
this basis is at the expense of medical training itself. From the exclusive standpoint 
of the medical school it is immaterial where the student gets the instruction. But it 
is clear that if it is to become the common minimum basis of medical education, some 
recognized and organized manner of obtaining it must be devised : it cannot be left 
to the initiative of the individual without greatly impairing its quality. Regular pro- 
vision must therefore be made at a definite moment of normal educational progress. 
Now the requirement above agreed on is too extensive and too difficult to be incor- 
porated in its entirety within the high school or to be substituted for a considerable 

1 Quoted by F. T. Lewis in " The Preparation for the Study of Medicine," Popular Science Monthly, 
vol. Ixxv., no. 1, p. 66. 

2 Including botany. 



26 MEDICAL EDUCATION 

portion of the usual high school course ; besides, it demands greater maturity than 
the secondary school student can be credited with except towards the close of his 
high school career. The possibility of mastering the three sciences outside of school 
may be dismissed without argument. In the college or technical school alone can the 
work be regularly, efficiently, and surely arranged for. The requirement is therefore 
necessarily a college requirement, covering two years, because three laboratory courses 
cannot be carried through in a briefer period, a fortunate circumstance, since it 
favors the student's simultaneous development along other and more general lines. 
It appears, then, that a policy that at the outset was considered from the narrow 
standpoint of the medical school alone shortly involves the abandonment of this 
point of view in favor of something more comprehensive. The preliminary require- 
ment for entrance upon medical education must therefore be formulated in terms 
that establish a distinct relation, pedagogical and chronological, between the medi- 
cal school and other educational agencies. Nothing will do more to steady and to 
improve the college itself than its assumption of such definite functions in respect 
to professional and other forms of special training. 

So far we have spoken explicitly of the fundamental sciences only. They furnish, 
indeed, the essential instrumental basis of medical education. But the instrumental 
minimum can hardly serve as the permanent professional minimum. It is even in- 
strumentally inadequate. The practitioner deals with facts of two categories. Chem- 
istry, physics, biology enable him to apprehend one set; he needs a different ap- 
perceptive and appreciative apparatus to deal with other, more subtle elements. 
Specific preparation is in this direction much more difficult; one must rely for the 
requisite insight and sympathy on a varied and enlarging cultural experience. Such 
enlargement of the physician's horizon is otherwise important, for scientific progress 
has greatly modified his ethical responsibility. His relation was formerly to his pa- 
tient at most to his patient's family; and it was almost altogether remedial. The 
patient had something the matter with him; the doctor was called in to cure it. Pay- 
ment of a fee ended the transaction. But the physician's function is fast becoming 
social and preventive, rather than individual and curative. Upon him society relies 
to ascertain, and through measures essentially educational to enforce, the conditions 
that prevent disease and make positively for physical and moral well-being. It goes 
without saying that this type of doctor is first of all an educated man. 

How nearly our present resources educational and economic permit us to ap- 
proach the standards above defined is at bottom a question' of fact to be investigated 
presently. We have concluded that a two-year college training, in which the sciences 
are "featured," is the minimum basis upon which modern medicine can be success- 
fully taught. If the requisite number of physicians cannot at one point or another 
be procured at that level, a temporary readjustment may be required; but such an 
expedient is to be regarded as a makeshift that asks of the sick a sacrifice that must 
not be required of them a moment longer than is necessary. Before accepting such 



PROPER BASIS OF MEDICAL EDUCATION 27 

a measure, however, it is exceedingly important not to confuse the basis on which 
society can actually get the number of doctors that it needs with the basis on 
which our present number of medical schools can keep going. Much depends upon 
which end we start from. 



CHAPTER III 

THE ACTUAL BASIS OF MEDICAL EDUCATION 

TAKING a two-year college course, largely constituted of the sciences, as the normal 
point of departure, let us now survey the existing status. The one hundred and fifty- 
five medical schools of the United States and Canada fall readily into three divisions: 
the first includes those that require two or more years of college work for entrance; 
the second, those that demand actual graduation from a four-year high school or 
oscillate about its supposed "equivalent;" the third, those that ask little or nothing 
more than the rudiments or the recollection of a common school education. 

To the first division sixteen institutions already belong; 1 six more, now demand- 
ing one year of college work, will fully enter the division in the fall of 1910 by re- 
quiring a second; 8 and several more, at this date still in the second division, will 
shortly take the step from the high school to the two-year college requirement. 3 
The Johns Hopkins requires for entrance a college degree which, whatever else it 
represents, must include the three fundamental sciences, French, and German. No 
exception has ever been made to this degree requirement ; but recently admission to 
the second-year class has been granted to students holding an A.B. degree earned 
by four years' study, the last of them devoted to medical subjects in institutions 
where those subjects were excellently taught. 4 At Harvard the degree requirement 
has been somewhat unsettled by a recent decision to admit students without degree, 
provided they have had two years of college science ; they are to be grouped as " spe- 

1 Johns Hopkins, Harvard, Western Reserve, Rush (University of Chicago), Cornell, Stanford, Wake 
Forest (N. C.), Yale, and the state universities of California, Minnesota, North Dakota, Wisconsin, 
Michigan (exclusive of the homeopathic department), Kansas, Nebraska, South Dakota. 

2 Universities of Indiana, Iowa (exclusive of the homeopathic department), Missouri, Pennsylvania, 
Utah, Syracuse. Several institutions ask one year of college work, without as yet definite announce- 
ment as to requirement of the second, e.g., Virginia, Fordham, Northwestern, North Carolina. In 
general, the one-year college requirement is hard to distinguish from the high school requirement, 
for if conditions are allowed, and they always are, it adds but little to the better type of high school 
education. Northwestern has had two years experience under the one-year college requirement, but 
has not yet really enforced it. The University of North Carolina was to require a year of college work, 
1909-10, but students were admitted on the strength of their unsupported statements " as having had 
a college year. . . . Practically, this means that the entrance requirements were not enforced." 

'Columbia, Dartmouth, Colorado. 

4 Practically, this amounts to a recognition of the A.B. degree won after three years of study, a 
movement deserving encouragement rather than criticism, as matters now stand. In fact, the Johns 
Hopkins degree was originally conferred at the close of three years of study, but the academic ma- 
triculation requirement was considerably higher than in institutions granting the A.B. degree after 
four years of study. Recently the academic matriculation has been lowered and the A.B. course 
lengthened to four years. In consequence, the action of the medical department above described in- 
volves unwittingly a curious discrimination against the Johns Hopkins A.B. degree, for this degree 
now requires four years and may not include medical subjects. To get the Johns Hopkins M.D., a 
student has two roads open to him : he may work four years for the Johns Hopkins A.B. and four 
more for its M.D., eight in all; or, starting at exactly the same point, he may get his A.B. in four 
years at an institution that includes in its A.B. the first year in medicine, then enter the Johns Hop- 
kins medical school and get its M.D. in three years, that is, seven years in all. A B.S. degree earned 
in three years, followed by the M.D. earned in four, gives the same result, a preference, once more, 
that operates against the Johns Hopkins A.B. 



ACTUAL BASIS OF MEDICAL EDUCATION 29 

cial" students, and are required to maintain higher standing in order to qualify for 
the M.D. degree. But as these students enter on a general rule and as a matter of 
course, and are, under a slight handicap, eligible to the M.D. degree, they are not 
accurately described as special. A special student is properly one whom no rule fits, 
one whose admission presents certain individual features requiring consideration on 
their merits. Such is not the case with the students under discussion : they enter just 
as regularly as the degree men, and without that limitation as to number which 
makes of the "special student" device something of a privilege. Harvard can thus 
admit any student who is eligible to the schools with the two-year college require- 
ment. 1 The other institutions under discussion telescope the college and medical 
courses: the preliminary medical sciences constitute the bulk of two college years; 1 
the next two years are reckoned twice. They count simultaneously as third and fourth 1 
years of the college and as first and second years of the medical course. At their I 
close the student gets the A.B. degree, but his medical education is already half 
over. Without exception, the schools belonging to this group are high-grade institu- 
tions. They differ considerably, however, in the degree of rigor with which their 
elevated entrance requirements have been enforced from the start. At the University 
of Pennsylvania, for example, in a class of 114, admitted this year (1909-10) on a one- 
year college basis, 75 (66 per cent) are conditioned; at Ann Arbor, of 36 entering on 
the two-year college basis, only 8 are conditioned at all, and those mainly in organic 
chemistry; at Yale, which advanced in 1909-10 from the high school to the two-year 
college basis, in a class of 23, there was only one partial condition in biology, and, 
best of all, failed members of last year's class on the old basis were refused re-admis- 
sion. Experience elsewhere indicates that the percentage of conditions declines 
rapidly as students learn by forethought to adjust their work to their ultimate pur- 
pose, and as the colleges facilitate adjustment by providing the requisite opportuni- 
ties: both of which processes will be accelerated, if the medical schools have the 
courage and the financial strength to close their doors to students who labor 
under anything more than a slight handicap. Here as elsewhere development follows 
hard upon actual responsibility. 

Our second division constitutes the real problem; out of it additional high-grade 
medical schools to the number actually required must be developed. About fifty insti- 
tutions, whose entrance standard approximates high school graduation, belong here. 
Great diversity exists in the quality of the student body of these institutions : the 
regents' certificates in New York, state board supervision in Michigan, the control 
of admission to their medical departments by the academic authorities of McGill 



1 The rule just described went into effect 1909-10 ; two students took advantage of it in a class of 62. 
In 1908 there were 254 students with degrees, 23 without. 

2 Cornell, Western Reserve, and Stanford combine academic and college courses to the extent of 
one year only. The pedagogical aspect of the combined course is discussed pp. 73, 74. 



SO MEDICAL EDUCATION 

and Toronto, insure as capable and homogeneous an enrolment as is obtainable at 
or about the high school level. A few others, not so well protected, are within mea- 
surable distance of the same category, the medical department of Tulane Univer- 
sity and Jefferson Medical College (Philadelphia), for example. In general, however, 
the schools of this division are difficult to classify; 1 for they freely admit students 
on bases that are not only hopelessly unequal to each other, but are even incapable 
of reduction to a common denominator. On their actual standards the catalogue 
statements throw little light: there the requirements are cast in the form of a de- 
scending scale, running from the top, down. Equally acceptable in their sight are a 
bachelor's degree from a college or a university, a diploma from an "accredited" 
high school, an examination in a few specified and several of a wide range of op- 
tional studies, and a certificate from the principal of a high school, normal school, 
or academy, from a "reputable instructor," from a state or city superintendent of 
education, or from a state board of medical examiners, that stamps the applicant 
as possessing the "equivalent" of a high school education. Now it is clear that the 
alternatives at the top are mainly decorative. The real standard is perilously close 
to the "equivalent" that creeps in modestly at the bottom. There is, of course, 
no active prejudice anywhere against Ph.D.'s and A.M.'s and A.B.'s and B.Sc.'s; 
they are apt to be rather conspicuously exploited, when they drift in. But they do 
not set the pace; they do not determine or even vitally affect the character of the 
school. In these instances the medical curriculum either contains the pre-medical 
subjects in an elementary form, or, what may be worse, tries to go ahead entirely 
without them. The real standard is not influenced by the presence of degree men, 
and the wonder is that any of them sacrifice the advantage of a superior education by 
resorting to these institutions. The minimum is, then, the real standard; all else is 
permissive; for to the needs of those admitted at the bottom the quantity and quality 
of the instruction must in fairness conform. 

To get at the real admission standard, then, of these medical schools, one must 
make straight for the "equivalent." On the methods of ascertaining and enforcing 
that, the issue hangs. Now the "equivalent" may be defined as a device that con- 
cedes the necessity of a standard which it forthwith proceeds to evade. The pro- 
fessed high school basis is variously sacrificed to this so-called "equivalent." The 
medical schools under discussion agree to accept at face value only graduation di- 
plomas 2 from "approved" or "accredited" high schools. These terms have a definite 
meaning: they indicate schools which, upon proper investigation, have been recog- 
nized by the state universities of their respective states, or by some other competent 
educational organization, in New England, by the College Entrance Certificate 
Board; in the middle west, by the North Central Association. High schools and acad- 
emies not acceptable at full value to state universities or to the bodies just named 

*In Part II each school is separately characterized. 

2 As a matter of fact, nongraduates are also admitted on certificates a violation of standard, of course. 



ACTUAL BASIS OF MEDICAL EDUCATION 31 

do not belong to the "approved" or "accredited" class: their diplomas and certifi- 
cates are not, therefore, entitled to be received in satisfaction of the announced 
standard. They are nevertheless freely accepted. At Tufts, for example, the first year 
class (1909-10) numbers 151, of whom only little more than half submit creden- 
tials that actually comply with the standard; of the others, 30 are accepted from 
non-accredited schools on the strength of diplomas and certificates entitled to no 
weight on the professed standard of the Tufts Medical School. 1 This is a common 
occurrence. It is defended on the ground that " we know the schools." That is, how- 
ever, quite impossible. The wisdom of Solomon would not suffice to determine the 
actual value of credentials so heterogeneous in origin and content. Universities deal- 
ing with far less various material organize registration and inspection bureaus for 
their protection and enlightenment. But not infrequently the medical departments 
of these very institutions, pretending to stand on the same basis as the academic de- 
partment, refrain from seeking the aid of the university registration office. The me- 
dical department of Bowdoin is on the college campus, yet its authorities accept cer- 
tificates that the college would refuse; the medical departments of Vanderbilt, Tufts, 
George Washington University, Creighton (Omaha), Northwestern, the Universities 
of Vermont and Pennsylvania, 2 are in easy reach of intelligent advice which they 
do not systematically utilize. In striking contrast, the medical department of the 
University of Texas at Galveston refers all credentials to the registration office of 
the university at Austin, the action of which is final. 

If the standard were enforced, the candidates in question, not offering a gradua- 
tion diploma from an accredited high school, would be compelled to enter by written 
examination. But the examination is, as things stand, only another method of eva- 
sion. Neither in extent nor in difficulty do the written examinations, in the rela- 
tively rare cases in which they are given, even approximate the high school stan- 
dard. Nor are they meant to do so. Colleges with medical departments of the kind 
under discussion do not expect academic and medical students to pass the same or 
the same kind of examination: a special set of questions is prepared for the medical 
candidates, including perhaps half the subjects, and each of these traversing about half 
the ground covered by the academic papers. At Tufts, the medical matriculate attempts 
six papers, representing, all told, less than two years of high school work ; and he is 
accepted on condition if he passes three. 3 Papers of similar quality are put forward at 
Boston University ; those at Bowdoin are more extensive and more difficult, though 
still below the supposedly equal academic standard. The written examinations held 
under the authority of the state boards in Kentucky, Pennsylvania, Missouri,* are of 

1 Those still remaining are commented on below. 

2 The academic authorities here pass on the college year. 

s Of the class above mentioned 38 were admitted by examination. 

4 A St. Louis cramming establishment, conducted by the wife of a teacher in a local medical school, 
offers to prepare in a single year, according to the Missouri standard, a boy who has never had any 



82 MEDICAL EDUCATION 

the same insufficient character. In Michigan they fairly well approximate high school 
value, in consequence of which they are decidedly unpopular. 1 In Illinois the writ- 
ten examination has been transformed into an informal after-dinner conversation 
between candidate and examiner, as we shall presently discover. 

There remains still a third method of cutting below an actual high school stan- 
dard, the method indeed that provides much the most capacious loophole for the 
admission of unqualified students under the cloak of nominal compliance with the 
high school standard. The agent in the transactions about to be described is the 
medical examiner, appointed in some places by voluntary agreement between 
the schools, elsewhere delegated by the state board, 2 or by the superintendent of 
public instruction acting in its behalf, for the purpose of dealing with students who 
present written evidence other than the diploma of an accredited high school. It is 
intended and expected that this official shall enforce a high school standard. In 
few states is this standard achieved. The education department in New York, the 
state boards in Minnesota and Michigan, maintain what may be fairly called a scho- 
lastically honest high school requirement; for they require a diploma represent- 
ing an organically complete secondary school education, properly guaranteed, or, in 
default thereof, a written examination covering about the same ground : there is no 
other recourse. 

Elsewhere the state board is legally powerless, as in Maryland, or unwilling to an- 
tagonize the schools, as in Illinois and Kentucky. The outside examiners, agreed on 
by the schools in the former case, designated by law in the latter, fall far short of 
enforcing a high school standard. The examiner, even where distinctly well inten- 
tioned, as in Kentucky, never gets sufficient control. The schools do not want the 
rule enforced, and the boards are either not strong enough or not conscientious enough 
to withstand them. Besides, the examiners lack time, machinery, and encouragement 
for the proper performance of their ostensible office. They are busy men : here, a 
county official; there, a school principal; elsewhere, a high school professor. 3 A single 
individual, after his regular day's work is over, without assistance of any kind, is 
thus expected to perform a task much more complicated than that for which Harvard, 
Columbia, and the University of Michigan maintain costly establishments. There is 

high school training at all. It is pointed out that by matriculating at once the student may escape 
any subsequent advance in entrance requirements. 

1 In Ohio the examinations are fairly representative of high school values, as far as they go. But up to 
this time they have not covered a complete high school course and they have little influence on enrol- 
ment, as tutor-certificates are freely accepted in their stead. 

*In these cases, the requirement is really a practice, not an educational regulation. But the effect is 
the same. 

Occasionally the school has an "arrangement" by which defective candidates are referred to a 
"coach," who is simultaneously "examiner ;" he thus approves his own work. This is the practice of 
the George Washington University medical department. Again, the school refers defective candi- 
dates to the preparatory department of its own university, and shortly after admits them on an as- 
surance of the "equivalent from that source. This is the Creighton school (Omaha) plan ; out of 56 
members of its first-year class (1908-9), 23 were admitted on certificates (not diplomas) of this kind. 



ACTUAL BASIS OF MEDICAL EDUCATION 33 

no set time when candidates must appear. They drop in as they please, separately: 
now, before the medical school opens, again, long after ; sometimes with their creden- 
tials, sometimes without them. There is no definite procedure. At times, the examiner 
concludes from the face of the papers; at times from the face of the candidate. The 
whole business is transacted in a free and easy way. In Illinois, for example, the law 
speaks of "preliminary" educational requirements; the state board graciously permits 
them to become subsequents. Students enter the medical schools, embark on the study 
of medicine, and at their convenience "square up" 1 with one of the examiners. An 
evening call is arranged ; there is an informal talk, aiming to elicit what "subjects" 
the candidate "has had." He may, after an interview lasting from thirty minutes to 
two hours, and rarely including any writing, be "passed" with or without "condi- 
tions;" if with conditions, the rule requires him to reappear for a second "exam- 
ination" before the beginning of the sophomore year; but nothing happens if he 
postpones his reappearance until a short time before graduation. 2 Besides, a condi- 
tion in one subject may be removed by "passing" in another! "No technical ques- 
tions are asked; the presumption is that the applicant won't remember details." 
Formerly, written examinations were used in part ; but they were given up " because 
almost everybody failed." And it may at any moment happen that an applicant actu- 
ally turned down by one examiner will be passed by another. The most flagrantly 
commercial of the Chicago schools 3 operate "pre-medical" classes, where a hasty 
cram, usually at night, suffices to meet the academic requirements of the Illinois 
state board: "the examiner's no prude, he'll give a man a chance," said the dean of 
one of them. 

In Pennsylvania there was until quite lately no high school requirement by law; 
but recent legislation fixes the high school or its equivalent, on which the better 
schools had previously agreed, as the legal minimum. Its value has hitherto varied. 
In the first place, the examiners have accepted three-year high school graduates: 
"They come every day and are not turned down." In the second place, the alterna- 
tives in the matter of studies are so many that he must indeed have had narrow op- 

1 Quotation marks indicate throughout words taken down on the spot in the course of interviews 
with officials. 

2 New York, while dealing strictly with applicants for practice who have been educated in New York 
state, deals somewhat more leniently with the outsider. The New York law provides that to be "re- 
gistered as maintaining a proper medical standard, "a school must, among other things, "require that 
before beginning the course for the degree, all matriculates afford evidence of a general preliminary 
education equivalent to at least a four-year high school course," etc. (Handbook 9, April, 1908, p. 45.) 
As a matter of fact, a student who received his degree from a school on the accredited or registered 
list (ibid., pp. 48-70) may, on applying for registration in New York, find his preliminary education 
to have been below the New York standard. In certain circumstances, he may be allowed to make 
good his defects, provided they are of limited scope. He is thus bringing his "preliminary " education 
up to standard, after he has received his M.D. degree. This is a concession that the New York Edu- 
cation Department makes to the loose educational administration of other states. It is to be hoped 
that after due notice given it may be discontinued. The offending schools may very properly be ex- 
cluded from the list. 

3 Bennett Medical College, Illinois Medical College, Jenner Medical College, Chicago Night Univer- 
sity, Reliance Medical College. 



34 MEDICAL EDUCATION 

portunities who cannot piece together scraps enough to gain conditional admission. 
"The more subjects, the more points," one dean is quoted as saying. Partial certifi- 
cates a year's work taken here, a subject or part of a subject taken there may be 
added up until the sum equals arithmetically the "units" of a high school course. 
Moreover, the same subject can be counted twice: English grammar and rhetoric are 
two subjects, not one; so are English literature and English classics; so biology and 
zoology. Now, aside from these duplications, it is absurd to sum up fragmentary or 
isolated "credits" of this kind as "equivalent" to a high school course, even if the 
details were each adequately tested, as they are not. For a school curriculum is an 
organic thing in whose continuity and interrelations its educational virtue resides. 
One subject bears upon another; one year reinforces another. A curriculum has, as 
such, unity, purpose, method. It is not merely a question of time, still less of de- 
tached specified amounts without reference to time. 1 

Things are not essentially different in Baltimore, where the entire matter is regu- 
lated by voluntary action on the part of the three schools belonging to the division 
under consideration. The "examination" is of the usual kind: "on a strict account- 
ing they would all fail." In Louisville, students are admitted into the local school, 
the medical department of the University of Louisville, by either examination or 
certificate. The examination covers less than a four-year high school course; certifi- 
cates are accepted from two-year high schools as full satisfaction of the requirements. 
Worse still, the school also admits students without either, in flat disregard of its 
professed standard and of the state board. St. Louis, Denver, Nashville, Pittsburgh, 
furnish further illustration. In none of these does the examiner exact, whether 
through examination or in evaluation of certificates, the preliminary standard which 
he is ostensibly appointed to enforce. In most cases the very word "preliminary" is 
a misnomer, just as we have found it to be in Illinois. For example, the Ohio re- 
quirement is not really preliminary to medical education. The schools on the so-called 
high school or equivalent basis admit students who have not completely satisfied the 
examiner. Strictly speaking, these students should not be allowed to proceed to the 
sophomore class; for their medical school credits beyond the first year cannot count 
until after the admission requirements have been satisfied. Meanwhile they may 
have reached the senior class. And the moment they satisfy the examiner in re- 
spect to "preliminaries," now "subsequents" to the extent of two or three years, that 
moment their previous work in the medical school automatically becomes "good." 
At Vanderbilt the first-year class had been studying two months, yet not a single 
"preliminary" credential had been even submitted to the examiner; at Louisville 

1 It is useless to review all the states separately, for the differences are not very significant. Ohio, 
however, may be instanced as a state in transit towards the Michigan standard. At present, the ex- 
aminer accepts as equivalent to graduation from an approved high school several alternatives, none 
of which is really equivalent: (1) whole years taken in different institutions, provided they sum up 
four; (2) certificates from "known instructors," testifying that candidates have "made up" condi- 
tions, no fixed periods of study being required in such cases; (3) examinations, covering hitherto 
less than the high school course. 



ACTUAL BASIS OF MEDICAL EDUCATION 35 

work begins November 15, but students have until January 8 before even calling on 
that functionary. Even Michigan wavers here: for March 1, 1910, had come around 
before all the first-year students of the Detroit School of Medicine had satisfied 
the state board. In such cases the requirement may be preliminary to graduation, 
or to practice, or to what-not; it is absurd to regard it as preliminary to medical 
education. For the whole purpose of a preliminary is to guarantee a certain degree 
of training, maturity, and knowledge before the student crosses the threshold of the 
medical school, on the ground that he is not fit to cross the threshold without it; 
and this purpose is abandoned if he is allowed to enter without it and subsequently, 
by hook or crook, in hastily snatched moments, to go through the form of a perfunc- 
tory compliance that becomes complete some time before he comes up for his M.D. 
degree. There is no retroactive virtue in such a feat. Educational futility can go no 
farther. A high school "preliminary requirement, 11 scrappily accumulated as a side 
issue incidental to attendance in the medical school, is worse than nothing to the 
extent that it has interfered with undivided attention to medical study. 1 

To all the disorder that prevails in schools of this grade in the United States, 
the Canadian schools at the same level present, with two exceptions, 2 a forcible 
contrast. There, too, "equivalents" are accepted; but they are equivalents in fact 
as in name, for they are probed by a series of written examinations, each three 
hours in length, held at a stated time and place, only and actually in advance of 
the opening of the medical school, entrance to which is absolutely dependent on 
their outcome. 

The quality of the student body thus accumulated in the schools under discussion 
bears out the above description. "The facilities are better than the students;" "the 
boys are imbued with the idea of being doctors ; they want to cut and prescribe ; all 
else is theoretical;" students accepted in chemistry or physics "don't know a baro- 
meter when they see it ;" "it is difficult to get a student to want to repeat an experi- 
ment (in physiology). They have neither curiosity nor capacity." "The machinery 
does n't stop the unfit." " Men get in, not because the country needs the doctors, but 
because the schools need the money. 1 " " What is your honest opinion of your own 
enrolment?" a professor in a Philadelphia school was asked. "Well, the most I would 
claim," he answered, "is that nobody who is absolutely worthless gets in"! 

1 Some state boards are already in possession of the legal right to enforce a preliminary requirement. 
The Illinois law, for example, says : "The State Board of Health shall be empowered to establish a 
standard of preliminary education deemed requisite to admission to a medical college in good stand- 
ing" (par. 6 b, ch. 91, Kurd's Revised Statutes, 1908). The board is apparently free to refuse ex- 
amination to any applicant whose completed entrance certificate does not bear date four years 
prior to his M.D. diploma. The present policy of the Illinois board thus squarely contravenes the 
obvious intention or the statute. Contrast with this lax procedure the Scotch requirement: "The 
student must within fifteen days of the commencement of study, obtain registration." (Regulations 
for the Triple Qualification, ch. i. 2.) 

8 Laval University, Montreal, which admits students below grade ; but they must come to the United 
States to practise, for they have no standing in Canada ; and Western University, London, Ont., 
which leaves the entire question to the discretion of the student, who, it is supposed, will conform 
to the local requirement of the place in which he expects to settle. 



86 MEDICAL EDUCATION 

We have still to deal with schools of our third division. They are most numerous 
in the south, but they exist in almost all medical "centers," San Francisco, Chicago, 
there plainly on the sufferance of the state board, for the law, if enforced, would 
stamp them out, St. Louis and Baltimore. Outside the south they usually make 
some pretense of requiring the "equivalent" of a high school education; but no ex- 
aminer of any kind is employed, and the deans are extremely reluctant to be pinned 
down. Southern schools of this division, after specifying an impressive series of ac- 
ceptable credentials ranging once more from university degrees downward, announce 
their satisfaction with a "grammar school followed by two years of a high school," 
or in default thereof a general assurance of adequate "scholastic attainments" by a 
state, city, or county superintendent, or some other person connected with education 
or purporting to be such ; but the lack of such credentials is not very serious, for 
the student is admitted without them, with leave to procure them later. Many of 
the schools accept students from the grammar schools. Credentials, if presented, are 
casually regarded and then usually returned ; a few may be found, rolled up in a 
rubber band, in a dusty pigeonhole. There is no protection against fraud or forgery. 
At the College of Medicine and Surgery, Chicago, a thorough search for credentials 
or some record of them was made by the secretary and several members of the fac- 
ulty, through desk drawers, safe, etc., but without avail. The school is nevertheless 
in "good standing " with the Illinois state board, and is "accredited" by the New York 
Education Department to the extent of three years' work. At the medical department 
of the University of Georgia I was told : " We go a long way on faith." In visits to med- 
ical colleges certificates were found from non-existent schools as well as from non-exis- 
tent places. 1 Of course a few fairly competent students may be found sprinkled in these 
institutions. But for the most part, the student body gets in on the "equivalent." 
At the Atlanta School of Medicine, 73 per cent of last year's first-year class entered 
thus; at the Mississippi Medical College (Meridian, Mississippi), 80 per cent; at Bir- 
mingham Medical College, 62 per cent. In point of quality, the classes are not com- 
petent to use such opportunities as are provided. In Atlanta the Grady Hospital is open 
for bedside clinics to groups of six students; on the average, two come. In Chattanooga 
it is "rare to get a medical student who knows even a little algebra; it is impossible 
to use with medical students the text-books in science used in freshman academic 
classes." At Charlotte I was told that "it is idle to talk of real laboratory work for 

1 Accepted certificates are in this form : 

To Dean : 

Sir : I have examined Mr , of , and find his scholastic attainments equal 

to those requisite for a first-grade teacher's certificate in our public schools, with the equivalent of two years 
of high school study. 

Yours very truly. 

(Siffn here) Superintendent of Public Inttruction. 

These are furnished to the student by the medical college ; he needs only to have them signed. The 
college does not investigate the signature ; no official mark or seal is asked. Even the medical de- 
partment of Vanderbilt accepts preliminary certificates in this form. 



ACTUAL BASIS OF MEDICAL EDUCATION 37 

students so ignorant and clumsy. Many of them, gotten through advertising, would 
make better farmers. There's no use in having apparatus for experimental physio- 
logy the men couldn't use it; they're all thumbs." 

Statistical proof of inadequacy of preparation is furnished by what one may fairly 
call the abnormal mortality within schools operating on the basis of "equivalents." 
The standards of promotion in these schools watch narrowly the action of the 
state boards, which are usually lenient. The schools are too weak financially to do 
otherwise; doubtful points are resolved in the boy's favor. 1 Hence the school exam- 
inations play less havoc than would follow tests strictly constructed in the public 
interest. Yet the mortality from one cause or another by the close of the first year 
runs from 20 to 50 per cent. At the Medico-Chirurgical College of Philadelphia an 
initial first-year enrolment of 152 in October fell to 100 2 by the following January 
first; of these, 60 passed without conditions, much less than one-half the original 
class enrolment; at Tufts the entering class 19089 shows in the catalogue an enrol- 
ment of 141 ; 75 were promoted, with or without conditions, into the sophomore 
class; 3 at Cornell, on its former high school basis, the failures at the close of the first 
year in a period often years averaged 28 per cent; at Buffalo, the failed and condi- 
tioned of three successive first-year classes amounted to 40 per cent of the total en- 
rolment; at Vanderbilt, out of a class of 70, the dropped, conditioned, and failed 
amounted to 44 per cent; at the College of Physicians and Surgeons, Atlanta, 70 per 
cent, out of a class of 99. In schools on the higher basis, i.e., two years of college 
work or better, the instruction is more elaborate, the work more difficult, and the 
examinations harder; for scientific ideals rather than chances with the state board 
dominate. Yet the mortality drops decisively. At the Johns Hopkins, the mortality 
during three successive years averages less than 5 per cent, only half of which is due 
to failure; at Ann Arbor, on the one-year college basis, the mortality is below 10 per 
cent. The exhibit made by institutions that have tried both standards is especially 
instructive. At the University of Missouri, during the last three years of the high 
school or equivalent basis, there was a mortality due to actual failure of 35 per cent; 
during the following three years, when one year of college work was required, the 
mortality fell to 12 percent. At the medical department of the University of Minne- 
sota, during the last three years of the high school requirement, the mortality was 

1 The dean of one school admitted that he carried "men easily from class to class, but plucked them 
in the last year," an excellent thing for the school : it collects three years' fees and still avoids a low 
record in the state board examinations. 

2 Some dropped out because unable to qualify, a few for lack of funds, others because of inability to 
do the work ; but the enormous number that drop or fail throws a strong light on the miscellaneous 
character of the enrolment obtained on the "equivalent" basis. 

3 It is relatively immaterial to our argument what became of the other 66 ; they represent fatalities 
for most of which low standards are to blame. As a matter of fact they are thus accounted for : 14 
were dropped students (not catalogued with their class on account of conditions); 20 failed of pro- 
motion ; 17 took all or a portion of first-year examinations 1908-9, but did not return 1909-10 ; 15 left 
before the final examinations. 



88 MEDICAL EDUCATION 

18 per cent; 1 in the three years following, on the basis of one year of college work, 
the mortality was about 10 per cent. At the University of Virginia, in the last two 
years on the old basis, 38 per cent of the students failed in one or more subjects; an 
increase in entrance requirements by one college year reduces the fatalities to 14 
per cent, despite the augmented difficulty of the work. The medical department of 
the University of Texas has gradually advanced from a two-year high school basis 
to a four-year high school basis; on the lower standard there were 34 per cent of 
hopeless failures in 1903, as against 13 per cent of hopeless failures in 1908, on the 
higher. The requirement of a college year assists doubly, first, in eliminating the 
sham equivalents; next, in strengthening the equipment of those who actually persist. 
Canada accomplishes the former by means of the examinations already noticed, with 
the result that the mortality there is distinctly less than ours, at something like the 
same ostensible level. 2 

The breaches made by the fatalities above described are repaired by immigration, 
which on investigation proves to be in most instances only another way of evading 
standards, entrance and other. To some extent, good students who find themselves 
in a poor school endeavor to retrieve their error by transferring themselves to a 
better ; again, there is a certain amount of enforced emigration annually from schools 
that, like the University of Wisconsin, offer medical instruction in the first two 
years only. In the main, however, the " lame ducks" move, and, strangely enough, 
into schools that are at the moment engaged in rejecting a number equally lame. 
The interchange is veiled by pretended examinations; but the character of the 
examination can be guessed from the quality of the students that pass it. Two 
standards are thus often broken at once : An ill equipped student registers in a low- 
grade Chicago school. At the close of a year or two, he transfers to the College of 
Physicians and Surgeons, which might have declined him originally. He has thus cir- 
cumvented its admission requirements. If, now, he has previously failed in the medical 
coursessofarpursued,and succeeds "on examination" in passing, he has simultaneously 
circumvented the professional requirements as well. Instances of both kinds abound 
in schools at and below the high school basis. In 1908-9 the Medico-Chirurgical 
College of Philadelphia accepted failures from the Jefferson Medical College and 

1 This relatively low mortality is to be ascribed to the fact that the student body, though on the high 
school basis, contained no "equivalents." 

1 A tabular statement will perhaps help to bring these facts home. Three institutions on the high basis 
(Johns Hopkins, Harvard, University of Minnesota) show : 

Total enrolment Dropped before examinations Failed and conditioned Patted without condition! 
757 2 per cent 17 per cent 81 per cent 

Seven of the strongest schools in the United States on the high school or equivalent basis (Jefferson 
Medical, New York University, University of Maryland, Medieo-Chirurgical, Tufts, Yale, and Uni- 
versity of Pennsylvania (the last two before elevating their standard) show : 

2390 11 per cent 38 per cent 1 per cent 

McGill and Toronto show : 

945 5 per cent 28 per cent 67 per'cent 



ACTUAL BASIS OF MEDICAL EDUCATION 39 

the University of Pennsylvania and advanced them to the classes to which they had 
been denied promotion by the teachers who knew them best; at the same time 
the Jefferson Medical College 1 itself accepted and in the same way advanced failures 
from New York University and the University of Pennsylvania; Tufts admits as 
"specials" students failed at Dartmouth, Queen's (Kingston, Ontario), and the 
Medico-Chirurgical of Philadelphia; the medical department of the University of 
Illinois (College of Physicians and Surgeons, Chicago) fairly abounds in rejected 
students from other schools, and in emigrated students from the low-grade insti- 
tutions of Chicago and elsewhere; of the same character is a large part of the en- 
rolment of the medical department of Valparaiso University. Failures from Ann 
Arbor are regarded as worthy of advancement by Northwestern (Chicago). The Physi- 
cians and Surgeons of Baltimore gives time and subject credit after "examination," 
of course to failures turned out of the University of Buffalo, New York University, 
the University of Pennsylvania, the Jefferson Medical College, and Yale; the Uni- 
versity of Maryland is equally indiscriminate, advancing to the classes which they 
had failed to reach students from most of the same institutions and some from the 
local College of Physicians and Surgeons and the Baltimore Medical College, besides. 
Other Jefferson Medical failures, not to be found in the two Baltimore schools just 
named, should be looked for in the Baltimore Medical College, together with failures 
from Tufts, Long Island Hospital Medical College, etc. The upper classes of two 
Baltimore schools the Maryland Medical College and the Atlantic Medical Col- 
lege are largely recruited by emigration from other schools; 2 the latter of these had 
(1908-9) a senior class of 31, a freshman class of 1, and every member of the senior 
class had been admitted to advanced standing from some other school. 3 

Is this the best that can be done? Will the actual enforcement of a real and ade- 
quate standard starve any section of the country in the matter of physicians? 

The question can be answered without guesswork or speculation. The south re- 
quires something like 400 doctors annually. 4 How high a standard can it enforce, and 
still get them? In the year 19089 there were 15,791 male students in four-year high 
schools in six southern states, 6 Alabama, Georgia, Louisiana, South Carolina, Vir- 

1 This institution, like others, admits to advanced standing a considerable number of students from 
schools whose entrance requirements are much below its own ; e.g., in the session above referred to, 
there were several students from the medical department of Fort Worth University, whose entrance 
requirement is nominal ; from the University or Oregon, College of Physicians and Surgeons, San 
Francisco, Keokuk, Denver and Gross. At the same time, it deals severely with its own student 
body, for it refuses promotion annually to a large number, who emigrate chiefly to Baltimore. 

2 Mississippi Medical College, Meridian, was similarly recruited. 

3 Among other schools guilty of advancing students to whom promotion had been refused by their 
own schools may be mentioned : College of Physicians and Surgeons, Atlanta, Georgetown Univer- 
sity (Washington, D. CA Denver and Gross, University of Colorado, George Washington Univer- 
sity, Milwaukee Medical College. 

4 The former secretary of the Southern Medical College Association calculated that 300 would suffice. 

5 For these figures we are indebted to a painstaking census conducted by the secondary school in- 
spectors maintained in these states by the General Education Board. 



40 MEDICAL EDUCATION 

ginia and Texas; there were in the previous year 5877 male students in the academic 
departments of the southern state universities, and 1653 more in endowed institu- 
tions of similar grade; 1 a population of over 23,000 2 bordering on high school gradua- 
tion and widely distributed over the entire area. Our question is thus already an- 
swered. The best material for the making of a few hundred southern doctors annually 
does not have to be torn from the plough. 

But these figures convey by no means the whole truth. The south is in the midst 
of a genuine educational renaissance. Within the last few years every southern state 
under the leadership of the state university, the state department of education, and 
certain endowed institutions like Vanderbilt University, has set enthusiastically to 
work to develop its common and secondary school systems after the admirable model 
furnished by the robust communities of the middle west. The professors of secondary 
education in the state universities are the evangelists of this auspicious movement. 
Young, intelligent, well trained, these sturdy leaders ceaselessly traverse the length 
and breadth of their respective states, stimulating, suggesting, guiding, organizing. 
It is an inspiring spectacle. Three years ago the high school had no legal standing 
in Virginia; to-day the state is dotted with two-year, three-year, and four-year high 
schools, created by local taxation, with a considerable subvention from the state 
treasury. There are already 2511 boys in fairly well equipped four-year high schools, 
and as many more in private institutions of equal value; and the two-year and three- 
year schools are growing rapidly into fuller high school stature. It needs no argument 
to prove that Virginia can at once procure its doctors from among the bvna-jide gra- 
duates of such high schools and better. What is true of Virginia is tine of every other 
southern state. In Alabama, for example, three years ago there was scarcely a pub- 
lic high school in the state ; to-day there are 61 public four-year high schools, 3 1 1 pri- 
vate four-year high schools, and 15 town and city three-year high schools. Of the 
345 teachers employed in these schools, 184 are college graduates and 55 more have 
had at least two years of college work. Of course the situation is uneven; it lacks 
homogeneity. Standards are more or less confused; distinctions are not everywhere 
clear. The schools have frequently shot up like ungainly boys, who first get their 
height and fill up afterwards; their four years are not yet the four years of Boston 
or Indianapolis. But this is a phenomenon of hopeful omen ; it provides the frame- 
work for a vigorous and imminent maturity. The universitiesand the professional schools 
have in this emergency a clear duty : to call things by their right names, to abandon 
the apologetic attitude, to cease from compromises which tempt the student from the 
high school and then set up the successful temptation as a sufficient excuse for their 

1 Compiled from the Report of the United States Commissioner of Education, 1908. 

* Not including four-year high schools of Mississippi, Florida, North Carolina, Tennessee, Arkansas, 
and Kentucky, which would considerably increase these figures. They are omitted because equally 
reliable data are not at hand. 

* Under legislative enactment approved August 7, 1907, the state contributes $2000 a year to aid any 
county that establishes its own nigh school 



ACTUAL BASIS OF MEDICAL EDUCATION 41 

own folly in so doing. Let them reinforce the high school by the opposite policy; 
they will soon perceive the needlessness of the exceptions which they still suggest, 
and often even require. How much longer will the southern people, generously spend- 
ing themselves in the effort to create high school systems, continue to handicap their 
development by allowing medical education legally to rest on an ante-bellum ba^s? 

The duty of the southern universities at this juncture is clear. They are equally 
bound to assist the development of the secondary school and to furnish the southern 
people an improved type of physician. They do both if, while actually enforcing the 
standard above advocated, they provide the best medical training obtainable at that 
level. As a matter of fact, a highly useful doctor can be trained on the high school 
basis if his defects, frankly admitted, are made the occasion for more, instead of less, 
efficient instruction. The weak southern schools apologize for their wretchedness by 
alleging the shortcomings of the student body. But the shortcomings of the students 
are a call for better, rather than an excuse for worse, teaching. On the whole, a south- 
ern university will for a time probably do best to put its strength unreservedly 
into the improved instruction of a larger body of students at the high school level, 
rather than to train a smaller body on a somewhat higher basis. What with the other 
influences working to discredit the proprietary medical school, if Tulane, Vanderbilt, 
and Texas furnish actual high school graduates with an education as good as that 
of Toronto or of McGill, they will soon get control of the field, they will educate 
the southern public to look to them for their physicians, and they will induce the 
state legislatures to support a position undeniably reasonable, so that when they at 
last make the upward move, there will be no low-grade medical schools to profit by 
the step and to make it a pretext for the continuance of commercialism in medical 
education. 1 

The state of Texas has taken a sound and yet conservative position. Beginning 
with 1909, it has decreed a gradual annual rise of standard that will shortly re- 
sult in making its four-year high school the legal basis of medical education. Cau- 
tious elevation thus avoids all danger of breaking with the state school system. The 
statute is not free from defects, for it provides for the acceptance, at their face value, 
of the medical student certificates of reciprocating states; but the Texas state board, 
having dealt vigorously with the worst of the Texas schools, will in all probability 
make effective use of the power in its hands. Other southern states must inevitably 
follow. It is of course important that they should not move faster than their edu- 
cational facilities; but it is equally important that they should not move any more 
slowly. Thus far, Texas alone has made an effort to keep pace. 

The situation is even clearer, in so far as it touches the rest of the country. We 
estimate 2 that outside the south 1500 doctors annually graduated will provide for 

1 For more detailed consideration on this point, the reader is referred to the discussions in Part II of 
the various southern states. 

2 In chapter a. 



42 MEDICAL EDUCATION 

all the real and many imaginary needs. There are at this date something like 8000 
public and over 1000 private high schools, so widely dispersed over the area under 
consideration that on the average few boys need go over five miles to school. 1 In 
the public high schools alone there are enrolled 300,000 boys. 8 What excuse exists 
for cutting under the high school? We can indeed do better than to accept as the 
basis of a medical education the high school "flat." In the colleges, universities, and 
technical schools of the north and west, exclusive of preparatory and professional 
departments, there were in 1908, 120,000 s male students. The number swells with 
unprecedented rapidity ; long before the country has digested the number of doctors 
now struggling for a livelihood, it will have doubled. Already in 1907, 903 of the 
doctors graduated in that year held academic degrees; that is to say, fully one-half 
of the number the country actually needed could conform to the standard that has 
been urged, or better. There is at this moment absolutely nothing in the educational 
situation outside the south that countenances the least departure from the scientific 
basis necessary to the successful pursuit of modern medicine. 

For whose sake is it permitted? Not really for the remote mountain districts of 
the south, for example, whence the "yarb doctor,"" unschooled and unlicensed, can in 
no event be dislodged; nor yet for that twilight zone, on the hither edge of which 
so many low-grade doctors huddle that there is no decent living for those already 
there and no tempting prospect for anybody better: ostensibly, "for the poor boy." 
For his sake, the terms of entrance upon a medical career must be kept low and easy. 
We have no right, it is urged, to set up standards which will close the profession to 
"poor boys." 

What are the merits of this contention ? The medical profession is a social organ, 
created not for the purpose of gratifying the inclinations or preferences of certain 
individuals, but as a means of promoting health, physical vigor, happiness and 
the economic independence and efficiency immediately connected with these factors. 
Whether most men support themselves or become charges on the community depends 
on their keeping well, or if ill, promptly getting welL Now, can anyone seriously 
contend that in the midst of abundant educational resources, a congenial or profit- 
able career in medicine is to be made for an individual regardless of his capacity 
to satisfy the purpose for which the profession exists? It is right to sympathize with 
those who lack only opportunity; still better to assist them in surmounting obsta- 
cles; but not at the price of certain injury to the common weal. Commiseration for 
the hand-spinner was not suffered for one moment to defeat the general economic 
advantage procurable through machine-made cloth. Yet the hand-spinner had a sort 
of vested right: society had tacitly induced him to enter the trade; he had grown 
up in it on that assurance; and he was now good for nothing else. Your "poor boy" 

1 Wilgus, Legal Education in the United States, p. 29. 

1 There are 33,000 more in the preparatory departments of colleges and universities. 

We are indebted for these statistics to the United States Commissioner of Education. 



ACTUAL BASIS OF MEDICAL EDUCATION 43 

has no right, natural, indefeasible, or acquired, to enter upon the practice of medi- 
cine unless it is best for society that he should. 

As a matter of fact, the attainments required by our entire argument are not, as 
a rule, beyond the reach of the earnest poor boy. He need only take thought in good 
season, lay his plans, be prudent, and stick to his purpose. Without these qualities, 
medicine is no calling for him ; with them, poverty will rarely block his way. Besides, 
if poverty is to be a factor in determining entrance standards, just where does pov- 
erty cease to excuse ignorance? Apparently the inexcusable degree of ignorance be- 
gins just where the ability to pay fees leaves off. For the schools that maintain 
"equivalents' 1 for the sake of the "poor boy" are not cheap, and the student who 
can pay his expenses in them can also pay for something better, and pay his fees the 
student must; for it is precisely the proprietary and independent schools, avowedly 
solicitous for the "poor boy," that do the least for him by way of scholarship or other 
exemption. 1 They exact a complete settlement in cash or notes. Thus a four-year 
medical education in Baltimore, Philadelphia, or Chicago schools, on the "equiva- 
lent" basis, costs a boy in tuition fees and board about $1420. The same student can 
go to Ann Arbor, get there two years of college work in the pre-medical sciences and 
modern languages, and four years in medicine, besides, for an expenditure of SI 466, 
covering the same items. Thus six years at Ann Arbor are not appreciably more ex- 
pensive than four years in Baltimore, Philadelphia, or Chicago. Or, if a large city be 
preferred, he can get his two years in the admirable pre-medical laboratories of the 
University of Minnesota, at Minneapolis, followed by his four-year medical work 
there, for very little more. Low entrance requirements flourish, then, for the benefit of 
the poor school, not of the poor boy. Meanwhile, opportunities exist, in a measure 
during the school year, still more during vacation, to earn part, perhaps all, of the 
required sum. 2 Doubtless in the near future, the problem will be still further simpli- 
fied in the interest of the better training by increased scholarship and other endow- 
ments, as in Germany. Meanwhile, it is dubious educational philanthropy to interrupt 
a poor boy's struggle upwards by inviting him into a medical school where there are 
excessively large chances of failure, escaping which he is at once exposed to a disad- 
vantageous competition with men better trained by far. 

So much from the standpoint of the individual. The proper method of calculating 
cost is, however, social. Society defrays the expense of training and maintaining the 
medical corps. In the long run which imposes the greater burden on the community, 

1 Three scholarships, amounting to tuition fees for one year, are, however, annually awarded at the 
University of Maryland. 

2 It is stated that at the University of Chicago "the opportunities for taking work are more numer- 
ous than the number of students desiring to take advantage of them. . . . There is ample opportunity 
for the energetic student to earn his way, either in whole or in part, and opportunities usually out- 
number those seeking them. " School Review, January, 1910 (Notes and News). It must, of course, be 
remembered that only the vigorous and talented can afford to undertake the study of medicine under 
such conditions. The others are barred just as effectively from the low-grade as from the high-grade 
school. Students are found "working their way through" at the medical departments of Harvard, 
Michigan, Toronto, McGill, etc. 



44 MEDICAL EDUCATION 

the training of a needlessly vast body of inferior men, a large proportion of whom break 
down, or that of a smaller body of competent men who actually achieve their purpose? 
When to the direct waste here in question there is added the indirect loss due to in- 
competency, it is clear that the more expensive type is decidedly the cheaper. Aside 
from interest on investment, from loss by withdrawal of the student body from produc- 
tive occupations, the cost of our present system of medical education is annually about 
83,000,000, as paid in tuition fees alone. The number of high-grade physicians really 
required could be educated for much less; the others would be profitably employed 
elsewhere; and society would be still further enriched by efficient medical service. 

The argument is apt to shift at this point. If we refuse to be moved by the "poor 
boy," pity the small towns; for it is speciously argued that the well trained, college- 
bred student will scorn them. Not sympathy for the poor boy requires us now to 
sacrifice the small town to him, but sympathy for the small town requires us to sac- 
rifice the poor boy to it. Two vital considerations are overlooked in this plea. In the 
first place, the small town needs the best and not the worst doctor procurable. For 
* the country doctor has only himself to rely on : he cannot in every pinch hail spe- 
cialist, expert, and nurse. On his own skill, knowledge, resourcefulness, the welfare 
of his patient altogether depends. The rural district is therefore entitled to the best 
trained physician that can be induced to go there. But, we are told, the well trained 
man will not go; he will not pay for a high-grade medical education and then con- 
tent himself with a modest return on his investment. Now the six-year medical edu- 
cation (that based on two college years) and the four-year medical education (that 
based on the high school or equivalent) may, as we saw above, be made to cost the 
same sum. As far as cost is concerned, then, the better sort of four-year medical edu- 
cation mifct have precisely the same effect on distribution of doctors as the six-year 
training furnished by the state universities. If a Jefferson graduate is not deterred 
by the cost of his education from seeking a livelihood in the country, the Ann Arbor 
or Minnesota man will not be deterred, either. But a deeper question may be raised. 
What is the financial inducement that persuades men scientifically inclined to do 
what they really like ? for a man who does not like medicine has no business in it. 
How far does the investment point of view actually control? Complete and reliable 
data are at hand. The college professor has procured for himself an even more elaborate 
and expensive training than has here been advocated for the prospective physician. 
Did he require the assurance of large dividends on his investment? "The full professor 
in the one hundred institutions in the United States and Canada which are financially 
strongest receives on the average an annual compensation of approximately $2500." * 
But the scholar does not usually advance beyond the assistant professorship : what fig- 
ure has financial reward cut with him ? "At the age of twenty-six or twenty-seven, after 
seven years of collegiate and graduate study, involving not only considerable outlay, 

1 " The Financial Status of the Professor in America and in Germany." Carntgit Foundation for th 
Adtanrement of Teaching, Bulletin II., p. vi. 



ACTUAL BASIS OF MEDICAL EDUCATION 45 

but also the important item of the foregoing of earning during this period, he is the 
proud possessor of his Ph. D. and is ready to enter his profession. The next five years 
he spends as instructor. In his thirty-second year he reaches assistant professorship. 
He is now in his thirty-seventh year, having been an assistant professor for five years. 
His average salary for the ten years has been $1325. ... At thirty-seven he is mar- 
ried, has one child, and a salary of $1800." * In Germany "the road to a professor- 
ship involves a period of training and of self-denial far longer and more exacting 
than that to which the American professor submits;" 3 in France "there are no pe- 
cuniary prizes whatever in their calling for even those who attain its highest posts." 3 
What is even more to the point, the posts of instructor and assistant in small col- 
leges situated in out-of-the-way places can be readily filled at slender salaries with 
expensively trained men. Of course there are compensations. But the point is that a 
large financial inducement is not indispensable, provided a man is doing what he 
likes. In most sections the country doctor has better worldly prospects. The fact 
stands out that it is not income but taste that primarily attracts men into scholarly 
or professional life. That granted, the prospect of a modest income does not effectually 
deter ; and not infrequently the charm of living away from large cities may even 
attract. 

Our limited experience with physicians trained at a high level sustains this view. 
We have thus far produced relatively few college-bred physicians; large cities have 
bid high for them, without, however, bagging all. Johns Hopkins graduates in med- 
icine, to take the highest quality the country has produced, are already scattered 
through thirty-two states and territories. As if to prove that money is not the sole 
deciding consideration^ dozen have gone as missionaries to the Orient and several into 
the army and navy. In this country there is a Johns Hopkins man practising at Clay- 
ton, Alabama, with 1000 inhabitants; at Fort Egbert, Alaska, with 458; at Gorham, 
Colorado, with 364; at Chattahoochee, Florida, with 460; at Fort Bayard, New Mex- 
ico, with 724; at Sonyea, New York, with 300; at Blue Ridge Summit, Pennsylvania, 
with 50; at Wells River, Vermont, with 660; at Fairfax, Virginia, with 200; at Fort 
Casey, Washington, with 300; at Kimball, West Virginia, with 2000; at Mazomanie, 
Wisconsin, with 900. They have scattered to the four winds, and inevitably. 4 No 
single influence controls : home, money, taste, opportunity, all figure. When we have 
produced as large a number of well trained doctors as Germany, they will be found 
in our villages, just as one finds them over there. Minnesota, closed after 1912 to all 
low-grade graduates, Kansas and North and South Dakota, agricultural states, Con- 

1 Statistics from twenty leading universities, discussed by Guido H. Marx in address. The Problem of 
the Assistant Professor, before Association of American Universities, January, 1910. 

2 Carnegie Foundation, Bulletin II., p. vii. 

3 Bodley : France, voL i. p. 54. 

4 Western Reserve men (three years of college required for entrance) are to be found in Cochranton, 
Pennsylvania (population, 724); Solon Springs, Wisconsin (population, 400); Kinsman, Ohio (popula- 
tion, 824) ; Rawson, Ohio (population, 552). 



46 MEDICAL EDUCATION 

necticut, Indiana, Colorado, look forward confidently to the high standard basis. Is 
there any reason founded in consideration for public welfare which holds back Illinois, 
New York, Pennsylvania, from similar action? 

There is, however, still another standpoint from which the question under discus- 
sion ought to be viewed. We have been endeavoring to combat the argument in 
favor of admittedly inferior schools dependent on fees on the ground that in the 
east, north, and west, these schools have already outlived their usefulness; that, even 
in the south, the need, greatly exaggerated, will gradually disappear. Let us, how- 
ever, for the moment concede that the south, and perhaps other parts of the country, 
still require some medical schools operating on the high school basis, or a little less. 
Does it follow that the proprietary or independent unendowed medical school has 
thereby established its place? By no means. It is precisely the inferior medical stu- 
dent who requires the superior medical school. His responsibilities are going to be 
as heavy as those of his better trained fellow practitioner : to be equally trustworthy, 
his instruction must be better, not worse. The less he brings to the school, the more 
the school must do for him. The necessity of recruiting the medical school with high 
school boys is therefore the final argument in favor of fewer schools, with better 
equipment, conducted by skilful professional teachers. 

The truth is that existing conditions are defended only by way of keeping un- 
necessary medical schools alive. The change to a higher standard could be fatal to 
many of them without in the least threatening social needs. Momentarily there would 
be a sharp shrinkage. But forethought would be thus effectively stimulated; trained 
men would be attracted into the field; readjustment would be complete long before 
any community felt the pinch. 1 Despite prevailing confusion legal, popular, and 
educational as to what good training in medicine demands, the enrolment in the 
five schools which have during the last four years required two or more years of college 
work is already 1186 students, and is increasing rapidly. 2 When the Johns Hopkins 
plans were under discussion in the middle seventies, Dr. John S. Billings, the adviser 
of the trustees in things medical, suggested that the graduating class be limited to 
twenty-five. " I think it will be many years before the number of twenty-five for 
the graduating class can be reached," he said. 8 The school opened in 1893; the first 
class, graduated in 1897, numbered 15; the third, graduated in 1899, numbered 32: so 
promptly did the country respond. Institutions that have switched from the high 

1 It has been calculated that in the supply of doctors the country is now "about thirty-five years in 
advance of the requirements"! Benedict : Journal of American Medical Auociation, vol. lii., no. 5, 
pp. 378, 379. 

1 In the sixteen schools on the two-year college basis there were (1908-9) 1850 students who had en- 
tered at that level. The total enrolment in these sixteen institutions was much greater, because the 
upper classes in several had entered on a lower basis. These figures are far from the total number of 
college men in medical schools. The pity is that they are scattered through institutions in which they 
lose the advantage which their education should give them. 

* Medical Education: Extract! from Lecture* before the Johnt Hopkins Univertity, 1877-8, p. 22 (Balti- 
more, 1878). 



ACTUAL BASIS OF MEDICAL EDUCATION 47 

school to the college standard after due notice given 1 have thus far lost only one- 
half or less of their former enrolment. The only thing that falls in proportion is the 
income from fees ; the percentage of graduates is reduced much less. At the Univer- 
sity of Minnesota, there used to be an average first-year attendance of 80 on the 
high school basis; on the two-year college basis it is now 40; at Harvard on the 
former basis, 160 new matriculants; now, on a college basis, 79. Western Reserve, 
with 34 on the high school basis, advanced suddenly in 1901 to a three-year college 
requirement; the enrolment fell to 12, but by 1908 the loss was practically recovered. 
Most significant is the demonstration that the greatest loss is due to the transition 
from the high school or equivalent to the one-year college basis ; the rise from one 
to two years of college has relatively little effect on enrolment. It would appear that 
the college requirement compels deliberation. Once decided, the student is not seri- 
ously hampered by the effort or the expense of an additional year. 

It does not follow, however, that if schools generally rose to the college require- 
ment, their losses would be only one-half and the recovery therefrom ultimately as- 
sured. For the schools that came off thus lightly were previously attended by a large 
proportion of high-grade men. 2 A much greater loss would undoubtedly take place 
in the lower-grade schools; many of them would be practically annihilated. For the 
tendency of elevated standards and ideals is to reduce the number of students to 
something like parity with the demand, and to concentrate this reduced student body 
in fewer institutions, adequately supported. 

The basis which we have urged for medical education gives an undoubted advan- 
tage to the university medical departments. We shall see in subsequent chapters 
that other equally important factors are at work tending to restore medical educa- 
tion to the university status ; but for the moment the difficulty of procuring anywhere 
else the necessary educational foundation is perhaps most cogent. A countermove, 
by way of avoiding this tendency, has recently emanated from certain Philadelphia 
schools, 8 in the form of a suggested five-year course, the first year to be devoted to 
the pre-medical sciences. 

Several serious objections to this proposition may be urged: (1) a single year is 
insufficient for three laboratory sciences, and makes no provision for modern lan- 
guages; the very best medical schools could with difficulty give one year's pre-medi- 

1 Cornell changed from the high school to the three-year college requirement with less than a year's 
notice. There was, of course, no chance to readjust matters; the next first-year class (1908) num- 
bered 15 ; in 1909, this increased to 23. 

2 In these schools standards were elevated in advance of the operation of the formal declaration to 
that effect. For example, Columbia (College of Physicians ana Surgeons, New York) goes to the 
two-year college basis 1910-11 ; but the entering class 1909-10 contained among its 86 matriculates 
48 students with degrees, and 1 1 more who had had two years of college work. 

3 These schools have no endowments ; and the pre-medical sciences cannot be properly taught out of 
fees, as will become evident in chapter viii., "The Financial Aspects of Medical Education. "Hence the 
work must be mainly make-believe. It would have to be given by already overburdened science 
teachers or, still worse, by practitioners. The Medico-Chirurgical College of Philadelphia offers these 
courses "in conjunction with classes in the sister department of pharmacy. "This is absurd. 



48 

cal work, they cannot possibly give two; as for anything more liberal, there is no 
chance at all. Hence the step would shortly prove an obstruction to further progress. 
(2) Unquestionably, the day is coming when the medical school proper will want a 
fifth or hospital year, a culmination that will be indefinitely postponed if the year 
in question is prefixed to the course and assigned to preliminary training. (3) Finally, 
the arrangement protracts our present educational disorganization. It proposes that 
the medical school should do the work of the college, just as it is either doing or 
doing without the work of the high school. Now the strength of an educational 
system is wholly a question of the competent performance of differentiated function 
by each of its organic parts. Our tardily awakened educational conscience and in- 
telligence find themselves confronted with several independent and detached educa- 
tional agencies, high schools, colleges, professional schools. Obviously, they are 
not indifferent to each other; they belong in a definite order and relation. We now 
know perfectly well what that order, what that relation, is. And the solidity of our 
educational and scientific progress depends on our success in making it prevail. 
To no inconsiderable extent, inefficiency has been due to irresponsibility resulting 
from just this lack of organized relationships; and the cure for evils due to lack 
of responsibility is not less responsibility, but more; not less differentiation, but more. 
The reconstruction of our medical education on the basis of two years of required 
college work is not, however, going to end matters once and for all. It leaves un- 
touched certain outlying problems that will all the more surely come into focus when 
the professional training of the physician is once securely established on a scientific 
basis. At that moment the social role of the physician will generally expand, and to 
support such expansion, he will crave a more liberal and disinterested educational 
experience. The question of age not thus far important because hitherto our demands 
have been well within the limits of adolescence will then require to be reckoned 
with. The college freshman averages nineteen years of age ; two years of college work 
permit him to begin the study of medicine at twenty-one, to be graduated at twenty- 
five, to get a hospital year and begin practice at twenty-six or twenty-seven. No one 
familiar with the American college can lightly ask that this age be raised two years 
for everybody, for the sake of the additional results to be secured from non-profes- 
sional college work. There is, however, little question that compression in the ele- 
mentary school, closer articulation between and more effective instruction within 
secondary school and college, can effect economies that will give the youth of twenty- 
one the advantage of a complete college education. The basis of medical education 
will thus have been broadened without deferring the actual start. Meanwhile we are 
so far from endeavoring to force a single iron-clad standard on the entire country 
that our proposition explicitly recognizes at least three concurrent levels for the 
time being: (1) the state university entrance standard in the south, (2) the two-year 
college basis as legal minimum in the rest of the country, (3) the degree standard 
in a small number of institutions. 



ACTUAL BASIS OF MEDICAL EDUCATION 49 

The practical problem remains. How is the existing situation to be handled? The 
higher standard is alike necessary and feasible. How long is it to be postponed be- 
cause it threatens the existence of this school or of that? In general, our medical 
schools, like our colleges, are local institutions; their students come mainly from 
their own vicinity. The ratio of physicians to population in a given state is there- 
fore a fair indication of the number of medical schools needed. Where physicians are 
superabundant, and high schools and colleges at least not lacking, the medical 
schools cannot effectively plead for mercy on the ground that elevated standards 
will be their death. New York has two schools on the two-year college basis or bet- 
ter; nine others rest on a lower basis. They would improve if they could "afford 
it." 1 But with one doctor for every 600 people in the state, with accessible high schools, 
with cheap and in New York City, at least, free colleges, it is absolutely immate- 
rial to the public whether they can afford it or not. The public interest demands the 
change. We may therefore at once assume (what everybody grants) that the problem 
is insoluble on the basis of the survival of all or most of our present medical schools. 
To live, they must get students ; they must get them far in excess of the number 
they will graduate; they must graduate them far in excess of the number of 
doctors needed. They will therefore require their clientele of ill prepared, discon- 
tented, drifting boys, accessible to successful solicitation on commercial lines. In- 
evitably, then, the way to better medical education lies through fewer medical \ 
schools ; but legal enactments on the subject of medical education and practice will 
be required before the medical schools will either give up or relate themselves soundly 
to the educational resources of their respective states. No general legislation is at the 
moment feasible. The south, for instance, may well rest for a time, if every state will 
at once restrict examinations for license to candidates actually possessing the M.D. 
degree, and require after, say, January 1, 1911, that every such degree shall ema- 
nate from a medical school whose entrance standards are at least those of the state 
university. Such legislation would suppress the schools that now demoralize the situ- 
ation; it would concentrate the better students in a few solvent institutions to which 
the next moves may safely be left. Elsewhere, every available agency should be em- 
ployed to bring examining boards to reinterpret the word "equivalent" and to adopt 
efficient machinery for the enforcement of the intended standard. Equivalent means 
"equal in force, quality, and effect." The only authorities competent to pass on such 
values are trained experts. The entire matter would be in their hands if the state boards 
should in every state delegate the function of evaluating entrance credentials to a 
competently organized institution of learning. In many states, the state university 

1 The dean of a superfluous southern medical school writes : "Our faculty gets only what's left after 
all expenses are paid, and that averages $400 per session of seven months. This we will cheerfully 
forego, and teach gratis, if only a class, or endowment, will pay cost of running the college. We will 
advance to the highest requirements just as soon as the conditions will admit, and are ready now to 
open next session under highest requirements if the wherewith to pay expenses is in sight" Ob- 
serve that there is small consideration here for the "poor boy" or the "back country;" it is simply 
a question of college survival. 



50 MEDICAL EDUCATION 

could very properly perform this duty ; elsewhere, an equally satisfactory arrangement 
could be made with an endowed institution. Whatever the standard fixed, it would 
thus be intelligently enforced. The school catalogues would then announce that no 
student can be matriculated whose credentials are not filed within ten days of the 
opening of the session, and that no M. D. degree can be conferred until at least four 
years subsequent to complete satisfaction of the preliminary requirement. These cre- 
dentials, sent at once to the secretary of the state board, would be by him turned 
over to the registrar of the state or other university, whose verdict would be final. 
A state that desired to enforce a four-year high school requirement could specify as 
satisfying its requirements: 

(1) Certificate of admission to a state university requiring a four-year high school 
education ; 

(2) Certificate of admission to any institution that is a member of the Association 
of American Universities; 

(3) Medical Student Certificate of the Regents of the University of the State of 
New York; 

(4) Certificates issued by the College Entrance Examination Board for 14- units. 
In exchange for such credentials, or for high school diplomas acceptable to the 

academic authorities acting for the state board, a medical student certificate would 
be issued; in default thereof, the student must by examination earn one of the afore- 
said credentials, in its turn to be made the basis of his medical student certificate. 
In the southern states, the legal minimum would be necessarily below the four-year 
high school; in Minnesota, above it. But the same sort of machinery would work. 
The schools would have nothing to do with it except to keep systematically regis- 
tered the name of the student and the number of his certificate; the state board or 
the university acting for it would keep everything else, open to inspection. 

This is substantially what takes place in New York, where the State Education De- 
partment superintends the process. What is wanted in other states is an agency 
similarly qualified. For the present nothing can so well perform the office within a 
given state as its state university, or, in default thereof, the best of its endowed in- 
stitutions. This suggestion is perfectly fair to all medical schools, for the credentials 
would pass through the hands of the state board to the reviewing authority without 
information as to the purpose of the applicant. The directions required would take 
up less space in the medical school catalogues than the complicated details they now 
contain. It should be further provided that the original credentials of every student 
be kept on file in the office of the state board or the reviewing university, and that 
they shall be open to inspection, without notice, by properly accredited representa- 
tives of medical and educational organizations. These simple measures would intro- 
duce intelligence and sincerity where subterfuge and disorder now prevail. The bene- 
ficial results to the high school and the medical school would be incalculable. Nor 
would the poor boy be subjected to the least hardship; for by exercising forethought, 



ACTUAL BASIS OF MEDICAL EDUCATION 51 

he could accumulate genuine scholastic credits by examination or otherwise, pari 
passu, during the time he is accumulating the money for his medical education. So 
much actually accomplished, the rest will be easier. The reduced number of schools 
will not resist the forces making for a higher legal minimum. The state universities 
of the west will doubtless lead this movement; for once established on the two-year 
college basis, they will induce the states to protect their own sons and the public 
health against the lower-grade doctors made elsewhere. The University of Minnesota, j 
having by statesmanlike action got rid of all other medical schools in the state, is thus 1 
backed up by the legislature and the state board. North Dakota and Indiana have 
taken the same stand. Michigan and Iowa will probably soon follow. "The adjust- 
ment is perhaps difficult, but not too difficult for American strength." 1 



1 Adapted from Billroth: Ueber das Lehren und Lrnn d*r medicinischen Wiuenachaft, quoted by 
Lewis, loc. cit. 



CHAPTER IV 

THE COURSE OF STUDY: THE LABORATORY BRANCHES 

(A) FIRST AND SECOND YEARS 

THREE characteristic stages are to be discerned in the evolution of medical teaching. 1 
The first and longest was the era of dogma. Its landmarks are Hippocrates (B.C. 460- 
377) and Galen (A. D. 130-200), whose writings were for centuries transmitted as an 
authoritative canon. Observation and experience had indeed figured considerably in 
their composition, 8 but increasingly remote disciples in accepting the tradition lost 
all interest in its source. The Galenic system took its place in the medieval univer- 
sity with Euclid and Aristotle, a thing to be pondered, expounded and learned; 
facts had no chance if pitted against the word of the master. So completely was 
medicine dominated by scholasticism that surgery, employing such base tools as sight 
and touch, was held to be something less than a trade and accordingly excluded 
from intellectual company. 

The second era is that of the empiric. It began with the introduction of anatomy 
in the sixteenth century, but did not reach its zenith until some two hundred years 
later. At its best it leaned upon experience, but its means of analyzing, classifying^ 
and interpreting phenomena were painfully limited. Medical art was still under the 
sway of preconceived and preternatural principles of explanation ; and rigorous ther- 
apeutic measures were not uncommonly deduced from purely metaphysical assump- 
tions. The debility of yellow fever, for example, Rush explained by "the oppressed 
state of the system;" and on the basis of a gratuitous abstraction, resorted freely to 
purging and bleeding. His first four patients recovered; there is no telling how many 
lives were subsequently sacrificed to this conclusive demonstration. The fact is that 
the empiric lacked a technique with which to distinguish between apparently similar 
phenomena, to organize facts, and to check up observation; the art of differentiation 
through controlled experimentation was as yet in its infancy. Under vague labels 
like rheumatism, biliousness, malaria, or congestion, a hodgepodge of dissimilar and 
unrelated conditions were uncritically classed; the names meant nothing, but they 
answered as explanation, and even sanctioned severe and nauseous medication. Igno- 
rant of causes, the shrewdest empiric thus continued to confound totally unlike 
conditions on the basis of superficial symptomatic resemblance; and with amazing 
assurance undertook to employ in all a therapeutic procedure of doubtful value in 
any. He combined the vehemence of the partisan with something of the credulity of 

1 Nothing would do more to orient the student intelligently than a knowledge of the history of 
medical science and teaching. It is a great pity that some effort is not made in the better medical 
schools to interest the student in the subject. A proper historical perspective would render impos- 
sible such opposition to improved medical teaching as is now based on conscientious but mistaken 
devotion to outgrown conditions. 

*"The correct inductive method was borne in on the triumph of Hippocrates." Compere's Greek 
Thinluri (translated by Magnus, vol. i. p. 308). 



THE LABORATORY BRANCHES 53 

a child, persuading too often by ardent insistence rather than by logical proof. His 
students were thus passive learners, even where the teaching was demonstrative. 
They studied anatomy by watching a teacher dissect; they studied therapeutics by 
taking the word of the lecturer or of the text-book for the efficacy of particular 
remedies in certain affections. 

The third era is dominated by the knowledge that medicine is part and parcel 
of modern science. The human body belongs to the animal world. It is put together 
of tissues and organs, in their structure, origin, and development not essentially un- 
like what the biologist is otherwise familiar with ; it grows, reproduces itself, decays, 
according to general laws. It is liable to attack by hostile physical and biological 
agencies ; now struck with a weapon, again ravaged by parasites. The normal course 
of bodily activity is a matter of observation and experience; the best methods of 
combating interference must be learned in much the same way. Gratuitous specu- 
lation is at every stage foreign to the scientific attitude of mind. 

We may then fairly describe modern medicine as characterized by a severely criti- 
cal handling of experience. It is at once more skeptical and more assured than mere 
empiricism. For though it takes nothing on faith, the fact which it accepts does not 
fear the hottest fire. Scientific medicine is, however, as yet by no means all of one 
piece; uniform exactitude is still indefinitely remote; fortunately, scientific integrity 
does not depend on the perfect homogeneity of all its data and conclusions. Modern 
medicine deals, then, like empiricism, not only with certainties, but also with pro- 
babilities, surmises, theories. It differs from empiricism, however, in actually know- 
ing at the moment the logical quality of the material which it handles. It knows, as 
empiricism never knows, where certainties stop and risks begin. Now it acts confi- 
dently, because it has facts; again cautiously, because it merely surmises; then tenta- 
tively, because it hardly more than hopes. The empiric and the scientist both theo- 
rize, but logically to very different ends. The theories of the empiric set up some 
unverifiable existence back of and independent of facts, a vital essence, for example; 
the scientific theory is in the facts, summing them up economically and suggesting 
practical measures by whose outcome it stands or falls. Scientific medicine, therefore, 
has its eyes open; it takes its risks consciously; it does not cure defects of knowledge 
by partisan heat; it is free of dogmatism and open-armed to demonstration from 
whatever quarter. 

On the pedagogic side, modern medicine, like all scientific teaching, is character- 
ized by activity. The student no longer merely watches, listens, memorizes; he does. 
His own activities in the laboratory and in the clinic are the main factors in his in- 
struction and discipline. An education in medicine nowadays involves both learning 
and learning how; the student cannot effectively know, unless he knows how. 

Two circumstances have mediated the transformation from empirical to scientific 
medicine: the development of physics, chemistry, and biology; the elaboration out 
of them of a method just as applicable to practice as to research. The essential de- 



54 MEDICAL EDUCATION 

pendence of modern medicine on the physical and biological sciences, already ad- 
verted to, 1 will hereafter become increasingly obvious in the wealth of the curricula 
based upon them, and no less in the poverty of those constructed without them. 
But the practical importance of scientific method as such to the general practitioner 
is by no means so generally conceded. Its function in investigation is granted : there 
it is justified by its own fruits. But what has this to do with the education or the 
daily routine of the family doctor? 

The question raised is fundamental; the answer decides the sort of medical edu- 
cation that we shall seek generally to provide. If, in a word, scientific method and 
interest are of slight or no importance to the ordinary practitioner of medicine, 8 we 
shall permanently establish two types of school, the scientific type, in which en- 
lightened and progressive men may be trained; the routine type, in which "family 
doctors'" may be ground out wholesale. If, on the other hand, scientific method is 
just as valuable to the practitioner as to the investigator, it may indeed be expe- 
dient partly, or even in some instances altogether, to set aside gifted individuals as 
teachers or investigators and to guard the undergraduate student against original 
work prematurely undertaken. But this will not be construed to involve the abrupt 
and total segregation of medical education from medical research. Much of the edu- 
cator's duty may consist in traversing a well known path; but if otherwise he is pro- 
gressively busy, the well known path will never look exactly the same twice. The 
medical school will in that case be more than the undergraduate curriculum. Ac- 
tivities will be in progress that at every point run beyond the undergraduate^ 
capacity and interest at the moment. But the undergraduate curriculum will not 
differ in spirit, method, or aspiration from the interests that transcend it. 

The conservative in medical education makes much of what he conceives to be a 
fundamental opposition between medical practice and medical science; occasionally 
a despairing progressive accepts it. The family doctor represents the former type. 
One can ask of him so the conservative thinks only that he be more or less well 
grounded in things as they are when he gets his degree. The momentum with which 
he is propelled from the medical school must carry him to the end of his days, on a 
gradually declining curve; but that cannot be helped. The other type the scien- 
tific doctor either himself "investigates," or has a turn for picking up increases 
due to others. How profound is the opposition here depicted ? Opposition of course 
there is between all things in respect to time and energy. The doctor who puts on 
his hat and goes out to see a sick baby cannot just then be making an autopsy on a 
guinea-pig dead of experimental dysentery. But does the opposition go any deeper? 
Is there any logical incompatibility between the science and the practice of medi- 
cine? 

1 Chapter ii. p. 24. 

1 This is the common contention of the routine schools that run on low admission requirements and 
employ practitioner teachers. 



THE LABORATORY BRANCHES 55 

The main intellectual tool of the investigator is the working hypothesis, or theory, 
as it is more commonly called. The scientist is confronted by a definite situation; he 
observes it for the purpose of taking in all the facts. These suggest to him a line of 
action. He constructs a hypothesis, as we say. Upon this he acts, and the practical 
outcome of his procedure refutes, confirms, or modifies his theory. Between theory 
and fact his mind flies like a shuttle; and theory is helpful and important just to 
the degree in which it enables him to understand, relate, and control phenomena. 

This is essentially the technique of research: wherein is it irrelevant to bedside 
practice? The physician, too, is confronted by a definite situation. He must needs 
seize its details, and only powers of observation trained in actual experimentation 
will enable him to do so. The patient's history, conditions, symptoms, form his data. 
Thereupon he, too, frames his working hypothesis, now called a diagnosis. It sug- 
gests a line of action. Is he right or wrong? Has he actually amassed all the signifi- 
cant facts? Does his working hypothesis properly put them together? The sick man's 
progress is nature's comment and criticism. The professional competency of the 
physician is in proportion to his ability to heed the response which nature thus 
makes to his ministrations. The progress of science and the scientific or intelligent 
practice of medicine employ, therefore, exactly the same technique. To use it, whether 
in investigation or in practice, the student must be trained to the positive exercise 
of his faculties; and if so trained, the medical school begins rather than completes his 
medical education. It cannot in any event transmit to him more than a fraction of 
the actual treasures of the science; but it can at least put him in the way of steadily 
increasing his holdings. A professional habit definitely formed upon scientific method 
will convert every detail of his practising experience into an additional factor in his 
effective education. 

From the standpoint of the young student, the school is, of course, concerned 
chiefly with his acquisition of the proper knowledge, attitude, and technique. Once 
more, it matters not at that stage whether his destination is to be investigation or 
practice. In either case, as beginner, he learns chiefly what is old, known, understood. 
But the old, known, and understood are all alike new to him ; and the teacher in pre- 
senting it to his apprehension seeks to evoke the attitude, and to carry him through 
the processes, of the thinker and not of the parrot. 

The fact that disease is only in part accurately known does not invalidate the 
scientific method in practice. In the twilight region probabilities are substituted for 
certainties. There the physician may indeed only surmise, but, most important of 
all, he knows that he surmises. His procedure is tentative, observant, heedful, re- 
sponsive. Meanwhile the logic of the process has not changed. The scientific physician 
still keeps his advantage over the empiric. He studies the actual situation with 
keener attention; he is freer of prejudiced prepossession; he is more conscious of 
liability to error. Whatever the patient may have to endure from a baffling disease, 
he is not further handicapped by reckless medication. In the end the scientist alone 



56 MEDICAL EDUCATION 

draws the line accurately between the known, the partly known, and the unknown. 
The empiricist fares forth with an indiscriminate confidence which sharp lines do 
not disturb. 

Investigation and practice are thus one in spirit, method, and object. What is 
apt to be regarded as a logical, is really but a practical, difficulty, due to the neces- 
sity for a division of labor. "The golden nuggets at or near the surface of things 
have been for the greater part discovered, it seems safe to say. We must dig deeper 
to find new ones of equal value, and we must often dig circuitously, with mere hints 
for guides." 1 If, then, we differentiate investigator and practitioner, it is because 
in the former case action is leisurely and indirect, in the latter case, immediate and 
anxious. The investigator swings around by a larger loop. But the mental qualities 
involved are the same. They employ the same method, the same sort of intelli- 
gence. And as they get their method and develop their intelligence in the first 
place at school, it follows that the modern medical school will be a productive as 
well as a transmitting agency. An exacting discipline cannot be imparted except 
in a keen atmosphere by men who are themselves "in training." Of course the busi- 
ness of the medical school is the making of doctors; nine-tenths of its graduates will, 
as Dr. Osier holds, never be anything else. But practitioners of modern medicine 
must be alert, systematic, thorough, critically open-minded; they will get no such 
training from perfunctory teachers. Educationally, then, research is required of the 
medical faculty because only research will keep the teachers in condition. A non-pro- 
ductive school, conceivably up to date to-day, would be out of date to-morrow ; its 
dead atmosphere would soon breed a careless and unenlightened dogmatism. 

Teachers of modern medicine, clinical as well as scientific, must, then, be men of 
active, progressive temper, with definite ideals, exacting habits in thought and 
work, and with still some margin for growth. No inconsiderable part of their energy 
and time is indeed absorbed in what is after all routine instruction; for their situa- 
tion differs vastly from that of workers in non-teaching institutions devoted wholly 
to investigation. Their practical success depends, therefore, on their ability to carry 
into routine the rigor and the vigor of their research moments. A happy adjust- 
ment is in this matter by no means easy ; nor has it been as yet invariably reached. 
Investigators, impressed with the practical importance of scientific method to the 
practising physician, tend perhaps to believe that it is to be acquired only in origi- 
nal research. A certain impatience therefore develops, and ill equipped student barks 
venture prematurely into uncharted seas. But the truth is that an instructor, devot- 
ing part of his day under adequate protection to investigation, can teach even the 
elements of his subject on rigorously scientific lines. On the other hand, it will never 
happen that every professor in either the medical school or the university faculty 
is a genuinely productive scientist. There is room for men of another type, the 

1 C. A. Herter : " Imagination and Idealism in the Medical Sciences," Columbia Univ. Quart., vol. xii., 
DO. 11, p. 16. 



THE LABORATORY BRANCHES 57 

non-productive, assimilative teacher of wide learning, continuous receptivity, critical 
sense, and responsive interest. Not infrequently these men, catholic in their sympa- 
thies, scholarly in spirit and method, prove the purveyors and distributors through 
whom new ideas are harmonized and made current. They preserve balance and make 
connections. The one person for whom there is no place in the medical school, the 
university, or the college, is precisely he who has hitherto generally usurped the 
medical field, the scientifically dead practitioner, whose knowledge has long since 
come to a standstill and whose lectures, composed when he first took his chair, like 
pebbles rolling in a brook get smoother and smoother as the stream of time washes 
over them. 

The student is throughout to be kept on his mettle. He does not have to be a 
passive learner, just because it is too early for him to be an original explorer. He 
can actively master and securely fix scientific technique and method in the process 
of acquiring the already known. From time to time a novel turn may indeed give 
zest to routine; but the undergraduate student of medicine will for the most part ac- 
quire the methods, standards, and habits of science by working over territory which 
has been traversed before, in an atmosphere freshened by the search for truth. 

For purposes of convenience, the medical curriculum may be divided into two 
parts, according as the work is carried on mainly in laboratories or mainly in the 
hospital; but the distinction is only superficial, for the hospital is itself in the full- 
est sense a laboratory. In general, the four-year curriculum falls into two fairly equal 
sections: the first two years are devoted mainly 1 to laboratory sciences, anatomy, 
physiology, pharmacology, pathology; the last two to clinical work in medicine, 
surgery, and obstetrics. The former are concerned with the study of normal and 
abnormal phenomena as such ; the latter are busy with their practical treatment as 
manifested in disease. How far the earlier years should be at all conscious of the 
latter is a mooted question. Anatomy and physiology are ultimately biological sci- 
ences. Do the professional purposes of the medical school modify the strict biologi- 
cal point of view ? Should the teaching of anatomy and physiology be affected by 
the fact that these subjects are parts of a medical curriculum ? Or ought they be 
presented exactly as they would be presented to students of biology not intending 
to be physicians? A layman hesitates to offer an opinion where the doctors disagree, 
but the purely pedagogical standpoint may assist a determination of the issue. Per- 
haps a certain misconception of what is actually at stake is in a measure responsible 
for the issue. Scientific rigor and thoroughness are not in question. Whatever the 
point of view whether purely biological or medical scientific method is equally 
feasible and essential ; a verdict favorable to recognition of the explicitly medical 
standpoint would not derogate from scientific rigor. There is no doubt that the 
sciences in question can be properly cultivated only in the university in their entirety 

*An introductory course in physical diagnosis is given in the second year; occasionally clinical work 
is begun in its latter half. 



58 MEDICAL EDUCATION 

and in close association with contiguous, contributory, or overlapping sciences. No 
one of them is sharply demarcated ; at any moment a lucky stroke may transfer a 
problem from pathology to chemistry or biology. There are indeed no problems in 
pathology which are not simultaneously problems of chemistry and biology as well. 
So far the rigorously and disinterestedly scientific viewpoint is valid. These con- 
siderations, however, still omit one highly important fact: medical education is a 
technical or professional discipline; it calls for the possession of certain portions of 
many sciences arranged and organized with a distinct practical purpose in view. That 
is what makes it a "profession." Its point of view is not that of any one of the sciences 
as such. It is difficult to see how separate acquisitions in several fields can be organi- 
cally combined, can be brought to play upon each other, in the realization of a con- 
trolling purpose, unless this purpose is consciously present in the selection and mani- 
pulation of the material. Pathology, for example, is a study of abnormal structure 
and function ; the pathologist as such works intensively within a circumscribed field. 
For the time being, it pays him to ignore bearings and complications outside his im- 
mediate territory. Undoubtedly, the progressive pathologist will always be at work 
upon certain problems, thus temporarily, but only temporarily, isolated. But in the 
undergraduate class-room he is from time to time under necessity of escaping these 
limitations : there he is engaged in presenting things in their relations. The autopsy, 
the clinical history, will be utilized in presenting to the student, even if incidentally, 
the total picture of disease. Similarly, the anatomist can score many a point for the 
physiologist without actually forestalling him. He views the body not as a mosaic 
to be broken up, but as a machine to be taken to pieces, the more perfectly to com- 
prehend how it works. The pharmacologist is in a similar relation to the clinician. 
The principles of bacteriology lose nothing in scientific exactitude because, taught 
as a part of the medical curriculum, they are enforced with illustrations from the bac- 
terial diseases of man rather than from those of animals and plants; and histology is not 
the less histology because tissues from the human body are preferably employed. 1 In 

JThe following quotations from "An Outline of the Course in Normal Histology," by L. F. Barker 
and C. R. Bardeen (John* Hopkins Hospital Bulletin, vol. vii., nos. 62, 63, p. 100, etc.), forcibly illus- 
trate the above contention. 

" In deciding as to the plan to Ke adopted we have been much influenced, too, by the fact that our 
students are students of medicine. Thus it will be noticed that in the selection of tissues, those from 
the human body make up a large part of the material used ; and when animal tissues are employed, 
special care has been taken to point out how they differ from the human. Moreover, in deciding what 
to exclude from the course thought was given to the bearing of the specimens on the practical work 
in medicine which was to follow, and stress was laid upon those portions of human histology which 
previous experience has taught us are of the most importance in the appreciation and interpretation 
of the pathological alterations in disease. In the present status of pathological histology a knowledge 
of certain details is of much greater value than that of others ; and for the student entering medicine, 
a judicious selection of what shall be given and what shall be left out should be made by some one 
who has had a more or less wide training in pathological histology. 

" Further bearing in mind the life-work for which the student is preparing himself, we have not 
always chosen the method which would show the finest structural details of the tissues. While the 
most delicate methods have been introduced in places, we have endeavored to familiarize the stu- 
dents with a large number of different modes of preparation. The student who has been brought up 
entirely on 'gilt-edged' histological methods will find himself sadly at a loss in battling with the 
rough and ready ' world in which the pathologist has to live." (Somewhat abridged.) 



THE LABORATORY BRANCHES 59 

short, research, untrammeled by near reference to practical ends, will go on in every 
properly organized medical school; its critical method will dominate all teaching 
whatsoever ; but undergraduate instruction will be throughout explicitly conscious 
of its professional end and aim. In no other way can all the sciences belonging to 
the medical curriculum be thoroughly kneaded. An active apperceptive relation must 
be established and maintained between laboratory and clinical experience. Such a re- 
lation cannot be one-sided; it will not spontaneously set itself up in the last two 
years if it is deliberately suppressed in the first two. There is no cement like interest, 
no stimulus like the hint of a coming practical application. 1 

Medical reference, in the sense that the laboratory sciences should, while freely 
presented, be kept conscious of their membership in the medical curriculum, has been 
discredited in this country, because it had so long meant a mechanical drill in an 
inert outline of the several sciences by untrained and busy practitioners. In the ef- 
fort to teach the modicum of chemistry or physiology or pathology that "the family 
doctor needs to know," they neglected to teach anything of permanent scientific 
value at all. A revulsion was inevitable. It was supposed that the harm was due to 
the simple fact of medical reference. Such was not really the case. The sciences were 
badly taught, not merely because they were made prematurely and excessively con- 
scious of medical application, though such had indeed been the case, but because 
the teachers lacked abundant scientific knowledge and spirit. Had they had these, 
the medical reference would neither have dominated nor impoverished their presen- 
tation. Our experience then furnishes a conclusive argument against delegating the 
teaching function to essentially unscientific practising physicians; it does not recom- 
mend the isolation of the laboratory sciences, locally or scientifically, from the clin- 
ical work. If it meant that, then institutions like the Johns Hopkins Medical 
School, in which laboratories and hospital are compactly organized from the stand- 
point of a scientific education in medicine, would labor under a positive disadvantage 
as compared with schools that, by reason of their situation, must in the scientific 
years forego the bedside and the autopsy altogether. In sober truth, four years are 
none too many thoroughly to saturate the student with medical enthusiasm and 
to give him the physician's standpoint; nor will laboratory and clinical ends make 
a genuine whole unless they have throughout a speaking acquaintance with each 
other. 

Physiology and pathology belong, then, in the university, because there is much 
more to them as sciences than the medical school has time for. In so far, however, 
as they figure in medical education, they cannot be allowed to be indifferent to this 
definite function. "There must be an outlying division of workers who will keep the 

1 " An individual mind appropriates those new points of view and those fragments of knowledge that 
find in the mind fitting points of contact ; but others that fail to meet with suitable receptors, to bor- 
row a term from the modern theory of immunity, remain unattached and alien. The more thoroughly 
we can utilize existing interests and established relations, the more likely is our teaching to be real 
training." Letter from Professor Edwin O. Jordan, University of Chicago. 



60 MEDICAL EDUCATION 

subject in touch with practical medicine, though the flower of the army, the impe- 
rial guard, are busy elsewhere." 1 This same consideration would appear conclusive 
as to the wisdom of crediting the medical student with such subjects when pursued 
in a college of liberal arts. Physiology, for instance, as an element of a liberal edu- 
cation, sweeps the whole horizon impartially, interested in genetic processes, search- 
ing for general laws. It works to best advantage with simple forms, with jellyfish and 
cats in preference to man : an admirable introduction to medical physiology, but not 
really the same thing. It does not follow, therefore, that because professional studies 
are now freely counted toward the bachelor's degree, ordinary college work in physi- 
ology is equally satisfactory to the medical school. The academic purpose is vague; the 
professional purpose, distinct; and a medical education is more than the sum of its 
constituent courses taken separately and without reference to their ultimate object. 1 

So much for the point of view; certain general considerations affect equally in- 
struction in all these laboratory sciences. The medical laboratories must be manned, 
equipped, and organized like university laboratories devoted to non-medical subjects. 
The laboratory staff consists necessarily of a chief the professor in charge with 
a corps of paid assistants, cooperating with him in the work of teaching, busy at 
other times with their problems, as he is with his, and with at least one intelligent 
departmental helper (Diener) who will relieve the staff of the care and handling of 
apparatus and material. The needs of pharmacology are in these respects not different 
from those of physics; and the pharmacologist can as little make the teaching of 
pharmacology a side issue to the practice of medicine or the conduct of a drug store 
as the physicist can subordinate his academic duties to the operation of a trolley 
line. Hardly less urgent is an adequate material equipment: class-rooms, laboratories 
for class use, private rooms adapted to the independent work of the staff, a reference 
library in regular receipt of important publications, and proper quarters for caring 
for an abundant and varied supply of animals. 3 

In methods of instruction there is, once more, nothing to distinguish medical from 
other sciences. Out-and-out didactic treatment is hopelessly antequated; it belongs 

1 W. H. Howell : "The Present Problems of Physiology," Congress of Arts and Sciencet, vol. v. p. 434. 
More concretely. Professor F. S. Lee (Columbia University), in discussing the medical curriculum, 
wrote: "Many experiments of merely technical physiological interest should be omitted, especially 
those that have only a remote connection with human physiology. . . . [In physiological chemistry] 
pathological constituents [of tissues and secretions] and changes should be touched upon." Professor 
Matthews (University of Chicago) took the opposite position. "As soon as possible these sciences 
should follow the example of physics, botany, and chemistry and leave the medical faculty and be 
regarded as subjects prerequisite to the study of medicine." The analogy seems hardly valid; physics 
and chemistry are, from the standpoint of medicine, of merely instrumental value. The medical sciences 
are not simply instrumental ; they deal with the actual phenomena and material which the physi- 
cian handles. Professor Lee employs pathological cases to illustrate and enrich his course in pnysio- 
logy at Columbia. The contrast between normal and abnormal deepens the student's impression of both. 

2 The same problem presents itself in the German university. See Paulsen, loc. cit., pp. 411, 412. 

* An utterly mistaken notion prevails as to the extent to which animal experimentation is practised 
in this country. Only a very small minority of our medical schools use animals at all; as a matter of 
fact, ordinary medical teaching suffers seriously from the failure to employ them. 



THE LABORATORY BRANCHES 61 

to an age of accepted dogma or supposedly complete information, when the professor 
"knew" and the students "learned." The lecture indeed continues of limited use. It 
may be employed in beginning a subject to orient the student, to indicate relations, 
to forecast a line of study in its practical bearings; from time to time, too, a lecture 
may profitably sum up, interpret, and relate results experimentally ascertained. 
Text-books, atlases, charts, occupy a similar position. They are not, in the first place, 
a substitute for sense experience, but they may well guide and fill out the student's 
laboratory findings. In general, the value of the recitation and of the quiz is in pro- 
portion to their concreteness and informality. Outside the workshop there is danger 
of detachment and rote. 

The curriculum of a medical school, requiring for admission at least a competent 
knowledge of physics, chemistry, and biology, offers in the first two years systematic 
instruction in the following subjects: 

First year: anatomy, including histology and embryology; physiology, including 
bio-chemistry. 

Second year: pharmacology, pathology, bacteriology, physical diagnosis. 

A brief discussion will show the relations of these subjects to each other and to 
the clinical work occupying the third and fourth years. 

The order in which subjects are taken up is largely determined by considerations 
inherent in the subjects themselves. Anatomy the study of the architecture of the 
body comes logically first. It is indeed the oldest of laboratory sciences, 1 and so fun- 
damental in medical study that for a time the student may well defer all other sub- 
jects whatsoever. For several centuries it was taught simply by professorial demon- 
stration. During the first half of the nineteenth century, gross dissection by the 
students themselves was in vogue. The subject, long almost a closed book, has tre- 
mendously expanded in recent years. Embryology, histology, physiology, and patho- 
logy have given it back its youth ; it is once more a green and flourishing science. 2 
The anatomist carries a steadily increasing load. The surgeon, embarking on hitherto 
undreamed-of ventures; the clinician, guiding himself by physical indications involv- 
ing the most delicate structural discrimination; the physiologist, the pharmacolo- 
gist, the pathologist, all lean upon him. With an eye to varied uses, the student 
must gain a picture of the body as a working whole ; of its parts, taken severally 
and in their relations; and finally of the microscopic structure of tissues and organs. 
The teacher of anatomy may take one of two roads. He may attempt to forecast 
literally the special requirements of each of the above branches, confining his instruc- 

1 " For over six hur dred years there has been at least some practical instruction in anatomy, and for 
over three hundreu years there have existed anatomical laboratories for purposes of teaching and in- 
vestigation, although only those constructed during the present century (nineteenth) meet our ideas 
of what an anatomical laboratory should be." Welch: The Evolution of Modern Scientific Labora- 
tories: an Address delivered at the Opening of the William Pepper Laboratory, University of Penn- 
sylvania, Dec. 4, 1895. 

2 For an extremely readable account of the development of the science and teaching of anatomy, see 
"Anatomy in America," by C. R. Bardeen, Bulletin of the University of Wisconsin, no. 115. 



62 MEDICAL EDUCATION 

tion to the indispensably useful thus arrived at; or he may handle his subject freely 
not unmindful of its practical value, but with broad scientific background and 
sympathy. It needs no argument at this point to vindicate the latter policy. Dis- 
section has therefore ceased to be synonymous with anatomy; for no one way of 
looking at or of dealing with the cadaver will enable the student to grasp even 
its gross structure. It is one thing to take the body to pieces ; it is something else 
to conceive these severed and dissociated elements in stereoscopic relation ; and it is 
a still further task to unravel the tissues themselves : hence, on the macroscopic side, 
the prominence now given to reconstruction through drawing and modeling, and 
the close study of charts and of cross-sections, of models and of special preparations 
that form the indispensable teaching museum. Courses in histology and embryology, 
closely correlated with gross anatomy, furnish the accompanying microscopical dis- 
cipline. Something like one-fifth of all the available time of the entire medical 
curriculum 1 is commonly absorbed by the various branches constituting a modern 
department of anatomy. How much of this may be profitably spent in the lecture- 
room is yet under discussion. It needs perhaps still to be emphasized that description 
is no substitute for tactile and visual experience, and that such experience, if intel- 
ligently controlled, both records and organizes itself with surprisingly little formal 
revamping. 

Outside of anatomy, the laboratory method in medicine is considerably less than 
a century old. Its rapid spread has been in conservative quarters decried as a fad; 
but the facts suggest a nobler view. For the century which has developed medical 
laboratories has seen the death-rate reduced by one-half and the average expectation 
of life increased by ten or twelve years.* Of these laboratories, physiology had the 
first, that of Purkinje, at Breslau, established in 1824. In general, the experimental 
physiologist has proceeded upon the hypothesis that physiology is the physics and 
chemistry of living matter. He employs the apparatus and procedure of the physical 
laboratory to study the mechanical properties of tissue and the physical conditions 
to which these properties respond. The mechanism of the nervous system, the circu- 
lation, respiration, assimilation, muscular activity, lend themselves more or less 
readily to description and interpretation from the physical point of view. The ap- 
paratus and procedure of the chemical laboratory have been brought to bear in the 
analysis of bodily tissues, fluids, and secretions, and in the experimental reproduction 
of digestive and other processes. Not infrequently the subject is presented in two 
divisions, the former called physiology, the latter physiological- or bio-chemistry. 
That the mechanical standpoint has richly justified itself is indisputable; neverthe- 
less, so far as concerns medical education, it is not yet ready wholly to absorb the 
functional point of view. An unbridged gap exists. Whether the physical sciences 
will ever so far refine their procedure as altogether to resolve function in mechanical 

1 Between 3600 and 4000 hours of instruction make up the entire curriculum. 
Welch: Univerrity of Chicago Rtcord, vol. xii., no. S, p. 79. 



THE LABORATORY BRANCHES 63 

terms, it is needless here to discuss. Such an outcome is at any rate more distant than 
the early investigators, in the first flush of their splendid successes, supposed : 

"For long the way appears which seemed so short 
To the less practised eye of early youth." 

Meanwhile, whatever its limitations, the physiological laboratory is of immense edu- 
cational importance to the prospective physician. Physiology is, in a sense, the cen- 
tral discipline of the medical school. 1 It is the business of the physician to restore 
normal functioning: normal functioning is thus his starting-point in thought, his goal 
in action. The physiological laboratory enables the beginner to observe the functions 
of the body in operation and to ascertain how they are affected by varying conditions, 
a wholesome discipline for two reasons: it banishes from his mind metaphysical 
principles, such as vital force, depression, etc. ; it tends, in exhibiting the infinite 
sublety and complexity of the physiological mechanism, to emphasize normal condi- 
tions rather than medication as ultimately responsible for its orderly working. The stu- 
dent who has been successfully trained to regard the body as an infinitely complex 
machine learns to doubt his capacity to mend it summarily. It is true he lacks time 
to master any considerable part of the field which experimentation has covered from 
this point of view; but characteristic and pregnant illustrations at least insure his 
sanity. He may do ever so little, yet for that little he cannot take anyone's word. 
His actual contact with facts puts him squarely on his feet and cures him once for 
all of mystical and empiric vagaries. 

Anatomy and physiology form but the vestibule of medical education. They teach 
the normal structure of the body, the normal function of the parts, fluids, organs, 
and the conditions under which they operate. The next step carries the student in 
medias res; he begins pharmacology, 2 the experimental study of the response of 
the body to medication. 

The science got its problem in the first place from the credulity of which the tra- 
ditional pharmacopoeia is the encyclopedic expression. It undertook to question the 
complacency and vagueness of the empiric. How far was his reliance upon specific 
agents justified? If at all, was it possible to ascertain the source of their efficiency 
and its limits? 

Pharmacology was thus originally negative and critical. It rapidly pruned away 
exaggeration and superstition, leaving, however, a vigorous growth behind. It ascer- 
tained, for example, that quinine was administered in vain nine times out of ten ; 
but that in the single condition in which it was applicable malaria it struck at 
the root of the disease by actually destroying in the blood the obnoxious parasite. The 
limits of the effectiveness of digitalis, atropine, strychnine, have been discovered and 
explained; and similarly, the utter uselessness of dozens of concoctions with which 

l About 450 hours of instruction are devoted to it on the average, in the best schools. 

8 The first laboratory of experimental pharmacology was that of Rudolph Buchheim in Dorpat, 1849. 



64 MEDICAL EDUCATION 

the digestive capacity of the race has long been taxed. Intelligence has thus been 
introduced into a realm for ages unguardedly open to ignorance and recklessness. 

The science did not long remain merely critical: the development of chemistry 
and experimental physiology created a positive opportunity. Given, in a word, this 
or that condition, a disease, a symptom, or pain itself, cannot an agent be de- 
vised capable of combating it? Cocaine, the antipyretics, the various glandular 
preparations, and serum therapy are among the affirmative replies that witness the 
constructive possibilities of pharmacodynamics. The strictly experimental science, 
thus richly rewarded, has reinforced physiological conceptions independently at work 
in the effort to rationalize materia medica and therapeutics. Instead of nai've reli- 
ance upon poly-pharmacy, diseases and their attendant symptoms have now been 
divided into some half-dozen provisional classes, subject to continuous revision, ac- 
cording to the method of attack to which they are at the moment most accessible. 
There are those that drugs actually combat, syphilis and malaria, for example; 
next, the self-limited diseases, in the course of which therapeutic measures may be 
used to avert dangerous symptomatic consequences, as bathing reduces the tem- 
perature in typhoid, as chloroform checks convulsions in strychnine poisoning, as 
morphine relieves mere pain. There are those in which the body's natural methods 
of defense may be hastened or strengthened, as through serum therapy; those in 
which our only reliance thus far is on environment or suggestion; and finally, those 
in which summary relief may be had through the surgeon. A great change, this, from 
indiscriminate and largely ignorant dosing! The body diseased is indeed like a city 
besieged. No single form of military manoeuvre can be prescribed as a sure defense; 
now a sally from the main gate discomfits the enemy; again, a diversion from some 
unexpected quarter; sometimes the inhabitants conserve their strength in the hope 
of wearing the enemy out, feeding the soldiers at the expense of all the others; and 
sometimes, as in tuberculosis, there is no hope except by actually decamping, leaving 
a vacant Moscow to a cheated foe. 

In the university, pharmacology has critically an extensive, creatively an appar- 
ently boundless, opportunity. The medical student can at best browse the field here 
and there. But as was found to be the case with experimental physiology, he cannot 
forego that opportunity, limited though it be. The young doctor's therapeutic en- 
vironment is still distinctly unfavorable. He is exposed to danger, front and rear. 
The traditions of the profession are in the main crudely empiric; they embody a 
"pop-gun pharmacy, hitting now the malady and again the patient, the doctor 
himself not knowing which."" 1 Besides, the practitioner is subjected, year in, year out, 
to the steady bombardment of the unscrupulous manufacturer, persuasive to the un- 
critical, on the principle that "what I tell you three times is true." 2 Against bad 

1 Osier, Aequanimitcu, p. 127. 

8 "On a basis of 5000 prescriptions examined, 47 per cent are for proprietary medicines." M. G. Mot- 
ter, in Bull. Amer. Acad. Med., vol. ix., no. 1. 



THE LABORATORY BRANCHES 65 

example and persistent asseveration, only precise scientific concepts and a critical 
appreciation of the nature and limits of actual demonstration can protect the young 
physician. The laity has in this matter more to fear from credulous doctors than 
from advertisements themselves: for a nostrum containing dangerous drugs is doubly 
dangerous if introduced into the household by the prescription of a physician who 
knows nothing of its composition and is misled as to its effect. 1 Experimental physi- 
ology and pharmacology must train the student both to doubt unwarranted claims 
and to be open to really authoritative suggestion: for it is equally important to 
reject humbug and to accept truth. Fortunately, even a brief concrete experience 
may teach one to be wary in weighing evidence. 

The course in pharmacology need include, therefore, actual experimental determina- 
tion by the student himself of the effect on animals of a relatively small number of 
carefully selected agents; demonstration of others by the instructor; and a critical 
survey of the rest by means of lectures and recitations. 2 Materia medica, now much 
shrunken, need concern itself only with the pharmaceutical side, aiming to familiarize 
the student with drugs of proved power and the most agreeable and effective forms 
in which these may be administered. Therapeutics subsequently adds to these agents 
whatever other resources the clinician has accumulated, baths, electricity, massage, 
psychic suggestion, dietetics, etc., approaching the subject from the standpoint of 
disease, as opposed to the pharmacological approach from the standpoint of the drug 
itself. 

The last division of the medical sciences and the most extensive includes 
pathology and bacteriology. The three subdivisions of pathology are symmetrical 
with anatomy, physiology, and physiological chemistry. To the first corresponds 
pathological anatomy; to the second, pathological physiology; to the third, chemical 
pathology. 

In its modern form the study began on a comprehensive basis when Virchow, 
called from Wiirzburg, established the first pathological institute in Berlin in 1856. 
His plans went far beyond the gross morbid anatomy then current. He conceived 
pathology not only as a descriptive but as an experimental science, whose laws are 
the laws of general biology. The pathological is not, in this view, an anarchic, extra- 
legal freak ; it is the product of agencies and forces, operating on regular and inev- 
itable lines. The problem of the pathologist is through observation and experiment 
to get the key to the pathological process, in order that he may understand its origin 
and significance, and, if necessary, avert or control it. The pathological is abnormal 
from the standpoint, not of biological law, but of the human interests that it some- 
times thwarts sometimes, only; for not infrequently it is a beneficent, compensa- 

1 See The Propaganda for Reform in Proprietary Medicines, published by the American Medical 
Association, Chicago, 111. 

2 On the average, about 150 hours are devoted to instruction in pharmacology; something more than 
half of these can be given to the laboratory, the remainder to recitations. 



66 MEDICAL EDUCATION 

tory adjustment, actually favorable to the individual. Experimental pathology has 
developed along both biological and chemical lines: the former, accentuating the 
life-history of the abnormal growth, the latter, endeavoring to trace back the changes 
observed to the chemical activities involved in the life-process. Somewhat recently, 
a shifting of emphasis has made the physiological point of view more prominent, 
a wholesome development, medically speaking. The physician is constantly in con- 
tact with disease processes that he is unable to correlate with the accompanying 
structural modifications. Occasionally the surgeon throws a stream of light upon such 
a situation ; too often, all is dark until the autopsy reveals the truth. Pathological 
physiology aims to study structural change from the standpoint of function. It asks 
primarily not what is the history of the structural modification itself, but what are 
its progressive consequences to the functional routine of the organism. It reproduces 
disease experimentally, interrupting its course at significant stages, in order, having 
observed the functional disturbance, to ascertain exactly the structural readjustment 
that corresponds. "In animals, 1 " says Professor Hektoen, " the course of disease may 
be cut short at any time for the purpose of investigation. The disease may be studied 
in all its phases. Comparative pathology became the refuge of the investigator, 
blocked by the necessary restrictions governing the study of human diseases. The 
great influence of the comparative method is shown in the relatively advanced state 
of our knowledge in regard to human diseases readily communicable to animals, as 
compared with our ignorance in regard to other human diseases which, so far as we 
know, are not transferable to animals." 1 For the prospective physician the value of 
such a course depends, of course, on the opportunity to compare the laboratory find- 
ings with the symptoms shown by patients in the hospital wards. 

In general, the effective teaching of pathology is dependent on ease and frequency 
of access to the autopsy-room. It would be difficult just now to over-emphasize that 
point. We shall soon see that the post-mortem is in this country relatively rare and 
precarious; that not infrequently pathological courses are organized and given whose 
illustrative material is limited to models, to a small number of preserved specimens, 
or even to bits of material already cut into microscopic sections or just lacking that 
last touch. Such instruction may do justice to the subject on the histological side, 
but it leaves much to the already overburdened third and fourth years. And it is 
surely a serious disadvantage to the teacher of pathology to find himself year after 
year teaching the subject without access to the post-mortem room. 

Specimens alone whether gross or microscopic are inadequate for several rea- 
sons. In the first place, gross fresh specimens are too perishable : they change quickly 
after removal from the body and in consequence of handling during transportation ; 
refrigeration avoids softening and putrefaction only at the cost of destroying the 
blood, a most important link in the chain. More important still, however, is the 
consideration that disease is not an affair of a single organ or tissue, still less, of a 
1 Conyrtu of Artt and Science*, voL vi. pp. 112, 113 (slightly abridged). 



THE LABORATORY BRANCHES 67 

microscopic portion of such organ or tissue. Even an acute disease pneumonia, 
diphtheria involves the body as a whole; chronic defects such as heart lesion or 
cancer affect the organism likewise in its entire extent. The pathologist, then, seek- 
ing to convey to the student an objective conception of the nature and effects of 
disease as a process, needs the entire body in order to do so. Pathology is taught for 
that purpose; it fails of its object just so far as the lack of autopsies makes it im- 
possible. Cancer, for example, is not a local disturbance involving this or that organ. 
The student who is expected to grasp its character cannot do so if all he does is to 
see a cross-section put up in gelatine, or to handle a papier-mache reproduction, or 
to observe the cell changes on a small slide. These things are well enough as far as 
they go, but they go only a short distance. The cancerous process is complicated and 
extensive. Other organs, far from the original site of the disease, are involved ; nay, 
the original site itself may be in question. The vastness of the involvements, the re- 
lationships of affected locations to each other, the response of the bodily mechanism 
fighting to achieve a readjustment only the autopsy can disclose these; and with- 
out them, the student cannot attain an intelligent conception of the subject he is 
studying. 

Pathology's greatest contribution to the comprehension and mastery of disease 
has been by way of illuminating its causation, or etiology. The student who is to 
comprehend the significance of disease must not only make the inventory of results 
disclosed by the post-mortem : he should be allowed to observe the process from the 
very start. To this end, a demonstrative course, using living animals, must be pro- 
vided. Tuberculosis, for example, should be exhibited through the inoculation of a 
few guinea pigs with different varieties of the tubercle bacilli, showing the various 
ways in which the bacilli enter and are distributed, and the variety of lesions that 
they produce. 

We thus cross the threshold of still another science, bacteriology, developed in 
late years in close sympathy with pathology. It presents the same two sides, bio- 
logical and chemical; the former investigating the life-history of the microscopic 
organism, the latter isolating and resolving its, toxic or other products. The search 
of the pathologist for the original causation of abnormal structural change has been 
immensely facilitated by the bacteriologist He can now account for as well as de- 
scribe the ravaged tissues that mark the path of a diphtheritic, typhoid, or tuber- 
culous infection. Out of the life-history of the parasites in question has sprung the 
serum therapy, which has already stripped tetanus, diphtheria, and meningitis of 
much of their horror. 

Perhaps even more important than its services to curative, have been the sugges- 
tions of bacteriology to preventive, medicine. It is hardly too much to say that mo- 
dern hygiene, largely the outcome of bacteriology, has elevated the physician from 
a mainly personal to a mainly social status. Directly or indirectly, disease has been 
found to depend largely on unpropitious environment. A bad water-supply, defective 



68 MEDICAL EDUCATION 

drainage, impure food, unfavorable occupational surroundings, matters, all of them, 
for social regulation, at once harbor our parasitic enemies and reduce our powers 
of resisting them. To the intelligent and conscientious physician, a typhoid patient 
is not only a case, but a warning : his office it is equally to heal the sick and to pro- 
tect the well. The public health laboratory belongs, then, under the wing of the 
medical school. It is the clearing-house into which data from an entire state should 
pour. Tax-supported institutions are most favorably circumstanced in this respect. 
The material which they readily accumulate is at once a basis for teaching, for in- 
vestigation, and for practical sanitation. Thus the laboratory sciences all culminate 
and come together in the hygienic laboratory; out of which emerges the young 
physician, equipped with sound views as to the nature, causation, spread, prevention, 
and cure of disease, and with an exalted conception of his own duty to promote 
social conditions that conduce to physical well-being. 

From the standpoint of medical education, a detached academic or scientific treat- 
ment of pathology and bacteriology would sacrifice needlessly much of their value. 
Both subjects are, indeed, full-grown biological sciences, university subjects, capa- 
ble of cultivation only in special laboratories, closely affiliated with general biology 
and chemistry. But the medical student in the brief five hundred hours which he 
can at most secure for them gains the clearest insight into their philosophy and 
their bearing by following out their principles mainly in the small group of phe- 
nomena illustrated in human disease. Experimental pathology concerns him because 
it enables him later to conceive his clinical problems intelligently. From an early 
hour in his pathological work, the student may then begin in the autopsy-room to 
saturate himself with the clinical spirit. This is not to be confused with the prema- 
ture "cutting" or the impatient "prescribing" to which the old-fashioned medical 
student was addicted. "Cutting" and "prescribing" may still be two years distant; 
but meanwhile it is both possible and "important to keep ever before the student 
the part which the work he is doing plays in leading to a more complete compre- 
hension of disease." 1 

One closes a brief review of the medical sciences with a feeling akin to dismay. 
So much remains to find out,- so much is already known, how futile to orient the 
student from either standpoint! Practically, however, there is no ground for despair. 
Enough can be achieved to give him precise conceptions in each of the realms touched 
upon; and the actual value of these conceptions and of the habits grounded on them 
depends less on the extent of his acquisitions than on his sense of their reality. 8 
Didactic information, like mere hearsay, leaves this sense pale and ineffective; a first- 

1 Report of Committee on Pathology, Council on Education, Araer. Med. Assn., Bulletin of Arner. 
Jted. Aim., Sept 15, 1909, p. 47. 

* That method rather than any particular content is the very essence of scientific discipline is admi- 
rably pointed out by Professor Dewey in his address "Science as Subject-matter and as Method," 
Science, xxxi., no. 787, p. 122. "Science has been taught too much as an accumulation of ready-made 
material, with which students are to be made familiar, not enough as a method of thinking, an 
attitude of mind, after the pattern of which mental habits are to be transformed." 



THE LABORATORY BRANCHES 69 

hand experience, be it ever so fragmentary, renders it vivid. After a strenuous labo- 
ratory discipline, the student will still be ignorant of many things, but at any rate 
he will respect facts : he will have learned how to obtain them and what to do with 
them when he has them. 

NOTE 

For the details of a course of study, framed on the lines above described, the reader 
is referred to the following: 

A. GENERAL, 

1. Report of Curriculum Committee, Council on Education, American Medical Asso- 

ciation, Bulletin of the Amer. Med. Asm., September, 1909. 

2. What Constitutes a Medical Curriculum f Issued by Association of American Med- 

ical Colleges. 

3. COLWELL, N. P.: In Bulletin of American Academy of Medicine, vol. x., no. 3. 

4. BILLKOTH, T. : Ueber Lehren und Lernen in Medicin. 

5. BICKEL, ADOLF: Wie Studiert man Medizinf (Stuttgart, 1906). 

B. SPECIAL SUBJECTS 

1. Anatomy. 

BARKER, L. F., and BARDEEN, C. R. : Outline of Course in Normal Histology and 

Microscopic Anatomy, Johns Hopkins Hospital Bulletin, vol. xii., nos. 62, 63. 
BARKER, L. F., and KYES, P. : On Teaching of Normal Anatomy of Central Nervous 

System to Large Classes of Medical Students, Proc. Assn. Amer. Anat., 1900. 
BARKER, L. F. : Study of Anatomy, Journal Amer. Med. Assn., March, 1901. 
DWIGHT, T. : Methods of Teaching Anatomy at Harvard Medical School, Boston 

Med. and Surg. Journal, vol. cxxiv. pp. 457-77. 

HUNTINGTON, G. S. : The Teaching of Anatomy, Columbia University Bulletin, 1898. 
KEILLER, W. : On Preservation of Subjects for Dissection, etc., Amer. Jour. Anat., 

1902-3, vol. ii. 

McMuRRicK, J. P. : Conservatism in Anatomy, Anat. Record, vol. iii., no. 1. 
MALL, F. P. : The Anatomical Course and Laboratory at Johns Hopkins University, 

Johns Hopkins Hospital Bulletin, vol. vii., nos. 62, 63. 
MALL, F. P.: On Teaching Anatomy, etc., Ibid., vol. xvi., no. 167. 
MALL, F. P. : On the Teaching of Anatomy, Anat. Record, vol. ii., no. 8. 
MOODY, R. C. : On the Use of Clay Modelling in the Study of Osteology, Johns Hop- 

Jcins Hospital Bulletin, 1903, vol. xiv. 

2. Physiology. 

PORTER, W. T. : The Teaching of Physiology in Medical Schools, Boston Med. and 
Surg. Journal, December 29, 1898. 



70 MEDICAL EDUCATION 

CHITTENDEN, R. H. : The Importance of Physiological Chemistry as a Part of Medi- 
cal Education, N. Y. Med. Journal, September 30, 1898. 

BOWDITCH, H. P. : The Study of Physiology, Univ. Pa. Med. Bulletin, June, 1904. 

HOWELL, W. H. : Instruction in Physiology in Med. Schools, The Michigan Alumnus, 
January, 1900. 

LEE, F. S. : Physiology (Series : Lectures on Science, Philosophy and Art, Columbia 
Univ. Press, 1909). 

5. Pharmacology. 

ABEL, J. J. : On the Teaching of Pharmacology, Materia Medica, and Therapeutics, 
Phila. Med. Jour., September 1, 1900. 

SOLLMAN, T. : The Teaching of Therapeutics and Pharmacology from the Experi- 
mental Standpoint, Jour. Amer. Med. Assn., September 6, 1902. 

4. Pathology and Bacteriology. 

ADAMI, J. G. : On the Teaching of Pathology, Phua. Med. Jour., 1900, pp. 399-402. 

DELEPINE, A. S. : On the Place of Pathology in Medical Education, Brit. Med. Jour., 
1896, vol. ii. 

JORDAN, E. O. : Place of Pathology in the University, Jour. Amer. Med. Assn., 1907, 
vol. xlviii. p. 917. 

BARKER, L. F. : On Methods of Studying Pathology, Amer. Text-Book of Path., Phila- 
delphia, 1901. 

5. Hygiene. 

DITMAN, N. E. : Education and its Economic Value in the Field of Preventive Med- 
icine, Columbia University Quarterly, vol. x., supplement to no. 3, June, 1908. 

WINSLOW, C. E. A. : Teaching of Biology and Sanitary Science in the Massachusetts 
Institute of Technology, Tech. Quarterly, vol. xix., no. 4, December, 1906. 

WESBROOK, F. F.: The Laboratory in Public Health Work, Twelfth Biennial Report 
of Iowa State Board of Health. 

WESBROOK, F. F. : The Public Health Laboratory, Jour. Amer. Med., vol. xi., no. 9. 



CHAPTER V 

THE COURSE OF STUDY: THE LABORATORY BRANCHES 

(B) FIRST AND SECOND YEAKS (CONTINUED) 

WITH the preceding characterization, the schools included in our first division l on 
the whole agree. They are all organic parts of full-fledged universities ; their medical 
courses are as a rule constructed upon the basis of adequate pre-medical scientific 
training. In general, the laboratories of institutions upon a college basis reflect uni- 
versity ideals in equipment, management, and appearance. 2 As a rule these institu- 
tions have at least four separate laboratories, for anatomy, physiology and bio-chem- 
istry, pharmacology, pathology and bacteriology. As their resources have grown, the 
departments have tended to increase by subdivision : histology, physiological chem- 
istry, clinical pathology, bacteriology, attain departmental stature. Hygiene is es- 
pecially prominent at the state universities, where effective departments of public 
health bring the laboratories of pathology and bacteriology into fruitful relation 
with local authorities and the local profession throughout the state ; and endowed 
schools are making determined efforts to develop departments of preventive medi- 
cine. In some cases abundant, in several others increasing, facilities are offered in all 
branches for both teaching and research; and teaching and research permeate each 
other. The various departments, in intimate communication with each other and with 
the general science work of the institution, are officered each by its own full-time 
professor, in most instances with a more or less satisfactory corps of paid assistants. 
Within these active hives of scientific interest a thoroughly charming relation pre- 
vails: a vigorous, stimulating, and appreciative chief, on the one hand, enjoying the 
cooperation of enthusiastic young disciples on the other. It is difficult to realize that so 
substantial an organization is so recent, hardly more than a half-century old in Ger- 
many, less than twenty years old in America. In this brief period the earlier subordi- 
nates have themselves become departmental heads in their own schools, or have gone 
forth to found or to reconstruct distant institutions. Laboratories have increased in 
number so rapidly that the rewards of early promise or of early performance have 
been alike great and prompt. It is unlikely that this pace will permanently keep up. 
In anatomy and physiology it occasionally occurs that the departmental head is 
not himself a graduate in medicine. 3 This innovation arises out of a dual motive : it 

1 i. e. , those requiring for entrance two or more years of college work ; a list of them is given on page 28. 

a A few of these, formerly on a lower basis, have elevated their entrance requirements, while leav- 
ing facilities as they were. Several schools are pledged to higher entrance requirements, though quite 
unable to improve their facilities. Indeed, as higher standards mean fewer students and reduced in- 
come, their facilities may suffer deterioration. 

3 Occasionally the dean of a medical school is a non-medical man. In such cases it is extremely im- 
portant that he be in close sympathy with the clinical side and well acquainted with modern devel- 
opments in clinical teaching. Even more dangerous is the expedient of making a professor in the 
academic department dean of the medical department. 



72 MEDICAL EDUCATION 

represents a reaction from the superficial methods of the practitioner professor, as 
well as a realization of the essential continuity of medical with biological science. The 
non-medical professor is not necessarily indifferent to explicit medical reference; his 
department need not lack sympathy with medicine merely because he has no M.D. 
degree; and his disinterested attitude is in any event indispensable. But the experi- 
ment is not free from danger, and its outcome will be watched with interest. Mean- 
while, there is no question that these posts cannot be satisfactorily filled by active 
physicians. The practitioner usually lacks impartial and eager scientific spirit; he 
can at best give set hours to teaching, and these are not infrequently interrupted 
by a patient's superior claim; of course he has little or no time and rarely any zest 
for research. Western Reserve and the New York City department of Cornell, alone 
of schools of this rank, continue an active surgeon in the chair of anatomy. 

Of the twenty-five institutions either now, or by the fall of 1910 to be, on the two- 
year college basis, or more, fourteen 1 offer the entire four-year course in one organized 
institution ; five 8 are divided, offering the laboratory branches in one place and the 
clinical branches, more or less independently organized, in another, sometimes close 
by, at other times widely separated; six 3 are half-schools, offering only the work 
of the first and second years. The complete school in touch with the rest of the 
university represents the normal and correct form. The study of medicine must 
center around disease in concrete, individual forms. The ease with which the clinics 
and the laboratories may there illuminate each other is an incontestable advantage 
to both. It is difficult to imagine effective teaching of pathology, for example, under 
conditions where the operating-room, the medical clinic, and the autopsy do not 
constantly contribute specimens and propound queries to the laboratory; and assuredly 
the teaching of medicine and surgery cannot proceed intelligently without constant 
intercourse with the laboratories. Any disintegration of hospitals and laboratories is 
harmful to both, and to the student, in shaping whom they must cooperate. So 
important is organic wholeness that the remote department, if entire, is from 
all points of view preferable to division. The initial difficulty that of sharing 
the university ideals may be met by liberal provision for intercourse with the 
academic body and by redoubled efforts to maintain creative activity, as Cornell, 
for example, has done at New York. Fortunately, our needs in respect to medical 

1 Johns Hopkins, Harvard, Western Reserve, Minnesota, Cornell (New York City department), Yale, 
Michigan, Indiana (Indianapolis department), Iowa, Pennsylvania, Syracuse, Columbia, Dartmouth, 
Colorado. Of these, two are not located in the same town as the university, Cornell (New York 
City), Indiana (Indianapolis). 

'Rush Medical College (of which, though both parts are in Chicago, the first two years belong to the 
University of Chicago, and the last two, given elsewhere in the city, are only affiliated with it), Cali- 
fornia (first and second years at Berkeley, third and fourth at San Francisco and Los Angeles), 
Nebraska (first and second years at Lincoln, third and fourth at Omaha), Kansas (first and second 
years at Lawrence, third and fourth at Rosedale), Stanford (first and second years at Palo Alto, third 
and fourth at San Francisco). 

Wisconsin, Missouri, South Dakota, North Dakota, Utah, Wake Forest. Cornell repeats the first 
year at Ithaca; Indiana duplicates the first and second years at Bloomington. 



THE LABORATORY BRANCHES 73 

schools can be met without considerable resort to either the divided or the remote 
department. 1 

The divided school begins by inheriting a serious problem. Its laboratory end, 
situated at the university, has been recently constituted of modern men; the clinical 
end, situated in a city at some distance, is usually what is left of the old-fashioned 
school which the university adopted in taking on its medical department. 2 In such 
cases, there are practically two schools with a formal connection; such is essentially 
the situation in California, Kansas, and Nebraska. In course of time these clinical 
faculties will be reconstituted of men of more modern stamp. But the separation of 
the clinical branch, with the increasing absorption of the teachers in practice, in- 
volves constant danger of fresh alienation. The clinical professor of the university 
is very apt to be a busy physician; and if so, pedagogical and scientific ideals are all 
the more easily crowded into a narrow corner, when he does not breathe the bracing 
atmosphere of adjacent laboratories. In time, a more exacting pedagogical code and 
increased sensitiveness to real scientific distinction may to some extent correct the ten- 
dency. Meanwhile, these institutions, so long as they continue, require much more vig- 
orous administrative supervision than they have anywhere received. A dean, moving 
freely between the two branches, and frequent opportunities for social and scientific 
intercourse between scientific and clinical faculties, may throw a more or less unsteady 
bridge across the gap. But there is little reason to believe that the divided school will 
ever function as an organic whole, though it may be tolerable as a halfway stage on the 
road from the proprietary school to the complete university department. "I cannot 
help wondering," said President Pritchett, 3 "how it would affect the pedagogic and 
professional ideals of an engineering school if its first two years were given in one 
place and the last two years in a place two hundred miles away. My impression is 
that there would be two separate schools with very little more reaction, the one upon 
the other, than exists between any other two schools so located." Thus far the diffi- 
culty seems hardly to have been suspected: the dean of Nebraska at Lincoln is a 
busy professor who has no real hold on the clinical men at Omaha; the dean of Cali- 
fornia is superintendent of the hospital in San Francisco, with no real control of what 
goes on at Berkeley, and surely without any possible control over the second clinical 
department at Los Angeles ; Kansas practically accepts the split by setting up a dean 
at each of the two ends, though they are only an hour and a half apart; Mississippi, 
with even better reason, does the same, for the journey from Oxford to Vicksburg, 
not great when measured in miles, takes the better part of a day even if one is lucky 
enough to make the necessary railroad connections. 

The problem of the half-school is different. The two-year school originated in 

1 See chapter ix. 

2 In a measure, also still true of some of the complete schools; but the constant contact of laboratory 
and clinical men tends gradually to bring the edges together. 

8 Address : "The Obligations of the University to Medical Education," before Council on Education, 
American Medical Association, Feb. 28, 1910 (Journal A. M. A., vol. liv. p. 1109). 



74 MEDICAL EDUCATION 

institutional expediency; but it may prove of actual pedagogical importance. When 
Columbia and Michigan arranged that the four years of the A.B. course might con- 
tain two years of the M.D. course, institutions lacking medical departments were 
impelled to offer just enough of the medical curriculum to meet the competition. 
The half-school thus avoids loss of time to the student and loss of students to the 
university. The arrangement took advantage of the break in the middle between 
the laboratory and the clinical years; but a deeper reason made the experiment 
feasible. 

The bachelor's course has under modern conditions a double aim : it is simultane- 
ously cultural and vocational. The sciences fundamental to medicine have obviously 
both characters: they are vocational to the extent that they are instrumentally in- 
dispensable; they are cultural, as is all enlarging and releasing experience, whether 
of men, books, or travel. Culture is indeed in this aspect an incidental value of all 
novel experience. So far, then, the combined course may be fairly said to be feasible, 
because it enriches the college curriculum ; and the college may do well to offer the 
opportunity. 

Is the scheme equally sound from the standpoint of medical education ? The pro- 
fessional and cultural standpoints, though obviously overlapping, are not identical. 
The professional purpose involves greater concentration, is on the lookout for definite 
correlations, and steers towards an evident practical goal. The medical curriculum 
possesses a certain organic unity in virtue of the fact that each of its parts does this 
same thing. The college as college is indifferent to the ultimate practical bearing; 
the medical school cannot afford to forget it. As to certain subjects, indeed, there 
is perhaps little to choose. The college has already taken chemistry wholly out of the 
medical curriculum ; it may be allowed to take bio-chemistry, too. In reference, how- 
ever, to other subjects, pathology, physiology, etc., it is important once more 
from the standpoint of medical education to distinguish between two forms which 
the combined course assumes. To take advantage of it at Columbia or Michigan 
complete four-year schools the student goes over into the medical department, 
which is compactly organized with laboratories and clinics interwoven. He spends 
the entire period of four years there. The college has nothing to do with it beyond 
registering his credits for the first two years towards his A.B. degree. That fact makes 
absolutely no difference to the medical teachers. The student is trained for four years 
just as he would be trained if he had his A.B. degree to start with. The combined 
course in this form exacts no sacrifice from the medical school. 

In the case of the half-school or the divided school the situation is different: the 
medical subjects are apt to be parceled out among the general scientific laboratories, 
and there are no clinics or clinicians at all. The professors themselves may lack medi- 
cal training. There is no observable goal to steady or beckon the teacher. 1 Counting 

1 The medical department of the University of Wisconsin, a half-school, combats the difficulty by 
appointing a professor of clinical medicine. 



THE LABORATORY BRANCHES 75 

the two years' work as the latter half of the A. B. course may, under these circum- 
stances, distinctly weaken it from the medical standpoint. It is, of course, true that 
the German medical schools are without the sort of organization we are now empha- 
sizing; but they have what we lack, ideals and traditions. Dispersion does not cost 
them their point of view. When our ideals are as sound, we too may be capable of 
dispensing with a more or less formal organization. Some of our schools may already 
be. 1 Would it, however, be equally safe even in Germany, if there were no clinics 
at all? 

Take, for instance, the subject of pathology. The two-year school, remote from hos- 
pitals and autopsies, can provide museum specimens, models, and microscopic mounts. 
Under favorable conditions, animal experimentation can still further supplement its 
resources. But the pathologist will suffer from isolation; he is part of the college, but 
not part of a hospital, and what is hurtful to him cannot be helpful to his students. 
For them much depends on the arrangement of courses in the institution to which 
they emigrate for their third and fourth years. Meanwhile, in any case, at the fateful 
moment of their introduction to the subject, however admirably they may have been 
drilled in the specific content of the course, little advantage can be taken of their 
general absorptive power. For even a fair student, while learning his lessons in patho- 
logical histology, might assimilate incidentally much that goes beyond. Not infre- 
quently what is most stimulating in his experience would be thus obtained. It would 
appear, then, that, while the college will surely gain, it is not certain that the medi- 
cal curriculum may not lose when the first and second years are separated or de- 
tached. 

There would be the less necessity for the cautious attitude here taken in reference 
to the two-year school if these departments were everywhere organized, as they have 
been by Wisconsin, Cornell, Missouri, and Indiana, with a keen appreciation of the 
ditiiculties to be surmounted and with financial resources capable of coping with them. 
Apparatus, books, animals, laboratory material, must be provided in abundance. In 
the institutions above mentioned they are. Too frequently, however, apparatus is 
limited, books are scarce, animals hard to get, running expenses reduced to a mere pit- 
tance. Skilled assistants and competent helpers may also be lacking. The teachers are 
young and well trained; but their professorial salaries are paid to them in part for 
menial labor. They care for apparatus, get it out, put it away, prepare all demon- 
strations and experiments, and clean up after class. Be the students ever so few, rou- 
tine drudgery and isolation will wear out the enthusiasm of their instructors. The 
men will grow stale, the department sterile. As the two-year schools now generally re- 
quire two years of college work for entrance, they cannot be parsimoniously organ- 
ized. Yet their rapid spread seems to indicate a mistaken notion that the laboratory 
years can safely be conducted on a small scale at comparatively slight expense. 

1 For an extremely lucid and able discussion from this point of view see the Harvard Bulletin, Nov. 3, 
1909 : "Education in Medicine: The Relations of the Medical School to the College." 



76 MEDICAL EDUCATION 

A uniform or fixed apportionment between various subjects is in schools of the 
highest grade neither feasible nor desirable. The endeavor to improve medical edu- 
cation through iron-clad prescription of curriculum or hours is a wholly mistaken 
effort; while mechanical regulation cannot essentially improve the poorer schools, it 
may very seriously hamper competent institutions. There is no one way to study 
medicine, still less one way to advance it. If the teaching is in inferior hands, printed 
directions will not save it. The prescribed curriculum is a staff upon which those 
lean who have not strength to walk alone. 

Fortunately, current practice varies widely. The Johns Hopkins, for example, offers 
700 hours' instruction in anatomy, of which about 400 are required, Harvard 427 ; 
Rush gives 108 hours to histology, Cornell 265; Columbia requires 490 hours in 
anatomy, embryology, and histology; Harvard gives 513 hours to pathology, Western 
Reserve 304. These discrepancies are of slight importance, for the medical curriculum 
is throughout constituted of overlapping parts : apparent deficiencies in one subject 
are supplied in another. Physiology revises and mends anatomy, and the clinical years 
may be safely relied on to build out here and there the details of pathology. A certain 
carefully selected, irreducible minimum in each subject must of course be common 
throughout these institutions; the rest may be left open, to vary from school to 
school, and within each school to vary to some extent with different individuals. The 
medical school is above collegiate grade ; it is a professional school on a college basis. 
Its students are presumably mature and will doubtless prove increasingly well trained. 
They are fit to be trusted with a certain degree of discretion, in a field within which 
selection between alternatives of equal importance must in any event take place. 
The fourth year at Harvard is left open to choice ; at Johns Hopkins one-fourth of 
each year is subject to election ; intensive study at certain points is encouraged with- 
out endangering the fundamentals common to all. The problem of medical education 
and orientation is not otherwise manageable. In the effort to force every important 
subject as it has developed into the common curriculum be it ever so inadequately 
the average curriculum now calls for something like 4000 hours of prescribed work. 
The demand is an impossible one. 1 It originates partly in the effort to make the medical 
school repair the omissions of preliminary education; higher standards will relegate 
something at least to the high school and college, and so far relieve congestion. As 
for the rest, we require a modified conception of what any sort of school can and 
ought to attempt. The mature student, competently guided, needs not to be policed 
like the "breeching scholar in the schools." His every moment must not be preempted 
by an assigned task. Von Striimpell rebukes the same tendency in Germany: "Some- 
what more rarely in the first, very often, however, in the later semesters, many students 
hear lectures for eight to ten hours a day. From morning to night their time is taken 
up with classes; they rush out of one lecture hall into another, hearing a huge mass 
of facts and theories put forward. One can readily imagine the condition inside their 
1 A large percentage of students are making up preliminary "conditions" besides. 



THE LABORATORY BRANCHES 77 

heads by the time night comes. The actual outcome of this absurd overcrowding is 
that only a small amount of what is heard is retained. One can profitably listen only 
when one can take in readily and follow up systematically with work at home." 1 

The maturity of the student body at this level makes possible another innovation. 
The low standard or immature type of medical student must have his medical 
knowledge carefully administered in homeopathic doses. He carries a half-dozen 
studies simultaneously because his untutored interest fatigues easily and his assimi- 
lative ability in any one direction is relatively slight. Time and energy are of course 
lost in hourly breaking off one connection and making another. But it is unavoidable; 
the practitioner teacher must leave at the close of his " hour" anyhow. At the uni- 
versity studies may be concentrated. The laboratories are open all day; the profes- 
sors are there at work. 2 The first months of the medical curriculum are then given 
over to anatomy alone; for it is clearly illogical to begin even physiology till the 
anatomist has made some headway. Concentration 3 is economical of time and energy, 
and stimulates the student to push on beyond definitely prescribed limits. How far 
it can wisely be carried is a point to be determined by experiment. 

The schools of our second division those requiring for admission high school 
graduation or the "equivalent" move within narrower limits. Two factors are at 
work. Most schools of this class live on their fees; McGill, Toronto, Tulane, are 
among the few that are enabled by additional resources to provide a complete lab- 
oratory outfit. The strongest of the others, Jefferson and Northwestern University, 
for example, relying practically altogether on income from students, can at best de- 
velop highly a department or two; 4 the rest are necessarily restricted. The quality of 
the student body is likewise a limitation. Laboratory courses, following the lines that 
we have marked out, are impossible to boys whose preliminary training in science has 
barely begun. At best the students have an elementary acquaintance with physics or 
chemistry; frequently not even that. Those that have and those that have not sit side 
by side on the same benches. A difficult dilemma is thus presented. It is impossible 
to teach the medical without the pre- medical sciences; the medical course, already 
crowded, cannot be either cut or compressed sufficiently to accommodate them. The 
situation cannot, therefore, be wholly retrieved within the medical school. Makeshifts 
vary somewhat from school to school. A rigid medical curriculum, clipped to the quick, 
leaves perhaps a few hundred hours available for pre-medical work. Chemistry as a 
rule absorbs them all; nothing is attempted in biology; occasionally physics gets a 
slight opportunity, as at Tulane, where first-year students hear one lecture a week, 

1 Ueber den Medizinisch-Klinischen Unterricht, p. 11 (Leipzig, 1901). To the same effect. Professor 
T. Clifford Albutt: On Professional Education, p. 49 (Macmiflan, 1906). 

2 "Die Studierenden sollen jederzeit eintreten diirfen," Virchow's laboratory motto, quoted by Orth : 
Berliner Med. Woch. Sch. vol. xliii. p. 820. 

3 See "The Concentration Plan of Teaching Medicine," by H. A. Christian, Proceed. Asm. Amer. 
Med. Colleges, March, 1910. 

* See p. 133. 



78 MEDICAL EDUCATION 

"abundantly illustrated,** or at St. Louis University, where sixty-four hours of didactic 
instruction are devoted to the subject. 1 

After all, however, there are different ways of meeting even a desperate condition ; 
and in this instance the variations are within limits amazingly wide. 3 There are schools 
that sink ignominiously without a struggle; others that take advantage of the stu- 
dent's plight to palm off cheap instruction at a profit; and a small number that by 
valiant effort minimize, and to no slight degree surmount, the difficulty. According 
as an institution reacts in one or another of these ways, we make out three main 
varieties among schools on the high school basis : 

1. Those that by careful selection of students and extraordinary pains in teaching 
make the very most of the situation; 

2. Those that, content to operate on a lower plane, are still commercially effective; 
8. Those that are frankly mercenary. 

We shall briefly consider these three types in succession. 

(1) These schools form a small minority. They are straining hard to get from the 
high school to the college basis; in equipment, organization, and scientific spirit 
they are to greater or less degree already there. They have usually four scientific 
departments, 8 already in most instances well equipped, each in charge of a full-time 
professor, for whom private quarters and more or less free time 4 procure some op- 
portunity to push ahead. Energy, sincerity, and intelligence are abundantly in evi- 
dence throughout these institutions. In resources they vary greatly, but in spirit they 
are alike; and all are admirable. Every possible point is scored : the more difficult the 
contest, the keener the play. However scant the resources, something is put into 
books; however hard pressed the instructor, a museum, carefully catalogued and 
labeled, has been painfully assembled. 

Of schools of this type, two Canadian institutions McGill and Toronto de- 
serve especial attention. In point of laboratory equipment they equal Minnesota and 
Michigan; their lower entrance requirement, minimized by conscientious adherence 
to a strict interpretation of their announced standards, is now compensated by the 
addition of a fifth year to the curriculum. 6 At Toronto the teaching is wholly in 

1 Sometimes the provision is sheer make-believe. At Denver and Gross College of Medicine (Denver, 
Col.) the physics is thus described: " One hour each week in practical chemistry as applied to med- 
icine. The first year's work will include medical physics, chemic philosophy, and organic compounds." 
Catalogue, 1908-9, p. 22. 

1 See table at close of this chapter. 

3 Anatomy, chemistry, physiology (including pharmacology), pathology (including bacteriology and 
hygiene). 

4 How much, depends on the quality of the assistants furnished. There is great variation in this 
respect 

'This is a very different thing from adding a year devoted to pre-medical sciences taught by the 
medical faculty of a proprietary school, a makeshift without possibility of development. The Cana- 
dian year is a year in the university, where teachers of science are in position to do their subjects 
justice ; eventually a second year will be demanded. The optional fifth year offered by our pro- 
prietary schools is commercially profitable and educationally futile. See page 47. 



THE LABORATORY BRANCHES 79 

charge of full-time instructors, for whose original work splendid provision has been 
made in laboratories of ideal construction and admirable equipment. McGill is in 
respect to full-time teachers somewhat less fortunate ; but its great museum, recently 
much damaged by fire, proves that genuine enthusiasm may succeed contrary to all 
the established rules of the game. In both institutions the shortcomings of the stu- 
dent body, instead of excusing perfunctory work, have rather been regarded as an 
obstacle to be overcome, a condition to be met. The students have had little high 
school science: all the more reason, then, to provide excellent laboratories, skilful 
teachers, abundant assistants. In keeping with effective performance are their mod- 
esty and candor. The number of "greatest anatomists" and "greatest pathologists" 
teaching on small salaries in obscure places in the United States, and of laboratories 
" as good as Johns Hopkins," is nothing less than staggering. Nor is a boastful pride 
in mediocrity lacking even in institutions of some real merit. At Toronto and McGill 
one hears in the medical schools no such bravado. There they deprecate the defects, 
which they hasten to show for fear they may escape notice. The absence of compe- 
tition 1 be it business competition between schools conducted for profit, or academic 
competition between endowed or tax-supported institutions, mad to "make a show- 
ing" may perhaps be responsible for their more guarded utterance and more as- 
sured ideals. 

Perhaps a dozen institutions in the United States belong with greater or less right 
to the category under consideration. Regard being had to the quality of the student 
body, to the number of full-time teachers and assistants, and to the adequacy of 
laboratories, museum, and library, the best of them, in respect to the first and second 
years, are New York University, Syracuse, 2 Northwestern University, Jefferson Medi- 
cal College (Philadelphia), Tulane University (New Orleans), St. Louis University, 
the University of Texas, handicapped though some of them are in one respect or 
another by resources inadequate to the ambition and competency of their faculties 
and by a student body of somewhat uneven composition. St. Louis University affords 
an excellent example of a brave, uphill contest, by no means barren of result. Unable 
for the moment to do all it wishes, it has, like a good general, concentrated its 
effort at critical points. It secures a pervasive scientific atmosphere in the first two 
years through the intensive cultivation of anatomy and physiology. The departmental 
head of the former subject stipulated that his routine work be kept in close bounds; 
with wise liberality he has been provided with an assistant professor, a draughtsman, 
and a competent helper; the productive department thus created has invigorated the 
entire school on the laboratory side. 

To the schools just described we must look for such further facilities in high-grade 
medical education as the country still requires. Their ideals are correct ; they lack 
only the means; and these they have already in comparative poverty shown the ca- 

1 There are eight medical schools in British America. 

2 Already requiring more than four-year high school education. 



80 MEDICAL EDUCATION 

pacity to use. Once the necessary resources have been bestowed upon them, the re- 
maining task will be merely the absorption or the suppression of the various types 
of medical school yet to be discussed. It is surely significant that with but a single 
exception, these schools are also, like those of the first division, bona-Jide university 
departments. 

So much for the best type of medical school on the high school basis. We consider 
next (2) the schools that on the same basis are shrewdly and more or less outspokenly 
commercial. A few of them those at Chicago, Philadelphia, and Baltimore have 
accumulated extensive and, in one or two departments, elaborate plants. 1 They are 
on a routine level and, within the limits marked out by state board examinations, 
pedagogically effective. They drill their students energetically in the elements of such 
of the sciences as they touch at all, but the atmosphere is at best that of a success- 
ful factory. There is no free scientific spirit. The teaching of chemistry at the Medico- 
Chirurgical College of Philadelphia is an extreme case in point. The course is sub- 
divided into fixed lessons, each of them so much raw material, for which the student 
receives a voucher, to be returned in proper shape before he can get the voucher for 
the succeeding task. The vouchers returned constitute an automatic record of atten- 
dance and form the basis of an oral quiz by an instructor. "The whole system is an 
imitation of the business system in vogue in the better organized business offices."" 2 
Mechanically admirable, no doubt; but what convincing evidence the system itself 
affords of the unfitness of the students for the study of modern medicine! 

Two schools of this group the Long Island College Hospital (Brooklyn) and the 
Albany Medical School are closely affiliated with laboratories which provide good 
teaching in certain branches : the Hoagland Laboratory at Brooklyn relieves the school 
of histology, pathology, and bacteriology; the Bender Laboratory at Albany carries 
the laboratory work in the same subjects. It will be noted that physiology and 
pharmacology are not properly provided by either; neither are they by the school. 
One might suppose that the school, relieved at one point, would become more effec- 
tive at another. Not at all. Both schools pay in dividends to prosperous practitioners 
the sums that should be used in completing their fundamental instruction. 

Scientifically, then, these schools may be called inert. They rarely cultivate any re- 
search at all; their faculties are generally composed of active practitioners whose 
training has rarely been modern. By way of exception Louisville has four full-time 
professors in the fundamental branches, the Medico-Chirurgical three, Creighton one. 
But very rarely has the full-time teacher opportunity to work ahead. His time and 
energies are bespoken by heavy routine, unlightened by a competent or organized 
force of assistants and helpers. In general, school positions are valued as professional 

1 Preeminently the Medico-Chirurgical (Philadelphia), University of Maryland and College of Physi- 
cians and Surgeons (Baltimore), and College of Physicians and Surgeons, Chicago. 

' From a description by the head of the department. 

Strictly speaking, even these are not full-time men in the medical school, since they also teach in 

pharmacy and dental departments. 



THE LABORATORY BRANCHES 81 

stepping-stones, not as scientific opportunities; laboratories are often slovenly and, ex- 
cept during class hours, entirely abandoned. Strange professorial combinations are 
found : anatomy and surgery, very commonly ; clinical medicine and physiology, at 
the University of Maryland; orthopaedic surgery and pathology, at the Baltimore 
Medical College ; medicine and pathology, at the Chicago College of Medicine and 
Surgery (Valparaiso University); pathology and the physical directorship of the 
academic department, at Bowdoin. Scientific chairs are held by non-residents at the Uni- 
versities of Colorado l and Vermont 2 and at the Medical School of Maine (Bowdoin); * 
and itinerant teachers, giving the same branches at several schools, are to be found 
in Philadelphia, New York, and Chicago. If the larger institutions under consideration 
chance to contain a full-time teacher, his time usually belongs equally to dental and 
pharmacy departments, developed as "business propositions" to keep the plant con- 
stantly going; despite the manifest incongruity, dental or pharmacy students mingle 
in the same classes with medical students at the Medico-Chirurgical College (Phila- 
delphia), Temple University (Philadelphia), and the Creighton Medical College 
(Omaha). 4 Occasionally a non-practising teacher will be found who is simultaneously 
holder of a municipal office, to which he devotes his main thought. The medical 
school gets the few brief hours that it pays for. Thus the non-practising professor 
of chemistry at the Creighton school is the city gas inspector; the professor of bacteri- 
ology at Denver and Gross is city bacteriologist, 6 with his laboratory at the City 
Hall. In the few cases where a non-practising full-time professor is found, 6 he is 
swamped with work ; for he has as a rule only student assistants to aid him in coping 
with several hundred pupils utterly inexperienced in laboratory manipulation. 

For many years a school of this sort was a veritable gold mine to its owners. Fees 
were divided outright, or invested in buildings which the faculty owned. Once in 
a while the income was split: a large share went to the teachers, the rest was de- 
voted to carrying mortgaged buildings held by the trustees. These structures them- 
selves were not infrequently erected in pursuance of business policy. Recent agita- 
tion has forced increased expenditure on buildings and equipment. The schools 

1 Anatomy, by a non-resident surgeon. 

2 Physiology, pathology, and hygiene. 

3 Anatomy and physiology. 

* Likewise at University of Maryland, Valparaiso University, College of Physicians and Surgeons 
(Chicago), Georgetown University, College of Physicians and Surgeons (Baltimore), Baylor Univer- 
sity, College of Physicians and Surgeons (San Francisco), Barnes (St. Louis), Starling-Ohio, Univer- 
sity of Texas, Toledo Medical College, Medical College of the State of South Carolina, Milwaukee 
Medical College, College of Physicians and Surgeons (Boston), Wisconsin College of Physicians and 
Surgeons. Even at Harvard, dental and medical students are mixed in some classes, though it is 
admitted that "the Dentals don't do as well and are harder to teach." Students are admitted to the 
Harvard Dental School on the basis of a four-year high school education. The discrepancy is there- 
fore considerable. 

5 The same is true at the University of Oregon (Portland), though in this case the laboratory is in the 
medical college ; it is also the only real laboratory there. 

Physiology, College of Physicians and Surgeons (Chicago) ; pathology, Creighton ; chemistry, Balti- 
more Medical College. 



82 MEDICAL EDUCATION 

have been willing enough to build; but in the matter of equipment they have usu- 
ally yielded as little as they could. The conclusive evidence of lack of educational 
conscience or pride is the general absence of a decent museum. 1 Material, of course, 
abounds, the expense involved is slight; but the practitioner simply will not take 
the trouble. The College of Physicians and Surgeons (Baltimore), Georgetown Uni- 
versity (Washington), Long Island College Hospital (Brooklyn), the medical depart- 
ment of Valparaiso University, the Chicago Hahnemann, Ensworth (St. Joseph, Mis- 
souri), are among the schools that have little or nothing in the way of a museum at 
all. Such specimens as one meets are often putrid, rarely labeled properly, and still 
more rarely catalogued. But a few exceptions may be fortunately noted : the great 
anatomical and pathological museum at McGill has already been mentioned. To the 
same class belong the excellent collections made by Souchon at Tulane and by Keiller 
at Galveston (University of Texas). A small but beautifully mounted collection at 
Boston University is once more an evidence of what conscience and intelligence will 
achieve despite slender financial resources. 

Practically the same may be said on the subject of books. The College of Physi- 
cians and Surgeons of Chicago and the Medical College of Virginia have small work- 
ing libraries; but in general no funds are set aside for the purchase of books. The 
school grind is merrily independent of medical literature. The University of Mary- 
land possesses indeed a large library under a separate roof, but the building was un- 
heated when visited in midwinter, and at best it is open only two hours a day. 
Denver and Gross (Denver, Colorado) and the Medico-Chirurgical College of Phila- 
delphia have limited accumulations of textbooks and cheap medical periodicals; 8 
Long Island and Albany have no books at all. In the College of Physicians and Sur- 
geons, Los Angeles, the word "Library" is prominently painted on a door which, on 
being opened, reveals a class-room innocent of a single volume. Once more it is 
pleasant to record exceptions: a good library, excellently administered, is to be 
found at Jefferson, at Buffalo, and at Galveston. 

In the matter of laboratory equipment and work, our progress may be facilitated 
by simple elimination. None of these schools has laboratories of pharmacology; in 
consequence, their teaching of materia medica and therapeutics is wholly on didactic 
lines. Only a few of them the Medico-Chirurgical (Philadelphia), University of 
Maryland (Baltimore), the College of Physicians and Surgeons, Chicago are well 
equipped to do either demonstrative or experimental work in physiology; as a rule, 
physiology is still didactically presented with a varying amount of experimental 
demonstration. The general laboratory equipment is therefore limited to chemistry, 
anatomy, pathology, and bacteriology. 

l Thc Hahnemann (Philadelphia), University of Maryland (Baltimore), Oakland College of Medicine 
and Surgery (California), each has a small museum. 

The former behind a counter in the business office, practically inaccessible; the latter at the Col- 
lege Club House. 



THE LABORATORY BRANCHES 83 

As a rule, chemistry advances little beyond the high school level; at the best, 
elementary organic chemistry is included. 1 The equipment is ordinary; there is no- 
where the faintest evidence of independent scientific interest, nowhere any interplay 
between the chemical and other laboratories. The ground covered satisfies the state 
board prescription, enabling the student to pass the state board examination. No- 
thing more is intended; the teaching is accordingly in large measure didactic and 
quiz drill. It cannot be otherwise; for even in the cases where sufficient desk space 
is provided, competent assistants are lacking. The instruction therefore quickly de- 
teriorates into demonstration and drill. 

The teaching of anatomy clings to thoroughly conventional lines. Embryology is 
practically unknown; osteology is taught by lectures instead of by practical methods, 
such as modeling, or the like; histology is relegated to pathology because the ana- 
tomical department possesses no microscopes, in the first place, and because the 
practitioner teacher rarely understands their use, in the second. The laboratory is a 
mere dissecting-room, in which the student is required to dissect part of a cadaver 
under the guidance of upper-class students or recent graduates. Into none of the 
schools mentioned have modern ideas as to the conduct of this department per- 
meated. Well conducted anatomical laboratories are in these days clean, attractive, 
sweet-smelling places; the cadavers, neatly covered when not in use, are moist, 
thoroughly well preserved, and not repulsive even to a layman. The dissecting-rooms 
under discussion are rarely clean, always unattractive, and not infrequently unplea- 
sant. They contain tables, cadavers, and a vat; usually nothing more. Not infre- 
quently the school skeleton is defective, as at Creighton, the College of Physicians 
and Surgeons, Milwaukee, and at the Kansas City Hahnemann. The models, charts, 
cross-sections, bone-sets, 2 drawings, microscopes, that complete the outfit of the modern 
anatomist, are conspicuously absent. Large and financially prosperous schools, such 
as the Medico-Chirurgical (Philadelphia), the University of Maryland (Baltimore), 
in immediate proximity to institutions like the University of Pennsylvania and the 
Johns Hopkins, where the subject is properly conducted, have profited nothing by 
opportunities to modernize their teaching. Of course it could not be otherwise. The 
professor is a busy physician or surgeon. He lectures to ill prepared students for 
one hour a few times weekly, in a huge amphitheater, showing a bone between his 

1 The Medico-Chirurgical College of Philadephia offers decidedly more. The instruction there occu- 
pies part of three years and requires 544 hours of work. Nothing could better illustrate our conten- 
tion that, with medical students on the high school or equivalent basis, anything like a thorough 
treatment of the pre-medical sciences within the medical curriculum is fatal to the medical curriculum 
itself. Chemistry here takes up over one-eighth of the entire medical curriculum. Of course physics and 
biology deserve something too, though they get practically nothing. What would happen to the medi- 
cal curriculum if a similar effort were made to teach them thoroughly? For the time being, the in- 
struction limps along without them. When their necessity is generally recognized, as that of chemistry 
is now recognized, it will be impossible to attempt them within the medical school, and the battle 
for the preliminary scientific training will have been won. 

2 At Cornell (Ithaca) a complete set of bones is given out to each student. There are over 100 com- 
plete skeletons. This makes a striking contrast with numerous schools that do not possess a single 
complete skeleton. 



84 MEDICAL EDUCATION 

finger-tips or eloquently describing an organ which no one but the prosector dis- 
tinctly sees; at the close of which oratorical performance he snatches his hat and, 
amid mingled applause and cat-calls, makes for his automobile to begin his round 
of daily visits. In the afternoons "demonstrators" supervise the dissecting, where 
eight or ten inexpert boys hack away at a cadaver until it is reduced to shreds. The 
actual emphasis falls on the didactic teaching and the quiz-drills; something like 
half the student's time is spent in the lecture-room: 220 out of 450 hours at Louis- 
ville, 360 out of 684 at the College of Physicians and Surgeons (University of Illi- 
nois), Chicago. The really effective work is not infrequently done by quiz-masters, 
who drill hundreds of students in memorizing minute details which they would be 
unable to recognize if the objects were before them. This is a flourishing industry 
in "great medical centers" like Chicago 1 and Philadelphia. 

Pathology is practically in the same condition. The best of these schools are well 
supplied with microscopes, microtomes, and material. But the teaching is usually 
uninspired routine drill. Sections are cut, stained, mounted, and observed. At the 
close of the year the student will perhaps have accumulated a box of several dozen 
slides, which he may carry home with him. But the work has been largely histolo- 
gical, devoid of experimental features, on the one hand, and but feebly articulated 
with clinic and autopsy, on the other. The autopsy is indeed the indispensable ad- 
junct of an effective department of pathology. "A course in pathology without au- 
topsy work and fresh material is like a course in systematic botany without field 
work." 2 The facilities of all but a few of our best schools are in this respect unduly 
limited; at no other point is the lack of a hospital under school control more acutely 
felt. Makeshifts of various kinds are invoked by way of remedy : in New York, for 
example, Columbia and Cornell have attached the two coroner's physicians who serve 
in the autopsy-room of the great Bellevue Hospital, thus procuring fresh material 
from a large number of cases. The arrangement still leaves the professor of pathology 
himself out of account. Of the schools belonging to the class under consideration few 
have even fair opportunities of this character; some of them rely altogether on a 
friendly coroner's cursory performance in the rear room of an undertaker's establish- 
ment. 3 The classes at the University of Maryland witness "perhaps ten [autopsies] 
a year;"" the College of Physicians and Surgeons, Baltimore, describes its opportu- 
nities as "restricted;" Georgetown University (Washington) gets a "few," Hahne- 
mann (Chicago), "four or five a year;" at Northwestern they are "scanty, the stu- 
dents do none;" at Cooper (San Francisco) they are scarce. For the most part, the 
student has merely made the microscopic rounds of the typical abnormal growths; 
his fundamental ignorance of biology, which no serious attempt is made to cure, comes 

1 A Chicago drill-master is reported as having classes of 300. 

1 Letter from Richard M. Pearce, professor of pathology. University and Bellevue Hospital Medical 

College (New York University). 

*e.g.. University of Oregon, Portland. 



THE LABORATORY BRANCHES 85 

between him and a really intelligent grasp of the principles and bearing of pathology. 
One is not surprised to find the instruction once more heavily inclined to the didactic 
side : 72 out of 144 hours at the College of Physicians and Surgeons, Chicago; 90 out 
of 140 at the College of Physicians and Surgeons, Baltimore. 1 

Bacteriology the last of the sciences concerning which there is even a pretense 
fares in general rather worse. At the Medico -Chirurgical of Philadelphia the sub- 
ject is the best developed of all the scientific branches; elsewhere it is a mere tag to 
pathology. Sterilizers, incubators, and culture- tubes are of course common enough; 
this is the orthodox equipment, stipulated by the state boards. But the subject 
cannot be intelligently studied without animals, cats, rabbits, or guinea pigs. In 
general, one finds no arrangements to care for animals either before or during exper- 
imentation. 2 As a rule, "they are too difficult to keep;" at Creighton, Oakland 
(California), the Cleveland College of Physicians and Surgeons, the University of 
Vermont, Georgetown University (Washington), they are "got as needed," else- 
where, often not even then. "I think I am not violating any confidence,"" says Dr. Victor 
C. Vaughan, 3 "when I say that there are certain men who teach bacteriology who 
start at the beginning of their lectures with a lot of tubes already made. They 
do not know enough about bacteriology to make cultures. They hold up these tubes 
and say, 'This is a diphtheria culture; this is a culture of tubercle bacillus,' and if 
by any chance a culture goes bad, they send and get another." 

(3) There yet remains for our consideration the third variety of school on the high 
school or equivalent basis, namely, those described as basely mercenary. In point 
of equipment and teaching methods these schools are not substantially different from 
institutions on a still lower basis. 4 Some of the latter institutions show, indeed, a 
better spirit : the University of Alabama, at Mobile, the College of Physicians and 
Surgeons and the School of Medicine, at Atlanta, the Medical College of the State 
of South Carolina, at Charleston, are not without traditions and a certain present 
dignity. Educationally, however, subject to certain exceptions to be specified from 
time to time, they may without violence be considered together; for limitations of 
one kind or another now of equipment, now of intention, again of both make 
the effective teaching of any of the laboratory sciences frankly impossible. They are 
for the most part cramming establishments, in many of which it is freely admitted 
that the students do not even own the regular textbooks. Their main weapon is the 
quiz-compend. Such laboratories as they have cannot be effectively used; of teaching 
accessories books, museum, modern charts, or models they are generally devoid. 

1 At the Johns Hopkins, out of a total of 400 hours, 40 are didactic ; at Minnesota, out of 456, 146; 
at Wake Forest, out of 195, 50. 

2 The College of Physicians and Surgeons, Baltimore, operates a Pasteur plant, but animals are only 
slightly used in teaching. 

8 Third Annual Conference, Council on American Medical Education, American Medical Attociation, 

held in Chicago, April 29, 1907, p. 59. 

4 Those in the south and elsewhere asking two years of a high school, or less. 



86 MEDICAL EDUCATION 

It is indeed stretching terms to speak of laboratory teaching in connection with 
them at all. 1 It is hardly more than make-believe; in the better schools, a futile imi- 
tation, without actual bearing on the subsequent clinical work ; in others, a grudg- 
ing compliance with the state board behest; occasionally there is nothing at all. 
The Mississippi Medical College (Meridian) did not, when visited, 8 own a dollar's 
worth of apparatus of any description whatsoever; the pathological laboratories of 
the Chattanooga Medical College and the College of Physicians and Surgeons, San 
Francisco, rejoice in the possession of one microscope apiece; Halifax Medical Col- 
lege provides one utterly wretched laboratory for bacteriology and pathology ; the 
Toledo school has a meager equipment in one or two branches, but for the rest is 
bare; the Detroit Homeopathic College has a dirty and disorderly room, with a few 
dozen wet specimens, that is called the pathological laboratory; at the Milwaukee 
Medical College, bacteriology is represented mainly by several wire baskets of dirty 
test tubes; Temple University (Philadelphia) has no individual outfit for students 
in any science at all; the Chicago National Medical University is practically as bare 
as the Meridian school ; the eclectic school at Lincoln, Nebraska, pretends to give 
clinical instruction in Lincoln, laboratory instruction at Cotner University, a few 
miles from town. When questions are asked in Lincoln regarding physiology or pa- 
thology, the answer is made: "That is given at Cotner ;" when the same question is 
asked at Cotner, it is answered: "That is given at Lincoln." A quick transit from 
one to the other failed to find anything at either. Prestidigitation is, however, fa- 
miliar enough in schools of this grade. Entrance credentials in the college safe fre- 
quently vanish as it is being opened : why should not equipment similarly resent in- 
spection? At the College of Physicians and Surgeons, Denver, the outfit in pathology 
and bacteriology was mostly stored in a certain compartment under a table. There 
was some difficulty and delay in opening it; by the time the key was found, every- 
thing had disappeared except an empty demijohn and some jugs, obviously too 
clumsy to whisk themselves away in such airy fashion. At Willamette University 
(Salem, Oregon) "physiology is taught experimentally." The apparatus? "That is 
kept in a physician's office downtown." At the Eclectic Medical College of New 
York an inquiry was made as to the teaching of experimental physiology, no outfit 
for which had been noticed in the course of the inspection. A mere oversight! A mes- 
senger was despatched to fetch it, and did a single small black box, of about the 
size and appearance of a safety-razor case, containing a small sphygmograph. "Good 
standing" requires the schools of St. Louis and Chicago to own a certain equipment 
in experimental physiology. They do; it is displayed prominently on tables, brand- 
new, like samples shown for sale on a counter ; the various parts had never been put 
together or connected at the College of Physicians and Surgeons or at the Hippo- 

l .y. t Western University (London, Ont.), Halifax Medical College, University of Arkansas, South- 
western University (Dallas, Texas), Fort Worth University, Epworth University (Oklahoma City). 
Other examples are given in the text. 

* January 12, 1909. It was then in its third year. 



THE LABORATORY BRANCHES 87 

cratean, both of St. Louis, at the Western Eclectic (Kansas City), or at the College 
of Physicians and Surgeons (Denver). The Littlejohn School of Osteopathy (Chicago) 
was in the throes of rebuilding to accommodate the growing classes that seek its su- 
perior advantages: every "laboratory" but that of chemistry was dismantled; there 
was no prospect that they could be again set up for months, but the teaching of 
"science" went on just the same. 1 

Chemistry is the "star" laboratory course of these schools "medical chemistry," 
of course. It never rises above a fair high school level and often falls far below it. At 
Chattanooga the students could not follow the subject, however simply presented. 
The laboratories are of the most elementary description, sometimes active and in 
good order, as at Mobile and Augusta, at the Illinois Medical College, and at the 
Eclectic Medical College of New York ; oftener in utter disorder, as at the Maryland 
Medical College (Baltimore). At the University of Oregon (Portland) and Willamette 
(Salem, Oregon) there is no running water at the desks ; at the North Carolina Medi- 
cal College (Charlotte) a single set of reagents is provided for the entire class; at the 
University Medical College, Kansas City (Missouri), instead of individual reagent 
sets, huge bottles are provided for general use. 

Almost, but not quite all the schools dissect. At Meridian (Mississippi), for example, 
anatomical material is too difficult to get. In Chicago they have learned how to teach 
anatomy practically without dissection. At the National Medical University the 
teacher dictates, the students learn ; this process is kept on, night after night, from 
October until the middle of April. So far there had been no dissection at all, but there 
would be ultimately, in "May or June," though there were no cadavers at hand as yet. 
At the Jenner Medical College also aChicago night school a similarly enlightened 
pedagogy was employed: "the subject is taught by lectures, with dissection from 
May 15 until the close of the session." The same methods are practised at Pulte 
the Cincinnati homeopathic school where dissection had not yet begun on Decem- 
ber 14: "the anatomy teaching goes on independent of dissecting." At Kirksville, 
Missouri, in the American School of Osteopathy, anatomy is taught with a textbook 
the first year; lectures, demonstrating, and dissecting are postponed to the second 
year, and the whole course takes but three years, all told. The Central College of 
Osteopathy, Kansas City, Missouri, holds that the student should know anatomy be- 
fore he dissects: "he will get more out of it." On November 8 there was no cadaver 
in the school: they already had had one and "will get another in February." At the 
Bennett Medical College, Chicago, there was witnessed a quiz in anatomy in a room 
without a skeleton, bone, or chart. At the College of Physicians and Surgeons, Den- 
ver, it was impossible to find any evidence of active dissecting; and it was admitted 
that material was scarce: "there had been two bodies this year, ten men on each." 

1 These schools are generally quite devoid of teaching aids, charts, modern models, etc. The rooms 
are bare. What they have is out of reach of the students : "if it were not locked up, it would disap- 
pear," a significant indication of the sort of students gathered in by low standards. 



88 MEDICAL EDUCATION 

Elsewhere, dissecting-rooms are indeed found, but the conditions in them defy de- 
scription. The smell is intolerable ; the cadavers now putrid, as at Temple University 
(Philadelphia), the Philadelphia College of Osteopathy, the Halifax Medical School, 
and in many 'of the southern schools, 1 including Vanderbilt; again, dry as tanned leather, 
at the University of Tennessee, Bennett (Chicago), Denver and Gross (Denver), 
Creighton (Omaha), College of Physicians and Surgeons, St. Louis, for example. At the 
Barnes Medical College (St. Louis) the first-year students listen to lectures only in the 
last "semestry ;" they are not permitted to dissect because first-year men only "hack 
and butcher." The dissecting-room of the Kansas Medical College, Topeka (the medical 
department of Washburn College), did duty incidentally as a chicken yard: corn was 
scattered over the floor along with other things and poultry fed placidly in the 
long intervals before instruction in anatomy began. 

A few of these schools have the apparatus requisite to teach pathology and bac- 
teriology in routine fashion: the Atlanta College of Physicians and Surgeons, for 
one. But in general they own an inadequate and at times decreasing supply of micro- 
scopes for every where one hears theft assigned in extenuation of a short supply or 
defective instruments. Post-mortems are practically nil. None are claimed at Chatta- 
nooga, Atlanta, Charlotte (North Carolina), or Dallas (Baylor and Southwestern Uni- 
versities) ; two in six years were remembered at the medical department of the Univer- 
sity of Georgia (Augusta). In default of post-mortems, material is sometimes obtained 
from the surgeons; but not all the schools can even then prepare it properly. To cut 
matters short, hardened material and sometimes sections are bought "in the east." The 
student at most stains and mounts them. Too frequently he does no more than look 
at them through the microscope. Whether he sees anything, remains a problem; for 
he rarely makes a drawing. In many cases it is impossible to believe that even this 
is done. At the College of Physicians and Surgeons, St. Louis, individual lockers are 
provided; on examination they prove to be empty. An explanation is offered: "the 
boys bring slides and cover-glasses along; they furnish their own and keep them at 
home." 

It is, of course, not to be supposed that these schools would be materially better 
even if well equipped and decently cared for. It makes very little difference to the 
student body that they assemble whether microscopes and incubators are provided 
or not. The poor fellow who in an unguarded moment is caught by advertisements, 
premiums, or canvassing agents 2 cannot be taught modern medicine, no matter what 
investments in apparatus the state boards force. Meanwhile the sole beneficiaries of 
the traffic are the teachers as a rule, the small group that constitutes the "faculty ;" 
in some instances, however, only the dean, who "owns" or "runs" the school. His 
associates profit indirectly by what is technically known as the " reflex." Their pro- 

1 An exception must be recorded in favor of the Memphis College of Physicians and Surgeons, where 
excellent rooms with hot and cold water are provided. 

1 Employed at Jefferson Park College, feeder to the Bennett Medical College, Chicago. 



THE LABORATORY BRANCHES 89 

fessorial dignity impresses the crude boys who will be likely to require with their 
first cases the aid of a "consultant." The "dean" of one such institution was frankly 
explaining his methods. "What do you give your teachers?" he was asked. "Titles," 
he replied. 

The less obviously commercial schools allege not infrequently that medical edu- 
cation no longer pays, that it is kept up for the sake of the "back districts." We 
have already shown that the back districts deserve and can get something better. 
Meanwhile the statement does not persuade. Hundreds of thousands of dollars an- 
nually pour into these institutions; in many cases, this has been going on for years. 
What becomes of the money? There is in general nothing to show for it; a few 
hundred dollars would replace the fixtures and equipment of most of them. 1 

The discreditable showing made by our commercial medical schools must not, 
however, be permitted to obscure the fact that we have at this date perhaps thirty 
institutions well equipped to teach the medical sciences in laboratories usually of 
modern construction, invariably of modern equipment. Twenty years ago we had not 
one. Our immediate problem has therefore two aspects : on the one hand, to strengthen 
these institutions, increasing their number only as actual need requires; on the 
other, with all the force that law and public opinion can wield to crush out the 
mercenary concerns that trade on ignorance and disease. 



*In a few places there is a considerable investment: Atlanta College of Physicians and Surgeons, 
Atlanta School of Medicine, the two Richmond schools, for example. See for detailed discussion, 
chapter viii. 



COMPARATIVE SCHEDULE, FIRST AND SECOND YEARS 
SHOWING BEARING OF ENTRANCE REQUIREMENT ON CURRICULUM* 

FIRST YKAR 



WETTERN RESERVE UNIVERSITY 
Si weeks per year 
(College basis) 


NEW YORE UNIVERSITY 
32 weeks per year 
(Four-year high school basis) 


M miri i I'll lit i RI ;u- AI. COLLEGE 

82 weeks per year 
(High school equivalent basis) 


UNIVERSITY OF ALABAMA 
28 weeks per year 
(Nominal requirement) 


Anatomy 


Did. 


Lab. 


Anatomy 


Hrs. 


Anatomy 


Hrs. 


Anatomy 


Hrs. 


Comparative anatomy 


24 


48 


Lectures & recitations 


96 


Lectures 


96 


Lectures 


56 


Descriptive anatomy 


84 




Demonstrations 


96 


Demonstrations 


96 


Recitations 


66 


Splanchnology 




32 


Practical work 


360 


Recitations 


32 


Comparative osteology 


120 


Neurology 




7 ' ** 


Histology and Embryo- 




Dissections 


98-144 


Practical anatomy ' 


144 


Dissections 




216 


logy 




Histology and Embryo- 




(all practical) 




Microscopical tech- 






Laboratory work 


128 


logy 




Inorganic Chemistry 




nique 




16 


Lectures and recita- 




Didactic 


64 


Chemical physics 


112 


Histology 


24 


32 


tions 


64 


Laboratory 


96 


Chemical laboratory 


168 


Microscopical anatomy 


40 


80 


Physiology 




Physiology 




Physiology 




Embryology 


40 


80 


Lectures 


48 


Didactic 


96 


(none in first year) 




Physiology and Bio-che- 
mistry 
Experimental physio- 
logy 
Bio-chemistry 
Organic chemistry 


16 
16 
64 


64 
64 
112 


Recitations 
Chemistry and Physics 
Lectures 
Inorganic chemis-") 
try(%) 1 
Organic chemistry j 


32 

96 


Laboratory 
Chemistry 
Didactic 
Laboratory 
General Pathology 
Didactic 


128 

160 
96 

64 


Physiological Chemistry 
(part practical) 
Biology, Embryology. < 
Histology 
Laboratory work 
Pharmacy 


22 

196 








Recitations 


32 


Hygiene 




Didactic 


28 








Laboratory work 


112 


Lectures 


32 












Bacteriology 




Recitations 


? 












Practical work 


64 


Materia Medica 


















Lectures 


64 
















Recitations 


? 
















Pharmacy 














.Vote page X says : 
For freshmen 




Lectures 
Laboratory 
Recitations 


32 

64 


1 2 to 5 p.m., 6 days per week, 
for 8 weeks. 










Total lecture* 138 hrs. 
Total recitations 6i hrs. 




Bandaging and Surgical 




Hours figured out from an- 
nouncement and the class 










Total laboratory 




Dressings 




schedule. See inspection re- 










work 112 hrs. 




Practical 


32 


port. 





SECOND YEAR 



WESTERN RESERVE UNIVERSITY 


NEW YORK UNIVERSITY 


MEDICO-CHIRURGICAL COLLEGE 


UNIVERSITY OF ALABAMA 


Anatomy 


Did. 


Lab. 


Anatomy 


Hrs. 


Anatomy 


Hrs. 


Anatomy 


Hrs. 


Descriptive anatomy 


84 




Lectures and recita- 




Lectures 


96 


Lectures 


56 


Dissections 




144 


tions 


96 


Demonstrations 


64 


Recitations 


56 


Applied anatomy 


64 




Demonstrations 


64 


Recitations 


32 


Practical anatomy * 


144 


Physiology and Bio-che- 






Practical work 


360 


Dissections 


216 


Chemistry 




mistry 






Physiology 




Physiology 




Lectures 


56 


Advanced experimen- 
tal physiology 

Advanced bio-chemis- 




6 


106 


Lectures and recita- 
tions 
Practical work 


96 
96 


Lectures 
Recitations 
Demonstrations 


64 
48 


Physiology 
Lectures and demon- 
strations 


86 


try 
Lectures and recita- 
tions 
Pathology and Preven- 
tive Medicine 


72 


32 


Chemistry 
Lectures 
Organic chemistry "j 
Physiological chem- ' 

iatrv 


48 


Laboratory 
Chemistry 
Didactic 
Laboratory 


48 

48 
128 


Laboratory work * 
Materia Medica 
Lectures* 
Histology 


64 
28 


Bacteriology 


40 


82 


IBI.I y 

Toxicology ^ 




General Pathology 




Lectures 


14 


Protoioology 


14 


28 


Recitations 


16 


Lectures 


64 


Laboratory 


112 


General pathology and 
pathological histolo- 
gy 
Gross pathological ana- 
tomy 


76 


145 
32 


Laboratory work 
Materia Medica and 
Pharmacology 
Lectures 


96 
64 


Laboratory 
Bctcteriology 
Laboratory 
Hygiene 


192 
96 


Bacteriology 
Lectures 
Laboratory 


11 
88 


Pharmacology. Materia 
Medica <t Therapeutics 






Recitations 
Laboratory work 


32 
63 


Didactic 
Laboratory 


64 
16 






Pharmacology, toxico- 






Pathology 




Pharmacology and 








logy, and prescription 






Lectures 


16 


Therapeutics 








wnting 


19 


88 


Recitations 


16 


Didactic 


96 






Experimental pharma- 






Laboratory work 


128 


Physical Diagnosis: Nor- 








codynamics 
Systematic pharmaco- 
logy 
Physical Diagnosis 


24 
12 


60 

6 
24 


Lantern demonstration 
Elementary Clinic 
Physical diagnosis 


16 
30 


mal 
Practical 
Physical Diagnosis: Pa- 
thological 


64 






Minor Surgery and Ban- 
daging 


30 




Practical work 

Ptinix 


16 


Lectures 
Demonstrations 


82 






Surgical Recitations 


60 




Lrlllllt. 


32 


General Etiology and 


















Symptomatology 


















Lectures 


32 
















Surgical Pathology 
Didactic 


16 


1 S to 6 p.m., 6 days per week, 
for 8 weeks. 














Laboratory 


82 


> 8 weeks of 8 hours per week 














Surgical Fevers and In- 




(i periods per week). 














flammations 




Only one hour (lecture) per 














Lectures 


16 


week. See schedule. 





* Creditable representatives have been selected in each instance. 



CHAPTER VI 

THE COURSE OF STUDY 
THE HOSPITAL AND THE MEDICAL SCHOOL 

THE THIRD AND FOURTH YEARS (A) 

LET us make an inventory of the presumptive acquirements of the well trained medi- 
cal student at the threshold of his third year. He knows the normal structure of the 
human body, the normal composition of the bodily fluids, the normal functioning 
of tissues and organs, the physiological action of ordinary drugs, the main depar- 
tures from normal structure, and in a limited fashion the significance of such de- 
partures both to the organs and tissues immediately involved and to the general 
economy of the organism. He will have had his first lessons in physical diagnosis, 
learning, perhaps in the class-room through examination of his fellow students, the 
use of the stethoscope, the arts of palpation, auscultation, and percussion, accus- 
toming his ear to the normal sounds, his fingers to the normal "feel," of the chest 
and abdomen in health. His studies in pathology will have introduced him further 
to the essential clinical terminology, obviating the necessity of a separate detached 
course in "elementary medicine." 1 

It remains, then, in the first place to teach the student how to get from the di- 
rect study of the patient himself whatsoever data remain to be collected. He will 
then possess two sets of facts : one in a way indirectly obtained, through microscopic 
or other study of excretions, secretions, tissues, etc. ; the other set procured directly 
at the bedside. He must learn the art of combining them ; he must see them together 
as the total picture of the situation with which he is called on to deal. Upon this 
inductive process all intelligent therapeutic procedure is based : hence his final task 
to learn through an extension of the elementary discipline that began in the phar- 
macological laboratory, the therapeutic measures calculated to meet the more or less 
precisely ascertained and inferred conditions, responsible for the disturbance he is 
trying to quell. 

A somewhat absurd controversy has at times raged as to which is of the higher 
scientific quality or diagnostic value the laboratory disclosures or the bedside ob- 
servations. Occasionally champions of the laboratory prejudge the issue by calling 
pathology a real or pure or more or less accurate science, as against the presumably 
unreal or impure or inaccurate data secured from the patient himself. It becomes 

1 The place of pathology in the American medical curriculum if the instruction takes advantage of 
it saves us from the difficulty encountered in Germany, where pathology and clinical medicine be- 
gin together. "According to current use the study of general pathology and pathological anatomy 
begin simultaneously with attendance on the clinic. For that reason the first semester of the clinic is 
of very slight value. . . . We ought first to procure for the student clear pathological conceptions ; 
only then will it be easy for him to follow the clinical instruction intelligently and profitably. I con- 
sider it absolutely necessary that the instruction in general pathology and pathological anatomy 
should precede the clinic." Von Striimpell, loc. cit., pp. 16, 17. 



92 MEDICAL EDUCATION 

a serious question of professional etiquette, who should speak first or loudest, the 
pathologist, armed with his microscope, or the clinician, brandishing his stetho- 
scope. To parallel the dispute, one must go back to the two knights who, meeting 
at a cross-road, disputed at the hazard of their lives as to the color of a shield which, 
as neither had stopped to reflect, had two sides. It is as profitable to discuss which 
was the right side of the shield as to raise the question of precedence between the 
laboratory and the bedside. Both supply indispensable data of coordinate impor- 
tance. The central fact may be disclosed now by one, now by the other, but in either 
case it must be interpreted in the light of all other pertinent facts in hand. The 
scientific character of the procedure depends not on where or by what means facts 
are procured, but altogether on the degree of caution and thoroughness with which 
observations are made, inferences drawn, and results heeded. The essence of science 
is method, the painstaking collection of all relevant data, the severe effort to read 
their significance in connection. These objects are promoted in some directions by 
the laboratory appliances that eke out our defective senses; even so, however, we do 
not escape or rise superior to these same senses; for with them we use the imple- 
ments in question. Whatsoever, then, the senses actually ascertain, pertinent to the 
matter in hand, is scientific datum. The way to be unscientific is to be partial, 
whether to the laboratory or to the hospital, it matters not. The test of a good 
education in medicine is the thorough interpenetration of both standpoints in their 
product, the young graduate. 

If, then, a laboratory is a place constructed for the express purpose of facilitating 
the collection of data bearing on definite problems and the initiation of practical 
measures looking to their solution, the hospital and the dispensary are laboratories 
in the strictest sense of the term. And just as it makes no difference to science 
whether usable data be obtained from a slide beneath a microscope or from a sick 
man stretched out on a cot, so the precise nature of the act or experiment is equally 
immaterial: it matters not in the slightest, from the standpoint of scientific logic, 
whether the step take the form of administering a dose of calomel, operating for ap- 
pendicitis, or stimulating a particular convolution of a frog's brain with an electric 
current. The logical position is in all three cases identical. In each a supposition, 
whether expressed or implied, whether called theory or diagnosis, based on suppos- 
edly adequate observation, submits itself to the test of an experiment. If proper 
weight has been given to correct and sufficient facts, the experiment wins ; otherwise 
not, and a second effort, profiting by previous failure, is demanded. The practising 
physician and the "theoretical" scientist are thus engaged in doing the same sort of 
thing, even while one is seeking to correct Mr. Smith's digestive aberration and the 
other to localize the cerebral functions of the frog. 

Certain conclusions as to clinical teaching follow. The student is to collect and 
evaluate facts. The facts are locked up in the patient. To the patient, therefore, he must 
go. Waiving the personal factor, always important, that method of clinical teaching 



HOSPITAL AND MEDICAL SCHOOL 93 

will be excellent which brings the student into close and active relation with the 
patient: close, by removing all hindrance to immediate investigation; active, in the 
sense, not merely of offering opportunities, but of imposing responsibilities. 

Clinical teaching has had substantially the same history as anatomical teaching. 
It was first didactic : the student was told what he would find and what he should do 
when he found it. 1 It was next demonstrative: things were pointed out in the amphi- 
theater or the wards, those who got the front seats 8 seeing them more or less well. 
Latterly it has become scientific: the student brings his own faculties into play at 
close range, gathering his own data, making his own construction, proposing his 
own course, and taking the consequences when the instructor who has worked through 
exactly the same process calls him to account: the instructor, no longer a fountain 
pouring forth a full stream of knowledge, nor a showman exhibiting marvelous 
sights, but by turns an aid or an antagonist in a strenuous contest with disease. 

The backbone of the structure is the clinic in internal medicine. 3 This central fact 
cannot in America be too strongly emphasized. The sufficiency of the school's clinical 
resources depends at bottom on its medical clinic; the value of its training depends 
on the systematic thoroughness with which it is in position to use an adequate sup- 
ply of medical cases. To sample a school on its clinical side, one makes in the first 
place straight for its medical clinic, seeking to learn the number of patients available 
for teaching, the variety of conditions which they illustrate, and the hospital regu- 

1 The reader must not suppose, however, that this method of teaching or practising medicine is ex- 
tinct. The following is quoted from the Chicago Night University Bulletin, vol. iii., no. 24, p. 169 : 

"A young married man, wife and babe recently returned from Arkansas. They were all loaded 
with so-called malaria. . . . The old mother came in to tell me of the cases and get some 'chill medi- 
cine.' She said they were all chilling three times a day. ... I sent the little tot ipecac 1M. She said 
the mother chilled every morning about ten o'clock, and that during the chill she had a very severe 
cough which hurt her right side. ... I sent the mother bryonia 200. She said the husband and father 
chilled at various times. Great thirst during fever, severe cough before and during the chill, with 
drenching sweat following the fever. I sent nim rhus tox, 75M. The prescriptions proved to be rifle- 
shots for the mother and babe, for they never chilled again ; but only a glancing shot for the husband. 
He missed his chill for a few days, when it returned with new symptoms and more severe and with 
which no medicine seemed to correspond. I saw him then personally. Found he still had cough during 
chill, but not before; that he wanted to be covered during fever just the same as during the chill, 
like nux v. and rhus t. ; he had other symptoms which ruled these out. After tearching several hours 
with repertory in hand, 1 decided that this was a mixed case and agreed with no medicine in the book. 
Hence, following Hahnemann's advice, I gave him cinchona (1M) to clear up his case. After twenty- 
four hours he chilled again. This time the most peculiar thing noticed was that he was very thirsty 
during the chill, but in no other stage. He drank large quantities, but during the heat and sweat, not 
a drop. Also that during the chill the coldness was relieved by the heat of a hot stove. He wanted to 
get near the hot stove. Remembering . . . that for a chill with thirst for large drinks of cold water, 
and no thirst in any other stage, ignatia stands alone, I gave him ignatia 1M. to be taken every two 
hours until he missed his chill then to be discontinued. Well, he missed the next chill and also every 
one which has been due him from that day to this." 

8 This method, too, survives in both medical and surgical clinics. It is in process of abandonment in 
medical teaching, just as rapidly as proper arrangements for ward and bedside work can be made. 
But it is still favored by surgeons, despite its very slight practical value. 

3 "For clinical studies proper, internal medicine forms the center at German universities. Medical 
education there follows the principle that medicine is a scientific whole ; ... all its varied disciplines 
must play upon each other ; and from this point of view internal medicine is regarded as the mother 
of all other clinical divisions." W. Lexis, Das Unterrichtswesen im Deutschen Reich, vol. i. pp. 138, 
139 (Berlin, 1904). 



94 MEDICAL EDUCATION 

lations in so far, at least, as they determine (1) continuity of service on the part of 
the teachers of medicine, (2) the closeness with which the student may follow the 
progress of individual patients, and (3) the access of the student to the clinical labora- 
tory. It matters much less what else a school has by way of clinical opportunity if it 
has this, though, of course, the school that has it will have whatever else it needs too. 
The main point is that there is no substitute for a good clinic in internal medicine; 
the school sampled and found wanting there suffers from a fatal organic lesion. Ex- 
cellent didactic instruction is no compensation ; successful passing of written state 
board or other examinations is no proof that the school has managed to do without. 
A large surgical service with amphitheater operations every day in the week, a dispen- 
sary crowded with eye, ear, and throat cases, these are all very well in their way. 
But one comes back to the medical clinic: that is the really important item. Until 
practical state board examinations can be trusted to disclose defective school facili- 
ties on the clinical side, it is thrice important to scrutinize carefully the situation 
of every medical school in this respect. For proper provision rests at this moment 
on the conscientiousness and intelligence of medical educators. Thus far the states 
have not adopted an examination procedure that will destroy schools not able to do 
their duty in regard to the medical clinic. 

The student's clinical work is classified under four heads: (1) medicine, in which 
pediatrics and infectious diseases may be included, (2) surgery, (3) obstetrics, (4) the 
specialties, such as diseases of the eye, ear, skin, etc. A teaching hospital consists 
essentially of a series of wards, accommodating patients belonging to these several 
departments, each ward systematically organized with a permanent staff; of a clinical 
laboratory, similarly organized and in close organic relation with the wards; and of 
an autopsy-room. The clinical laboratory of the hospital is not the same as the 
pathological laboratory of the medical school. "A clinic of medicine needs a labora-\ 
tory equipped with apparatus for chemical, physiological, pathological, and bacterio- 
logical work, not so completely equipped as is the laboratory of these respective 
departments in the medical school, but specially equipped for certain needs of the 
work." 1 On the value of the data thus obtainable it is unnecessary longer to dwell. 
The clinical laboratory is the connecting link between the two parts of the medical 
school ; and it must be immediately accessible. The clinical teacher cannot stop for 
data that he must perhaps cross town to get; the student responsible for a parti- 
cular case will not include in the facts on the basis of which he is making up his 
mind the results of an examination of blood, sputum, and feces, if these must be 
transported for study much beyond the hospital walls. Nor will the interne or the 
young practitioner require the knowledge in question before coming to a conclusion, 
unless he has formed at school the habit of so doing.* In this laboratory a theoreti- 

1 Henry A. Christian: "The Clinical Laboratory," in Columbia Unwernty Quarterly, vol. xi., no 3, 
p. 339. 

' "We see the necessity of laboratories with room for each clinical student, each with his work-place 



HOSPITAL AND MEDICAL SCHOOL 95 

cal course in clinical microscopy will precede the period when the student is speci- 
fically charged with responsibility for the laboratory facts in his own "cases," shortly 
to be described. Of equally essential importance to the rounding out of the medical 
curriculum is the autopsy -room, where the wise are brought to book. "Successful 
knowledge of the infinite Variations of disease can only be obtained by a prolonged 
study of morbid anatomy. While of special value in training the physician in diag- 
nosis, it also enables him to correct his mistakes, and if he reads its lessons aright, 
it may serve to keep him humble." 1 

The teaching dispensary follows the same lines as the teaching hospital in respect 
to both organization and equipment, and must be constructed with its pedagogical 
use in view. It consists essentially of a commodious receiving-room, leading from 
which are separate rooms, sufficiently large, clean, well lighted, each assigned to a 
separate department. The several rooms are appropriately equipped with instruments, 
apparatus, etc., and with a recording system which enables the workers to keep track 
of each patient and to collate readily all cases of the same general character. Each 
department must have an organized teaching staff; the receiving-room must be in 
charge of a physician, who will assign patients to the departments to which they 
severally belong. The clinical laboratory must be at hand so that the necessary mi- 
croscopical examinations can be made without loss of time. 

From the teaching point of view, the hospital and the dispensary differ in certain 
respects; certain classes of cases do not usually enter the hospital wards at all: minor 
surgery, trivial medical ailments, numerous afflictions involving eye, ear, nose, throat, 
skin, etc. Ambulatory patients are also under less satisfactory control ; a large propor- 
tion never come a second time. The dispensary is therefore excellently adapted to show 
a large variety of conditions; it is a relatively poor place to watch their development. 
In the dispensary the student can become expert in initial physical examination; 
but only the hospital wards enable him to study progress, to observe nature's com- 
ment on therapeutic moves. The dispensary corresponds to the "office hour," so 
important an item in the physician's early progress; the hospital ward represents the 
sick-room. Clearly, a huge dispensary does not wholly offset a defective hospital. 

Between dispensary and hospital, clinical instruction in the third and fourth years 
is variously apportioned. 2 But apportioned they must be ; for the mingling of third 

properly equipped. In building this well arranged laboratory the university has by no means erected 
something superfluous. ... It has simply met a positive need. In putting the laboratories in such in- 
timate relations with the hospital, and especially with the dispensaries, it has provided means for an im- 
mense increase of its facilities. It is a place for practice, for doing as an undergraduate the things that 
must be done afterward in carrying on the profession of medicine." George Dock, "Address at Open- 
ing of Clinical Laboratory of the University of Pennsylvania Hospital,' University of Pennsylvania 
Medical Bulletin, Aug., 1909 (slightly abridged). 
1 Osier, loc. cit., p. 144. 

8 Taking a four-year curriculum of 4100 hours as a basis, the pattern curriculum worked out by 
the Council on Education of the American Medical Association allowed 1970 hours to anatomy, phy- 
siology, physiological chemistry, pathology, bacteriology, pharmacology, toxicology, and therapeutics, 
or, in other words, the scientific subjects included in the first two years. Clinical instruction gets 
2130 hours, distributed as follows: 



96 MEDICAL EDUCATION 

and fourth year students in clinical work is severely reprehensible, an infallible in- 
dication of deficient clinical material, imperfect teaching organization, or of both. 
As for the rest, there can be no fixed rule. Important, mainly, is it that the student 
be brought into immediate and increasingly responsible contact with the disordered 
machine. 

Let us consider briefly the dispensary first. The classes are divided into small 
rotating sections, each with regular appointments in every one of the dispensary 
departments. The sections, in charge of separate instructors, should not contain more 
than ten students apiece rather fewer would be even better. The student is trained 
at once to take the patient's history, to make the physical examination, to examine 
blood, sputum, etc., and on the basis of all the facts thus amassed to make a diag- 
nosis and suggest a course of treatment. The instructor stands by, to correct and to 
stimulate by question, criticism, or suggestion. Everything is a matter of record, 
and the student's work is thus part of, in a sense the basis of, the complete dispen- 
sary records. In the surgical out-patient department, bandaging, stitching up a wound, 
administering anesthetics, quickly fall to his lot. Schools favorably located in large 
cities are able to develop considerable out-patient obstetrical work. Thus the student 
not only amplifies his experience, but learns to combat the conditions under which 
he will subsequently be called upon to work. He should, of course, in justice to his 
charge, be accompanied by an instructor, though in the weaker schools this is by no 
means always arranged. Even so, however, out-patient obstetrical work, though an 
experience, is not a discipline: it does not dispense with the necessity of careful 
training in method under ideal hospital conditions. The young physician will never 
learn technique and the importance of technique properly except in the maternity 
hospital; having learned them there, his problem in practice is to secure the essen- 
tials even amidst the most unpromising environment. In certain of the specialties 
dermatology, ophthalmology the bulk of the direct instruction received is in the 
dispensary service. To some extent, of course, the conditions observed in them come 
under repeated observation in the medical clinics of both third and fourth years ; 
full mastery of a specialty belongs of course to the postgraduate years. But the stu- 
dent must be sufficiently at home to help himself in emergencies and to know when 
and whence to seek further assistance. 

The fourth year is spent in the hospital under precisely the same conditions. The 
class is again broken up into small groups. Each student gets by assignment a suc- 
cession of cases, for a full report upon each of which he is responsible; he must 
take the history, conduct the physical examination, do the microscopical and other 
clinical laboratory work, propound a diagnosis, suggest the treatment. For this 

Medicine (including clinical pathology and pediatrics), 800 hours 
Surgery OM " 

Obstetrics and gynecology 240 ' 

DiMMM of the eye, ear, nose, and throat 140 * 

Dermatology and syphilis 00 * 

Hygiene and medical jurisprudence 120 " 



HOSPITAL AND MEDICAL SCHOOL 97 

purpose he has easy access to the hospital wards. His "beds" are under his con- 
tinuous observation from the day his "patient" is admitted until the day of dis- 
charge; or, in the event of death, he and the physician ultimately responsible for 
the steps taken in treatment repair with others to the autopsy-room to bring their 
knowledge to the test, as Thomas Bond quaintly phrased it. Meanwhile, the clinical 
teaching has closely followed the development of the case. At brief and regular 
intervals its status is reviewed. All other members of his group, and the patient 
too, are at hand when the student presents his report, which forms, once more, 
part of the permanent record of the case. At every point he has been checked up; 
the instructor in charge of the clinical laboratory inspects and verifies his work 
there; the clinical instructor, here. The latter officer reviews everything, pointing 
out omissions, errors, misinterpretation. The student has always an appeal. He may 
on second trial convince himself of his blunder. He may, however, be only the more 
convinced he was right, whereupon another look may persuade the instructor that 
it is he who errs ! Subject to this control, complete, of course, from the standpoint 
of treatment followed, the student is a physician practising the technique which, it 
is to be hoped, may become his fixed professional habit ; learning through experience, 
as indeed he will continue to learn, long after he has left school, a controlled, 
systematized, criticized experience, however, not the blundering, helpless ** experi- 
ence" upon which the didactically or demonstratively taught student of medicine 
has hitherto relied for a slow and costly initiation into the art of medicine. 

In the surgical ward, a similar arrangement is feasible. The student assists in the 
operation of his own "case" and follows the after-treatment. Obstetrical training 
pursues analogous lines. After preliminary drill with the manikin, the student first 
assists, then has charge under an instructor, of the cases in question. He learns 
in the hospital wards the proper care and manipulations, his experience supple- 
mented, as we have pointed out, by a regularly organized out-patient department, 
which brings him in the home, in contact with the trying conditions that he will 
encounter in practice. Pediatrics and infectious diseases are likewise scheduled and 
organized. A simple method of rotation carries the student in this intimate and 
responsible fashion through all departments in the course of two years. 

Demonstrative teaching necessarily accompanies the method described: in each 
group of five, only one student personally explores each case. 1 At the next bed a new 
protagonist comes to the front ; and so on, until each man has had his turn. Always, 
then, four of the five men are getting demonstrative teaching, though of a somewhat 
intimate kind. The demonstrative method must, for lack of time, also be more widely 
employed : large sections are sent on ward rounds, in the course of which the instruc- 
tor demonstrates the salient features of a considerable number and variety of cases. 
The defects of the method are manifest: it is not sufficiently direct, accountable, and 
systematic to constitute the sole lasting discipline. At best, the student becomes in 
1 In some schools two students have charge of each case, the principle remaining the same. 



98 MEDICAL EDUCATION 

this way familiar with conditions singly and in their combination and interconnec- 
tion. He gets cross-sections of disease a most important experience, but, once more, 
not the same thing as the continuous observation of the developing disease process 
and the influence thereon from day to day of whatever therapeutic procedure is 
adopted. In the same way, an instructor in physics might take his students through 
a large laboratory, showing them how electrical attraction or some other single factor 
produces a particular type of effect in each of a dozen different experiments, a most 
valuable method to impress upon them the specific tendency or effect of the force 
under discussion ; but no substitute for experiments performed by the student him- 
self from beginning to end, in which electrical attraction and much besides come into 
play. Under any but the most vigorous teaching, the demonstrative method may 
fail to stimulate sufficiently: the student looks and listens, a passive attitude that 
may relapse into something more deeply negative. Finally, the ease with which an 
expert passes from case to case, the necessity of confining attention to decisive fea- 
tures which he selects, may, if not elsewhere corrected, tend to encourage the super- 
ficial examination and the hasty conclusions with which current practice may be 
justly reproached. Outside the wards there is a narrowly limited use for demonstra- 
tive instruction in the class-room or small amphitheater, where groups of cases can 
conveniently be shown ; but the value of demonstration increases apace, as it ap- 
proaches the intimacy of the individual experiment. Remoteness is quickly fatal. 
"The larger the circle of listeners, the more difficult for the teacher to hold the in- 
terest of them all; as soon as those sitting some distance off no longer see and hear 
exactly what is to be seen and heard, their thoughts run wild, they lose the logical 
thread of the diagnostic process.' 11 This is especially true of spectacular amphitheater 
surgery, which is of meager educational value, though as a rule prominently exploited. 

Other methods have their uses also; even the didactic lecture may not perhaps be 
wholly dispensed with. Case work is discrete; students rarely possess sufficient gen- 
eralizing power to redeem it from scrappiness. At the bedside not much time is avail- 
able for comprehensive or philosophical elucidation. The lecture hugging as closely 
as may be the solid ground of experienced fact may therefore from time to time 
be employed to summarize, amplify, and systematize. In time, the student's sense of 
reality will be sufficiently pronounced to enable him to grasp a rare condition that he 
knows only through exposition. The wards may have failed to supply an example. 
But however used whether to classify first-hand knowledge or to fill up a gap 
the didactic lecture would appear to be pedagogically sound only at a relatively late 
stage of the student's discipline. It has no right to forestall experience, filling the 
student with ill comprehended notions of what he is going some time to perceive. 

Some ingenious Harvard men, profiting by the experience of the Harvard law 
school, have evolved an effective discipline in the art of inference. Just as a prelimi- 
nary course in physical diagnosis, teaching the student how to gather his facts, is 

1 Von Stniinpcll, loc. eit., p. 23. 



HOSPITAL AND MEDICAL SCHOOL 99 

valuable, so, it is urged, a formal training in the inductive handling of ascertained 
data may be of use to students whose logical habit has been none too strictly formed. 
"Let us assume such and such data : what do they mean ? What would you do ?"" This 
is the essence of the case method, a method, by the way, excellently adapted to class 
use, calculated there to develop the friction, competition, and interest which are 
powerful pedagogical stimulants. It is, moreover, economical, for it brings consider- 
able numbers in touch with fertile teachers, at a minimum expenditure of time and 
energy. 

The class in medicine has another use: it may be made the means of training stu- 
dents to use the " literature;" once more, of course, only by way of amplifying an 
actual sense- experience. One's own experience always falls short; yet without a 
very vivid realization of just what one's own experience is and means, one is in no 
position to use a vicarious experience intelligently. The careful taking and keeping 
of records is in the first instance the means of clarifying the student's own experience; 
the instructor's comments raise the questions which he may profitably investigate in 
the literature. The case record in full and an abstract of important publications on 
the same subject may well fill a regularly appointed hour given to informal confer- 
ence and discussion. The student will thus get into the way of reading substantial 
journals and "running down" literature in the course of his actual practice. 

It is a nice question as to how the student's time in the third and fourth year is 
to be apportioned between patient work, ward work, demonstrative and class exer- 
cises, and didactic lectures. The number of hours is itself necessarily elastic : for if 
the hospital is a laboratory, it is open at all hours, and, subject to the limitations 
fixed in each case by the condition of the patient, the wards may be used by stu- 
dents, even though no teaching is going on. The principle upon which division may 
be made has been, however, very clearly stated by Cabot and Locke. "Learning 
medicine is not fundamentally different from learning anything else. If one had one 
hundred hours in which to learn to ride a horse or to speak in public, one might 
profitably spend perhaps an hour (in divided doses) in being told how to do it, four 
hours in watching a teacher do it, and the remaining ninety-five hours in practice, 
at first with close supervision, later under general oversight." 1 

In what relation is the medical school to stand to its hospital if the methods 
above described are to be instituted? Exactly the relation which it occupies to its 
laboratories generally. One sort of laboratory may as well be borrowed as another. 
The university professor of physics can teach his subject in borrowed quarters quite 
as well as the university professor of clinical medicine. Courtesy and comity will go 
as far in one case as in the other : in both it keeps teaching to the demonstrative 
basis, or worse, according to the limitations prescribed. The student can never 
be part of the organization in a hospital in which he is present on sufferance. A 

1<l The Organization of a Department of Clinical Medicine," by Richard C. Cabot and Edwin A. 
Locke, p. 9. (Reprinted from Boston Med. and Surg. Journal, Oct. 19, 1905.) 



100 MEDICAL EDUCATION 

teaching hospital will not be controlled by the faculty in term-time only; it will not 
be a hospital in which any physician may attend his own cases. Centralized admin- 
istration of wards, dispensary, and laboratories, as organically one, requires that the 
school relationship be continuous and unhampered. The patient's welfare is ever the 
first consideration; we shall see that it is promoted, not prejudiced, by the right 
kind of teaching. The superintendent must be intelligent and sympathetic ; the fac- 
ulty must be the staff, solely and alone, year in, year out. There will be one head to 
each department a chief, with such aides as the size of the service, the degree of 
differentiation feasible, the number of students, suggest. The professor of medicine 
in the school is physician-in-chief to the hospital; the professor of surgery is surgeon- 
in-chief; the professor of pathology is hospital pathologist. School and hospital are 
thus interlocked. Assistants, internes, students, collaborate in amassing data and 
compiling case records. The student is part of the hospital machine ; he can do no 
harm while all the pressure of its efficient and intelligent routine is used to train 
him in thorough and orderly method. There comes a time, indeed, in a physician's 
development when any opportunity to look on is helpful ; but only after he is trained : 
his training he cannot get by looking on. That he gets by doing: in the medical 
school if he can; otherwise, in his early practice, which in that case furnishes his 
clinical schooling without a teacher to keep the beginner straight and to safeguard 
the welfare of the patient. 

The relationship here indicated has not thus far, as a rule, proved attainable in 
the United States except through the separate creation of a university hospital. In 
Germany, where hospitals and universities belong to the same government, our 
problem does not arise; nor in England and Scotland, where hospital and school 
have grown up together. In the United States outside, once more, the few fortunate 
institutions like Johns Hopkins, the University of Virginia, and the University of 
Michigan the schools developed as detached faculties, craving, after a while, some 
sort of demonstrative teaching privilege in hospitals conducted by the municipality 
or by philanthropic associations as temporary homes for sick people. Political reasons 
in the former instance, prudential in the latter, generally forbade an exclusive re- 
lationship. Lack of funds interfered with the establishment of laboratories; compe- 
tition between rival schools required that privileges be both divided and restricted; 
finally, the inferiority of the students was an insuperable obstacle to any teaching 
method which sought to use them in the wards in any responsible way whatsoever. 
More intelligent conceptions are becoming current: the student body improves; 
competition yields here and there to consolidation. Even so, there remain generally 
insuperable difficulties: purely philanthropic enterprises must be economically con- 
ducted, and they cannot in most places play favorites in the local profession. Ade- 
quate equipment, effective organization, and continuous staff service are therefore 
as a rule improbable. The hospital and dispensary which the medical school must 
provide to obtain these conditions need be large enough to furnish only the funda- 



HOSPITAL AND MEDICAL SCHOOL 101 

mental training of the student body in method and to afford the various members 
of the faculty their own several workshops. Each department needs beds and accom- 
panying facilities enough to care for typical clinical cases for instruction and for 
such other cases as the teacher himself wants to study under the most favorable 
conditions. Beyond this requirement, other local hospitals may well provide supple- 
mentary illustrative material, particularly for advanced students. Once more, a long 
list of such supplementary opportunities scattered through the town is no substitute 
for the fundamental teaching and working hospital, on the existence of which even 
a fairly satisfactory use of additional and imperfectly controlled clinical material 
depends. Indeed, without such a teaching hospital, the school cannot even organize 
a clinical faculty in any proper sense of the term. 

The control of the hospital by the medical school puts another face on its rela- 
tions to its clinical faculty. What would one think of an institution that, requiring 
a professor of physics, began by seeking some one who had his own laboratory or 
had got leave to work a while daily in a laboratory belonging to some one else? That 
is the position of the medical school that, in order to gain even limited use of a hos- 
pital ward, has to cajole a staff physician with a professorial title! When the hospital 
belongs to the medical school, appointments are made on the basis of fitness, emi- 
nence, skill. A man is promoted if he deserves it; if a better man is available else- 
where, he is imported. Opportunities are his in virtue of the university's choice : it is 
absurd to reverse the order. The men thus freely selected will be professors in the 
ordinary acceptation of the term : they hold chairs in an institution resting on a 
collegiate basis, a graduate institution, in other words. They will be simulta- 
neously teachers and investigators. Non-progressive clinical teaching involves a con- 
tradiction in terms. The very cases which are exhibited to beginners have their 
unique features. New problems thus spring up. Every accepted line of treatment 
leaves something to be desired. Who is to improve matters, if not your university 
professor, with the hospital in which he controls conditions, with a dozen laboratories 
at his service for such aid as he summons, with a staff who will be eyes and ears and 
hands for him in his absence? These conditions exist in Germany, and clinical science 
has there thriven ; they are lacking here, and clinical medicine droops in consequence. 
Undoubtedly, outright research institutions for clinical medicine are also necessary, 
the routine of the clinical teacher cuts into his time, to some extent limits the tasks 
he may essay, for the knotty problems of clinical medicine are excessively compli- 
cated and difficult. But the field abounds in questions for which the university hos- 
pital with its laboratories is the right place. Nor will the young doctor, for all his 
admirable technique, prove a progressive practitioner, even to the extent of keeping 
up his reading, unless his teachers have been so before him. 

By the laboratories connected with the university hospital we do not mean merely 
the fundamental laboratories, described in a previous chapter, or the clinical labo- 
ratory, just mentioned: the former as such deal with the subject-matter of their 



102 MEDICAL EDUCATION 

respective sciences, in their general relations; the latter is part of the routine ma- 
chinery of the hospital. To suffice for clinical investigation the laboratory staff must 
be so extended as to place, at the immediate service of the clinician, the experimental 
pathologist, experimental physiologist, and clinical chemist in position to bring all 
the resources of their several departments to bear on the solution of concrete clinical 
problems. Of these branches, experimental pathology and physiology have already 
won recognition ; the next step in progress seems to lie in the field of clinical chemistry, 
thus far quite undeveloped in America. 

It follows that in other respects, too, the clinical professors will be on the common 
university basis: salaried, as other professors are. Of course, their salaries will be in- 
adequate, i.e., less than they can earn outside, all academic salaries paid to the 
right men are. But there is no inherent reason why a professor of medicine should 
not make something of the financial sacrifice that the professor of physics makes : 
both give up something less and less, let us hope, as time goes on in order to 
teach and to investigate. The clinical teacher should indeed not arbitrarily restrict 
his experience: he may wisely develop preferably in close connection with the hos- 
pital a consulting practice, assured thus that his time will not be sacrificed to 
trivial ailments. On the same basis, other university facilities are at the service of 
those who require unusually skilful aid; for at all points only good can come of 
educational contact with unsolved problems, practical or other. But a consulting 
practice developed in a professional or commercial, rather than in a scientific spirit 
may prove quite as fatal to scientific interest as general practice. University hos- 
pitals, academic salaries, etc., make the conditions in which clinical medicine may 
be productively cultivated. They do not create ideals; and without ideals, super- 
abundant and highly paid consultations are perhaps as demoralizing as superabun- 
dant low-priced "calls." 1 

The financial resources at this moment available are far from adequate to provide 
hospitals exclusively and continuously the laboratory of the clinical departments 
of medical schools, and faculties composed in the first place of scientific teachers of 
clinical medicine. Twenty-five years ago as much would have been said in reply to 
a plea for thirty medical schools each equipped with a complete set of scientific 
laboratories. When the number of our medical schools is once reduced to our actual 
requirement, the sum involved in properly equipping them with hospitals will not 
appear impossibly formidable. Meanwhile, existing hospitals may well enlarge their 
teaching facilities, where such facilities are open to a high-grade student body. No- 
thing is clearer than that an intimate relation to medical education properly carried 
on is to the advantage of all concerned, to the larger public, by producing better 
physicians, to the patient, by procuring for him more competent attention. On this 
point there is no room for doubt. " I speak after an experience of nearly forty years," 

Sce, for example, Graham Lusk :" Medical Education," Journal Amer. Med. Atm., April 17, 1909, 
pp. 1229, 1230, and S. J. MelUer, "The Science ofClinical Medicine, " ibid., August H, 1909, pp. 50&-12. 



HOSPITAL AND MEDICAL SCHOOL 103 

says Dr. Keen, "as a surgeon to a half-dozen hospitals, and can confidently say that 
I have never known a single patient injured or his chances of recovery lessened by 
such teaching. Moreover, . . . who will be least slovenly and careless in his duties, 
he who prescribes in the solitude of the sick-chamber and operates with two or three 
assistants only, or he whose every movement is eagerly watched by hundreds of eyes, 
alert to detect every false step? ... I always feel at the Jefferson Hospital as if I 
were on the run, with a pack of lively dogs at my heels." 1 Miss Bun field, after an 
ample experience, looking at the question solely from the standpoint of patient and 
nurse, takes the same position: "As a matter of fact, in a properly administered hos- 
pital, medical schools are a protection to the patient rather than otherwise, for it 
usually means that the hospital is a very live one. ... In teaching hospitals, I think 
that on the whole patients are generally better nursed, for every one is kept up to 
the mark, including the professors." 2 The committee appointed in 1905 to inquire 
into the financial relations between the hospitals and the medical schools of London, 
touch in their conclusions the point here in question : "We find," they say, "that 
the presence of a body of eager young men watching the proceedings of their teacher 
has the tendency to keep the medical man on the alert and to counteract the effects 
of the daily routine of duties." 3 

There is little difference of opinion as to the necessary size of a teaching hospital. 
Less than two or three hundred beds, in practically continuous occupation, can 
hardly supply either the number or the variety of cases required. It is held that a 
hospital of 400 beds will support a medical school of at least 500 students. It is 
highly important that the instructor should have the material that he needs when he 
needs it. The material must, moreover, be properly distributed: an abundant clinic 
in diseases of the eye is no substitute for defects in the departments of internal 
medicine and obstetrics ; seventy -five cases of operated appendicitis do nothing to 
compensate for the lack of typhoid, pneumonia, or scarlet fever. 

The size of the school has, of course, some bearing on the necessary size of the 
hospital, though the hospital cannot be allowed to shrink in exactly the same ratio 
as the number of students. Because two hundred beds may be made to suffice for one 
hundred students, it does not follow that twenty beds suffice for ten students. Twenty- 
five students require in general the same minimum as one hundred students. On the 
other hand, it is fair to weigh advantages and disadvantages against each other. A 
small number of students in a small but still fairly representative and completely 
controlled university hospital, through whose corridors fresh scientific breezes from 
the university and medical school laboratories blow, will get a better discipline in the 

J W. W. Keen: "The Duties and Responsibilities of the Trustees of Public Medical Institutions," 

Transactions Congress Amer. Physicians and Surgeons, 1903. 

2 Maud Banfield : "Some Unsettled Questions in Hospital Administration in the United States," 

Publications of Amer. Acad. Pol. and Soc. Science, no. 351, pp. 46, 47 (slightly abridged). 

3 Report of the Committee. Published for King Edward's Hospital Fund for London, by George 

Barber, 93 Furnival Street, Holborn, E. C. p. v, 15 (B). 



104 MEDICAL EDUCATION 

technique of modern medicine than a larger body, loosely supervised in an antiquated 
city hospital where "students" are eyed askance as interlopers. The defects of the 
former, due to somewhat circumscribed experience, a hospital year will quickly re- 
deem, for he has, and knows how to use, the tools; the defects of the latter will as a 
rule never be repaired at all. Such a hospital year is in any event highly desirable. 
It is to be hoped that a more effective and economical organization of preliminary 
education and a more intelligent public opinion may presently make its exaction 
generally feasible. 1 

On the basis of the undergraduate instruction described, opportunities for ad- 
vanced or graduate instruction must supervene. Such opportunities serve two quite 
different functions. In the first place, the various specialties must be systematically 
and thoroughly developed as graduate pursuits, resting on a thorough training and 
experience in general medicine. The number of these specialties is increasing, as more 
varied and more effective appliances suggest increased differentiation, a safe ten- 
dency, in the interest of efficiency, provided the discipline required does not infringe 
upon undergraduate territory. In the next place, to these postgraduate institutions 
the hard-run intelligent practitioner in smaller towns will at intervals return, in 
order to be invigorated at the head- waters : he will want to get in touch with recent 
improvement, to see in a brief period a large variety of interesting material, handled 
by experts in his own field. To both these purposes, the larger hospitals of our great 
cities may freely lend themselves. Their abundant wards can be used to excellent 
advantage, even though they may continue to be governed by their present boards. 
It is probable that the obstacles to such use will largely disappear as the competitive 
and commercial exploitation of medical education is itself abandoned. For beyond 
all doubt, not the least serious of the deplorable consequences that have followed in 
the wake of mercenary medical education is the limitation of hospital opportunities, 
due to the rivalry of "faculties" and to the incompetent student body to which, largely 
because of such antagonisms, the intimacy of the ward privilege would have had to 
be extended. 



1 Our required medical course, prior to practice, now covers four years. In Germany five years must 
be spent at the university, a sixth in a hospital; in England, "official statistics published recently 
under the authority of the General Medical Council show that the mean length or the curriculum in 
the case of 1 1 1 1 students investigated was three weeks less than seven years ; only 14 per cent suc- 
ceeded in obtaining a qualification in the minimum period of five years, 35 per cent obtained it in the 
sixth year, 18 per cent in the seventh year, 13 per cent in the eighth year. When the remaining 20 
per cent obtained it does not appear, probably never. Looking at the figures in another way, we 
find that at the end of six years less than half had obtained a qualification for registration, and at 
the end of seven years only two-thirds." Britith Medical Journal, Sept 5, 1908, p. 634. 



CHAPTER VII 

THE COURSE OF STUDY 
THE HOSPITAL AND THE MEDICAL SCHOOL 

THE THIRD AND FOURTH YEARS (CONTINUED) 

IN the end the final test of a medical school is its outcome in the matter of clinicians. 
The battle may indeed be lost before a shot is fired : a low average of student intel- 
ligence and inferior laboratory training will fatally prejudice even excellent clinical 
opportunities, for they rule out certain essential features of clinical training on a 
modern basis. A serviceable type of doctor was doubtless once produced under con- 
ditions that we now pronounce highly unsatisfactory; again, students defectively 
trained sometimes meet with success in examination or other tests designed to ascer- 
tain the quality of their instruction. It is not necessary to investigate closely the 
merits of the test in order to refute the argument that it endeavors to sustain. The 
institutions that seek to establish the non-importance of facilities that they do not 
possess emphasize strongly the importance of those they do. And with good reason. 
Before undertaking the responsibility of instruction in chemistry or physics or bio- 
logy, a competent teacher stipulates that he be provided with this, that, or the other. 
He is not to be put off with the assurance that some men have successfully mastered 
the subject without laboratory or tools. Very properly he takes the ground that 
whatever may be true of individuals, in general boys will be much better trained in 
a laboratory with the essentials than in a bare room practically without them. It is 
equally true of clinicians. Doctors have after a fashion been made by experience, 
i.e., their patients paid the price; further, some graduates of every feeble clinical 
school in the country have passed state board examinations or obtained hospital 
appointments, at times after competitive examinations in which they defeated stu- 
dents from schools more highly favored; it still remains true that to do full duty by 
the young student of clinical medicine, his teachers need access to acute cases of 
disease in respectable number and variety; that the school which lacks such medical 
facilities is in no position to teach modern medicine. 

In the matter of laboratories we discovered no slight cause for satisfaction. Within 
two decades the laboratory movement has gained such momentum that its future, 
even its immediate future, is in no doubt. A race of laboratory men has been trained 
and quite widely distributed. They know their place and function ; they have edu- 
cated the college administrator to accept them at their own valuation. Where deficient 
resources still force a compromise, the apologetic attitude is a sufficient promise of 
more liberal provision by and by. On the clinical side the outlook is less reassuring. 
The profession itself has in large measure still to be educated ; the clinical faculty 
often stands between the university administrator and a sound conception of clinical 
training. It happens, therefore, not infrequently that a university president will hear 



106 MEDICAL EDUCATION 

with astonishment, if not with resentment, that facilities made up of insecure and dis- 
connected privileges scattered here and there through the hospitals, public and private, 
of a community now large, now small, do not satisfy the fundamental requisites of 
clinical discipline surpervening upon modern laboratory work; or that a surgical 
clinic is no substitute for a clinic in internal medicine. The regeneration of clinical 
education is therefore apt to proceed somewhat slowly : the sources from which well 
trained clinical teachers can be drawn are few; the places in which they can be 
freely utilized are equally restricted. Students trained in the laboratories on modern 
lines enter clinical departments still more or less unconverted. The result is at best 
a half-result, yet upon it progressive amelioration in large measure depends. 

Once more a few schools meet the specifications set forth in the preceding chapter. 
We there urged that the backbone of clinical instruction must be a pedagogically 
controlled hospital best developed on its medical side. The exact status of the hospi- 
tal may indeed vary : a proper footing has been obtained now through coordinate and 
cooperative endowment, 1 again through state support in connection with the state 
university, 3 at times through a really effective affiliation. 3 The crucial points are 
these: (1) the hospital must be of sufficient size; (2) it must be equipped with teach- 
ing and working quarters closely interwoven in organization and conduct with the 
fundamental laboratories of the medical school; (3) the school faculty must be the 
sole and entire hospital staff, appointment to which follows automatically after ap- 
pointment to the corresponding school position ; (4) the teaching arrangements to 
be adopted must be left to the discretion and judgment of the teachers, subject only 
to such oversight as will protect the welfare of the individual patient. 

As long ago as 1869 the department of medicine of the University of Michigan 
began in a remodeled dwelling-house, capable of accommodating twenty patients, the 
development of a university hospital on fundamentally sound lines. From this modest 
beginning a teaching hospital of two hundred beds has now grown up, every patient 
available for the purposes of instruction, in so far as his own welfare permits. The 
staff of the hospital is the faculty of the school; the ward service in his own depart- 
ment is the laboratory of the professor. Ward rounds and amphitheater clinics are 
used for demonstrative teaching; but, better still, students are assigned to indi- 
vidual cases, which they work up at the bedside and in the clinical laboratory. An 
isolation ward is provided for infectious diseases; a lying-in ward is administered by 
faculty obstetricians and senior students; recently a psychopathic hospital, thoroughly 
modern in construction and management, has been made available. Difficulties, of 
course, of a serious nature have been encountered ; the state by a liberal policy has 
minimized them. Ann Arbor is a small residential town; it is necessary to attract or 

1 Johns Hopkins. 

* Michigan ; Iowa. 

* Lakeside Hospital and Western Reserve (Cleveland). The newly endowed Barnes Hospital 
(St. Louis) will occupy \ similar position in reference to Washington University. 



HOSPITAL AND MEDICAL SCHOOL 107 

to transport thither many cases from other parts of the state. The outcome practically 
formulates for us the terms upon which such an enterprise is feasible : a modern equip- 
ment, a salaried clinical faculty, clean-cut ideals, and careful husbandry will build up 
a substantial clinic in a small American as in a small German town. It can be sup- 
plemented by bringing the hospitals of the entire state into working relation with 
the medical department of the state university. The expense of the establishment is 
relatively great; but the advantages over a divided, perhaps even a remote depart- 
ment, 1 are on the whole cheap at the price. How many more such institutions we 
should, however, now undertake to create is of course quite another question. 2 

The Johns Hopkins Medical School has been even more highly favored. Its hos- 
pital endowment was, fortunately, sufficient to warrant a comprehensive design from 
the start. The general teaching hospital then provided has been recently supplemented 
by generous benefactions that add separate clinics for tuberculosis, pediatrics, and 
psychiatry ; wards, dispensary, clinical and scientific laboratories, cooperate for both 
pedagogic and philanthropic purposes. The clinical departments are organized like 
any other. Nowhere else in the country has so consistent a scheme been so admirably 
realized. The student is made a factor in the conduct of the hospital : he assists on 
the clinical side as clerk, on the surgical side as dresser, following the admirable 
method long in vogue in the Scotch and English schools. In each department he 
serves an appointed novitiate, following his "cases" from start to finish, now to 
recovery, again to autopsy. 

There is no insuperable reason why several other medical schools should not take 
advantage of a fortunate relation to hospitals to bring about an equally effective 
organization. In one place lack of money, in another, hampering tradition, alone pre- 
vents. The organization above described cannot be perfected unless these two defects 
are simultaneously cured. If hospitals are to enter into exclusive and practically com- 
plete relationship with a single medical school, the university must on its side pro- 
cure funds which enable it to be independent of the local profession. Unless these 
two conditions are coincidently fulfilled, the clinical situation cannot be thoroughly 
made over. Three Philadelphia schools (the University of Pennsylvania, the Jeffer- 
son Medical College, and the Medico-Chirurgical College), two Baltimore schools 
(the University of Maryland and the College of Physicians and Surgeons), and one 
Chicago school (Rush Medical College ),s are in sole and complete control of excellent 
hospitals, more or less adequate in size. The same intimacy is equally desirable and 
equally feasible for both parties in interest between Wesley Hospital and North- 

1 The divided department is discussed from the laboratory side, page 74 ; from the clinical side, 
page 119. For an account of remote departments, see (Part II) University of Texas, University of 
Indiana, Cornell University. 

2 Similar hospitals, not as yet so well developed, are at present connected with several other state 
universities : the Universities of Iowa, Colorado, Minnesota, Texas. The details are given in Part II, 
under the several institutions. 

'But in this instance the patient's consent must first be obtained. 



108 MEDICAL EDUCATION 

western University, 1 between Roosevelt Hospital and Columbia University. The re- 
luctance of the hospital to go the whole length is in these latter cases the most for- 
midable obstacle to perfecting a relation that would be of incalculable advantage to 
all concerned. For assuredly the university medical schools just named, if offered com- 
plete teaching control, could cope with the problem of procuring means with which 
to reorganize their clinical faculties on a scientific and pedagogical basis. The en- 
lightened action of its trustees is rapidly perfecting the same connection between the 
admirable Lakeside Hospital of Cleveland and Western Reserve University. The new 
Barnes and Children's Hospitals of St. Louis have engaged to do as much for the 
reconstructed medical department of Washington University. McGill, Toronto, the 
University of Manitoba (Winnipeg), and Tulane are in practically secure possession 
of clinical facilities that are adequate in respect alike to extent and control. It is to 
be noted that the schools above named do not own the hospitals in which their clini- 
cal teaching is given. Western Reserve and Lakeside thus prove the feasibility of a 
smooth working connection between a university department of medicine and a pri- 
vate hospital; Toronto proves the same as between a university medical school and 
a municipal hospital. Technically, neither set of trustees can renounce control; they 
must ratify appointments ; but that act can either be reduced to a formality or ex- 
panded into meddlesome supervision, as the trustees choose. In the two instances cited, 
it has become a mere form; and two objects, both precious, are most effectively pro- 
moted in consequence. On the strength of these instances it is perhaps worth while 
to make one more plea for an understanding between existing hospitals and deserving 
medical schools. Cannot an arrangement be consummated by which the administra- 
tion and financing of a private or a municipal hospital shall be left to the trustees 
and their appointed agents, while equally, even though not technically, complete and 
separate responsibility for the medical conduct of the hospital and for teaching 
within its wards is left to the medical faculty ? As these functions are absolutely dis- 
tinct from each other, there is no reason why two bodies of intelligent men, desirous 
of doing right in their respective spheres, should not thus cooperate. If, of course, 
the trustees are every now and then going to overrule the university in the securing 
of a teacher or to overrule a physician in his treatment of patients, the situation be- 
comes intolerable and impossible. Instances have occurred, for example, in which the 
board of women managers of a children's hospital has forbidden the use of lumbar 
puncture. It is not strange that these things have happened, because neither party 
to the arrangement has had definite ideas as to the limits of its province. Now, how- 
ever, that there is no further doubt as to just what the trustees ought to do, on the 
one hand, and as to just what the university ought to do, on the other, it would ap- 
pear an auspicious time for extending the experiment. The list of teaching hospitals 
as above given is so far not large. It may, however, to some extent be lengthened by 

1 At present, clinics at Wesley Hospital are not limited to Northwestern University students. 



HOSPITAL AND MEDICAL SCHOOL 109 

adding schools with hospitals not as yet adequate in size, of which type the Univer- 
sity of Virginia furnishes the most satisfactory example. Long contentedly a didactic 
school, this institution has just undertaken to develop a modern clinical department. 
The new and excellent University Hospital, with eighty ward beds, is still under size. 
But a speedy development may be somewhat confidently anticipated. Its problem 
is that which Michigan has already shown how to solve; meanwhile it is perfectly 
clear that the justification of such a school lies in the fact that its situation makes 
possible the most intimate relations between the clinic and the scientific laboratories, 
and a discipline in medical technique so thorough and so vigorous that a few gaps in 
the student's experience may prove relatively insignificant. There is every indication 
that the University of Virginia thoroughly appreciates both points. 

By no means every hospital owned by a medical school is, however, to be reckoned 
a teaching asset. The details require to be closely scanned. In many cases they are 
private institutions, in process of being paid for out of their own profits and out of 
the fees of medical students, who are lured by the advertisement of a school hospi- 
tal from which they get no good at all. Barnes Medical College (St. Louis) adjoins 
Centenary Hospital, " which affords clinical facilities surpassed by none and equalled 
by few;" but except for part of one floor, the building is given over to private rooms. 1 

Where control ceases, ideals necessarily change. A medical school with its own 
hospital may of course be sterile. Unwise appointments may cut off all possibility 
of productivity; too much consultant prosperity may be fatal to scientific zeal; in- 
breeding may exhaust fecundity. On the other hand, an occasional clinician may 
keep his lamp trimmed despite every obstacle, poor facilities, a precarious term of 
service, lack of appreciative sympathy. Neither the one nor the other contingency, 
however, militates against the position that as between the two systems a school 
hospital is in America essential to the existence of an efficient department of clinical 
medicine; that in its absence the general plane of instruction settles down to a dis- 
tinctly lower level. 

The best of the schools without a hospital which they can call their own do not 
lack for abundance or variety of clinical material. Rush, Northwestern, the College of 
Physicians and Surgeons (Chicago), Columbia, Cornell, and the University and Belle- 
vue Hospital Medical College (New York), Harvard and Tufts (Boston), are not 
troubled for clinical material; some of them have more of it than they can possibly 
use, much more than several of the university hospitals can ever hope to command. 
But the conditions to which they submit in order to gain access to it at all, though 
varying somewhat from place to place, are alike fatal to freedom and continuity of 
pedagogic policy. Our clinical failure concurs with the clinical success of the Germans 
in proving that freedom is the very life-breath of scientific progress, freedom on 

1 Similar is the relation between the medical department of Lincoln Memorial University (Knoxville) 
and its hospital next door ; between the University Medical College and the University Hospital (Kan- 
sas City) ; and between the Milwaukee Medical College and Trinity Hospital. 



110 MEDICAL EDUCATION 

the part of the university to choose its own teachers, finding them where it may ; 
freedom on the part of the teachers to strike out along whatever path they please. 
An artificial impediment will in general entail barrenness. 

The institutions above named are necessarily confined to the local profession for 
clinical teachers, a restriction that they would find intolerable in any other depart- 
ment and that they endure under protest in medicine, only because they are not yet 
financially in position to throw off the yoke. No disrespect to the practising profes- 
sion in these large cities is implied: they are doubtless as good doctors as can be 
found anywhere. But they are not teachers; they have neither time for, nor effective 
interest in, productive teaching. If they were really as much interested in clinical sci- 
ence as in professional prosperity, they could as a body do much to improve hospital 
conditions on the pedagogical side. As a matter of fact, professional prominence and 
institutional rivalry keep the college tenure insecure, often chop the hospital services 
into short terms, compel hospital authorities to abridge teaching privileges in order 
to avoid friction, and present a solid and opposing front to the importation of outsid- 
ers, even though the outsider chance to reside in the same town. Under such condi- 
tions it becomes at once impossible to entertain in clinical medicine the ideals set up 
in the laboratories of pathology, physiology, or chemistry. One pitches one's ex- 
pectations lower. It becomes a scramble for abundance and variety of "facilities'* on 
the part of the schools ; public hospitals split up and overload their services in order 
to distribute their favors widely; private institutions promote their prosperity by de- 
clining exclusive alliances. In Chicago staff positions in the great Cook County Hos- 
pital are awarded every six years by competitive examination; and the schools make 
what terms they can with the winners, who rotate from ward to ward at stated pe- 
riods. No bedside clinics are allowed; patients are wheeled into teaching-rooms or 
amphitheaters for demonstration ; anyone who purchases a ticket may attend any 
clinic that he pleases. The student gets an excellent chance to see detached conditions; 
what he loses is the opportunity to observe individual cases of disease in process of 
development and to correlate his own laboratory findings with symptoms observed 
at the bedside. As for the professors, whisked about in rotation, scientific study is 
out of the question. At Bellevue Hospital (New York), Columbia, Cornell, and New 
York University have each a "division," within which, however, they are not supreme; 
the medical board, composed of the entire visiting staff of all three schools and the 
fourth division, the outsiders, limits the freedom of the several parties in interest; 
final authority is lodged with a lay board, who have, for example, recently overruled 
Columbia in its own division. At Boston neither Harvard nor Tufts has the initia- 
tive in filling staff positions in the hospitals used in teaching. Appointments are 
made by seniority; it is well-nigh impossible for the school to break the line. In 
Boston as in New York, the large hospitals tend to have their own pathological de- 
partments, the permanence of whose relation to the corresponding department of 
the medical schools is decidedly uncertain. Money and educational opportunity are 



HOSPITAL AND MEDICAL SCHOOL 111 

thus both wasted. As a rule, services rotate every three or four months; the hospitals 
sometimes provide clinical laboratory space in which students work. 1 All these in- 
stitutions possess supplementary facilities. In general, however, supplementary clini- 
cal opportunities are of fragmentary and precarious character; the medical school 
has as such no uniform constitution, nor is a single department an organized entity; 
clinical clerks may be employed by one teacher for three months, only to be spurned 
by his successor in the service at the close of his brief term. Fresh pathological ma- 
terial may be procured by giving a faculty appointment to a coroner's physician, 
while the professor of pathology scours the city in vain for admission to a dead -room; 
instead of compact departments pulling as a whole towards a definite goal, a half- 
dozen professors of medicine and surgery stand on an equal footing, each compelled 
to conform to conditions imposed by the hospital on the staff of which he is a tran- 
sient sojourner, or holding the whip-handle over his own school, because the school 
cannot antagonize the clinical professor without imperiling its clinical opportuni- 
ties correspondingly. The normal relation of school and teacher is inverted. The 
question is not, "Who is a good teacher?" but rather, "Who controls a hospital 
service?" In a large city, the curtain rises on a dozen hospitals, each already provided 
with a staff, and several medical schools, each requiring a faculty of men who can 
bring as their dower "clinical facilities." There is a lively competition: at once, every 
holder of a hospital service finds himself a potential professor of medicine, surgery, or 
whatnot. When the scramble is over, the counted spoils appear in the catalogue in 
the form of a list of the hospitals "open to students of this school." The hospital 
appointments are therefore valuable "plums." They give the holders the call in the 
matter of school rank; and school positions are still in most places of substantial 
commercial value. It happens, in consequence, that the schools under discussion are 
put together of two dissimilar pieces : the laboratory branches are of one texture, 
the clinical branches of another. The laboratory men are imported; their produc- 
tivity has been increased by crossing the breed. The clinical men are local 2 and, with 
some notable exceptions, contentedly non-productive. There is little intercourse across 
the line in either direction. The redeeming feature of these schools is, then, simply 
the amount and variety of clinical material that their students see. 

The plane drops once more as we leave behind these large schools and approach 
the next class. Conditions now become rapidly worse through aggravation. Hospital 
management becomes increasingly unsympathetic or unintelligent, thus keeping the 
schools on the anxious bench. In truth, not much can be expected. "Amongst the 

1 In a few services a continuous term prevails for the time being, sometimes by arrangement among 
the teachers themselves, sometimes by way of personal compliment to an individual. Welcome as 
such improvements are, they are far from curing the trouble. 

2 One can in a few lines give a complete list of schools that can and do go outside the local profession 
to procure clinical teachers : Johns Hopkins, University of Michigan, University of Virginia, Yale, 
Tulane (in medicine), University of Pennsylvania, and Washington University. These institutions 
have imported perhaps a score or two of clinical teachers ; there are almost 4000 more clinical pro- 
fessors in the United States and Canada who are practising local doctors. 



112 MEDICAL EDUCATION 

hospital superintendents I know of, there are, besides a very few physicians, an ex- 
newspaper reporter, a ward boss, a china factory hand, various clerks, and a still 
more varied assortment of clergymen. ... In order that domestic complaints may 
be removed, a committee of ladies is sometimes appointed, . . . their only claim to 
knowledge being that of the 'born housekeeper' supposed to be inherent in every 
woman. The organization and management of institution households, however, hav- 
ing little in common with that of a few maids and no sick people, the management 
of details by visiting committees is often but an added discomfort." 1 

Such institutions are mere boarding-houses for the sick. Physicians call there as 
they call at a private house, seeing twenty patients in the former instance, a single 
patient in the latter. It is the difference between wholesale and retail, no other; 
scientifically the " calls " are on the same level. The visiting staff of physicians is ap- 
pointed through favor, pull, or bargain, and the schools make the best of it. A small 
clique occasionally controls the situation. Conspicuous fitness cannot be the sole or 
main consideration. A school rich in facilities to-day may be beggarly to-morrow. 
The medical department of Toledo University has just lost its main clinical sup- 
port as one outcome of a local political overturning. The University of Minnesota 
has been fortunately hastened in the resolution to build its own hospital because a 
local upset reduced its former privileges. The Woman's Medical College of Phila- 
delphia adjoins a hospital of which its faculty was once the staff; now there is no 
commerce between them. The Hering Medical College at Chicago (homeopathic) is 
in even closer proximity to a homeopathic hospital : a bridge connects them ; but the 
barred doorway bears the legend, " No students admitted." Medical politics are de- 
cisive at Albany ; to keep control in the hands of the dominant clique of the Albany 
Medical School (the medical department of Union University), the size of the fac- 
ulty was recently increased, all the new members being adherents of the side in 
power. The City Hospital at St. Louis, the County Hospital at Denver, are frankly 
described as being "in politics." 2 Staff appointments made for personal or political 
reasons may of course be revoked for reasons that are no better. The uncertainty of 
any one connection constitutes a good reason for getting hold of as many as possible. 
Columbia, for example, used to be supreme at Roosevelt Hospital, opposite its lab- 
oratories; it is being gradually edged out, a deplorable condition for all concerned; 
but it has recompensed itself abundantly elsewhere. The medical department of the 
George Washington University protects itself by providing that "every clinical 
teacher shall cease to be such teacher should his facilities for giving clinical instruc- 
tion cease before the end of his term of service." 8 If a school drops an indifferent 
teacher, it may be worse off than if it retained him ; for he keeps, and the school 
loses, the "clinical facilities'" that he represents. St. Louis University, in purchasing 

1 Banfielcl, loc. fit., pp. 42, 43 (abridged). Occasionally, feeling is cordial, as at Topeka, for example. 

'The same is admitted at Halifax, N. S. 

8 Ordinance to Reorganize the Department of Medicine, section 3. 



HOSPITAL AND MEDICAL SCHOOL 118 

its present medical department, contracted to keep the clinical professors in their 
chairs for a term of years. When the term expires, they are free to drop them, at 
the cost, however, of cutting down their clinics in the same ratio. In a few places 
things are held together somewhat more compactly by an arrangement that gives 
the school faculty the hospital services during term time. Such is the case at Mobile, 
Birmingham, and Chattanooga. But in general a hospital staff is composed of hetero- 
geneous elements, appointed for reasons that cannot be classified. Representatives of 
no school and representatives of all schools, serving now through the year, again for 
a few weeks, now in one ward only, now rotated through several, make up a situa- 
tion unfavorable to every interest involved. In New York the ancient ecclesiastical 
evil of plural benefices crops out unexpectedly : one individual may hold several ap- 
pointments in hospitals so far removed from each other that he cannot possibly do 
even his perfunctory duty by them ; instead of surrendering superfluous perquisites, 
he sub-lets them at will, according as fancy or personal interest may determine : the 
staff appointments appended to his name are so many scalps hung about his belt ! 
There is no such thing as hospital policy : the wards have as little wholeness, as little 
intimacy of relation with each other, as the private homes in which these same physi- 
cians treat their personal patients; only a local accident puts one roof over them. 

Teaching is obviously but an incident in the routine of these institutions. Not 
infrequently amphitheaters have been included in their construction ; but they usu- 
ally lack a clinical laboratory in which students may work, not a few lack it altogether. 
The failure to provide clinical laboratory space thus keeps instruction to the level of 
passive demonstration. The student has presumably spent two years in mastering cer- 
tain medical sciences. A large part of this laboratory discipline was designed to en- 
able him to gather a greater variety of facts than the bedside examination will dis- 
close. Blood, sputum, urine, etc., all contain important evidence which the laboratory 
years equip the student to utilize. He has been taught to do certain things. But at 
the critical moment, when doing them will count, he may get no chance, in the first 
place, because at many hospitals, among them those mainly relied on by the Univer- 
sity of Nebraska (Omaha), Denver and Gross (Denver), the Hahnemann Medical Col- 
lege (Philadelphia), and most southern schools, there is no clinical laboratory at all. 
At Denver "there is no equipment to make a culture, and the internes are rarely 
equal to it, anyway."" At Omaha, the clinical microscopist of the university faculty 
was unable even to get material from the County Hospital; when he wanted gastric 
juice for demonstration, he had to manufacture it himself. In the second place, where 
a clinical laboratory is provided, "students" are as a rule not admitted. The work 
is done by a resident pathologist who has no connection with any of the several 
"schools'" that are permitted to demonstrate cases in the amphitheater or in the 
wards; or by internes, equally detached and too frequently of very doubtful com- 
petency by reason of just the educational limitations we are deploring. To the clinical 
laboratories connected with the municipal hospitals of St. Louis, Chicago, Minne- 



114 MEDICAL EDUCATION 

apolis, students have no access, though in these hospitals, rich in material, the students 
of St. Louis University, Rush and the College of Physicians and Surgeons (Chicago), 
the University of Minnesota, respectively, ought to be getting the best part of their 
clinical training. Not infrequently it is alleged that the students do "carry material 
for examination back to the college:" the students of the Creighton School (Omaha) 
and of the Los Angeles schools would thus have to transfer specimens of urine, feces, 
and gastric contents on the street cars across town, distances of several miles. At 
Southwestern University (Dallas, Texas), a section of four students has an assigned 
patient at the City Hospital, perhaps a mile and a half distant, where there is no 
clinical laboratory ; to work up material, they must carry it to the college building, 
where there is no clinical laboratory, either. Educationally, an "academic" labo- 
ratory discipline that thus hangs loose, that cannot be brought to bear on specific 
clinical cases, must be largely wasted. There is no merit in making a blood-count 
unless the student has been disciplined to connect the blood-count with all other 
symptoms of the patient whose blood is counted. As it is, he beholds a patient, sees 
things pointed out, may even listen to his heart-beat ; away off in the college labo- 
ratory, he has previously examined some one's urine, counted some one's blood, tested, 
perhaps, an artificially prepared gastric juice. But there is no connection; the dis- 
cipline splits in the middle. Scientific habits of practice are not established in that 
way. Nor are loose habits, thus contracted, cured by an interneship. Pupils are more 
apt to disappoint than to astonish their teachers; they do not generally better their 
instruction. In consequence hospital records made by internes graduated by these 
schools are scant and unsystematic. Defective methods at the University of Buffalo 
were extenuated on the plea that as internes they learn better ; but the meager records 
of the Buffalo General Hospital disprove the claim. Whoever is responsible, poorly 
kept records are very apt to denote inferior bedside instruction. The situation is this : 
there lies the patient ; teacher, interne, and students surround the bed. The case is up 
for discussion. A question arises that requires for its settlement now a detail of the 
patient's previous history, now a point covered by the original physical examination, 
now something brought out by microscopic examination at some time in the course 
of the disease. If complete, accurate, and systematic records hang at the bedside, there 
is an inducement to ask questions ; doubtful matters can be cleared up as fast as they 
are suggested. That, then, is the place for the records, full records, at that. In few 
instances are the records full ; in still fewer are they, full or meager, in easy reach. 
At the University of Kansas, at Lane Hospital (Cooper Medical College, San Fran- 
cisco), there is no uniform method of making or keeping records : " some men do 
better than others;" "it depends on the man." At the Protestant Hospital, Colum- 
bus, Starling-Ohio graduates are internes, the records are nurses' charts ; at Trinity 
Hospital (Milwaukee), attached to the Milwaukee Medical College, the same is true. 1 

1 Similar instances can be cited from all other sections of the country : the records are nurses' charts 
at the hospital of the College of Physicians and Surgeons, Little Rock, and at the City Hospital 



HOSPITAL AND MEDICAL SCHOOL 115 

The clinical facilities of the ordinary medical school are put together of scraps, the 
general character of which have now been described. They offer a medical clinic here, 
an obstetrical clinic there, a skin clinic somewhere else. Faculties numerically out of 
all proportion to the number of students are assembled in order to piece out the 
quilt : Fordham University has 72 instructors for 42 students; the New York Medi- 
cal College for Women has 45 instructors for 24 students; the Toledo Medical Col- 
lege, 48 instructors for 32 students ; the Oakland College of Medicine and Surgery, 
42 instructors for 17 students. As the hospitals are scattered, time is wasted in going 
to and fro. All told, our 150 medical schools have resulted, among other things, in 
some 4000 professorial titles. 1 

Imagine the engineers that would be produced if students were sent to a series of 
shops to see things done, as far as they could be seen without interfering with the 
workmen ! In no two of these hospitals is exactly the same kind of teaching privi- 
lege granted; and the privileges granted are highly precarious: the hours are arbi- 
trarily limited, and number of beds is usually too small. Nowhere do they approach 
the ideal which the school might readily institute in its own hospital. They fall 
short, however, in varying degrees. In St. Louis the situation is lamentable. The 
City Hospital has a medical and surgical staff who "do no teaching," and a teaching 
staff who "do no doctoring." Fjach of the half-dozen schools in the town has one 
afternoon; the instructor must go out to the hospital the day before to select two 
cases for demonstration, an amount of trouble which the better men are reluctant 
to take. The instruction consists in pointing out features and suggesting what ought 
to be done : in surgery, it may have been done already ; in medicine, there is no tell- 
ing. In either case, the entire process remains purely hypothetical. These opportu- 
nities are not infrequently treated as they deserve: at the St. Louis College of Physi- 
cians and Surgeons it was stated: "This is hospital day; lots of them don't go." In 
the County Hospital at Los Angeles, the main reliance of two university depart- 
ments of clinical medicine, one of them (the University of California) requiring for 
admission three years of college work, students are not permitted to handle sur- 

used by two schools at Memphis ; at Ensworth Hospital, one line in a ledger contains all the facts 
on record ; at Topeka, the same is true ; it is added that " laboratory reports are not kept, and physi- 
cal examinations could not be found ;" the histories, made up by internes at the Kansas City Hos- 
pital, are so irregular that " the visiting staff don't even read them." They are imperfect at the Uni- 
versity of Texas (Galveston) ; defective and careless at the Maine General Hospital (Portland). 
1 See Table in Appendix, for a complete list. The disproportion in point of number between laboratory 
and clinical chairs is instructive. For example : 

NUMBER or FCLL PROFESSORS IN 



Institution Anatomy 
Cornell 2 
Columbia 1 
St. Louis 1 
Denver and Gross 1 
University of Louisville 1 


Pathology 
2 
2 

1 
1 
1 


Physiology 
1 

1 
8 
1 
1 


Medicine 
3 
8 
5 
5 
4 


Surgery (not in- 
cluding gynecology) 
9 
5 
6 
5 
8 



Contrast with these 
Johns Hopkins 



116 MEDICAL EDUCATION 

gical patients, and teachers "shall not conduct bedside clinics when possible to re- 
move patients from the ward;" 1 on these terms 100 beds are available, for six hours 
weekly in surgery, and perhaps for a few more in medicine. At Creighton, students 
"witness the operation," and are admitted to about 90 beds. In Denver, students 
"are not much at the bedside; they just look on;" the hours are from 8.30 to 
10 a.m., daily, the early hour having been fixed, it is alleged, to prevent the atten- 
dance of the state university boys at Boulder. There are "ward classes" at Memphis 
as many as fifty students in a group at once ! 

Where things are patched up in the way described, it is of course impossible that 
proportions and relations should be observed. We have urged that the backbone of 
clinical training must be internal medicine. But it is precisely here that the schools 
are in general weakest. The sum total of accessible beds may amount to a hundred : 
not infrequently less than one-fifth of them will contain medical cases. The "addi- 
tional facilities " of the larger schools are mainly surgical in character; and in gen- 
eral, the less a school has to offer in the way of clinical facilities, the more heavily 
is surgery overweighted. Its pedagogical value is relatively slight; for operations are 
performed in large amphitheaters in which the surgeon and his assistants surround 
the patient, to whom they give their whole mind, in practical disregard of the 
students, who loll in their seats without an inkling of what is happening below. Most 
of the students see only the patient's feet and the surgeon's head. Only in rare cases, 
previously mentioned, in which the student helps to form the machine, do desig- 
nated individuals take turns and become part of the operation, making the exam- 
ination, watching the procedure at close range, and "cleaning up" afterwards. 
Inadequacy in general is thus aggravated by increasing predominance of surgical 
over medical clinics. Clinical teaching thus tends more and more to concentrate 
in the amphitheater. The laboratory side sinks further and further into the back- 
ground; the bedside work becomes more and more contracted. The whole thing is 
demonstrative and at steadily increasing remoteness. At the University of Ver- 
mont juniors and seniors have most of their medical and surgical clinics together, 
averaging in medicine about three hours weekly one year and four hours weekly the 
next ; and the work is mostly in the amphitheater. Dartmouth Medical School has 
access to 24 beds, eighty per cent of the patients occupying which are surgical cases. 
Bowdoin to complete the list of the smaller New England schools uses the 
Maine General Hospital, Portland, where surgery greatly predominates. Tufts has an 
imposing array of clinical facilities; but its medical clinic is limited to the Boston Dis- 
pensary and one service in the City Hospital. Kansas Medical College relies almost 
wholly on three hospitals, in which it gets a total of nine or ten hours^ instruction 
weekly : in two of the three hospitals all the work is surgery; in the remaining, two- 
thirds of it. In the university hospital at Rosedale (University of Kansas), there were 
last year 240 patients, 190 of them surgical; six free beds are this year reserved for 

1 Rulet and Regulations, Lot Angela County Hospital, section 4, rule 12. 



HOSPITAL AND MEDICAL SCHOOL 117 

medicine. Of course, the school has privileges elsewhere; but this small hospital is 
all that it controls, though two years of college work are required for admission. 
The Starling-Ohio Medical College (Columbus) uses several hospitals: in one 150 
beds are open, "mostly surgical;" in another 40 beds, "mostly surgery." The De- 
troit College of Medicine has access to two hospitals; one of them, with 100 teach- 
ing beds, is fortunate in a fairly equal division between medicine and surgery; the 
other describes its work as nine-tenths surgical. The clinical instruction of Ep- 
worth University (Oklahoma City) is given in a hospital within which 30 to 40 
beds are available, two-thirds to three-quarters of the cases being surgical. Drake Uni- 
versity uses 30 beds during a weekly total of twelve or fifteen hours in two hospitals, 
in neither of which is the student essentially other than a passive witness. The Chicago 
College of Medicine and Surgery being the medical department of Valparaiso 
University has a hospital of 75 beds, about one- fourth usable for teaching; the 
Bennett Medical College (Chicago) has a hospital of 40 beds, 20 claimed as free; at 
Chattanooga, the city hospital contained, all told, in the course of the year 1908 
something over 500 patients; at Augusta,about 300. Temple University (Philadelphia) 
has a hospital with 20 free beds; the Woman's Medical College (Philadelphia), 27; 
the New York Eclectic Medical College sends parties limited to three students to the 
Sydenham hospital twice weekly. The Physio-Medical College of Chicago got along 
last year with 167 patients; Western University (London, Ontario) has access to an 
average of less than 30 beds a year. At Trinity Hospital (Milwaukee), with 75 beds, 
mostly pay, a part of Milwaukee Medical College, nine-tenths of the cases or 
more are surgical. 

We have, however, by no means even yet exhausted the subject of arbitrary clinical 
limitations. As a rule, only the general medical and surgical wards are open at all. 
Few of the hospitals possess an isolating ward, and not all of these permit students 
to see infectious diseases. The instruction in that important branch is therefore 
usually didactic. This holds true of some schools that ask two years of college work for 
entrance, Yale and the University of Kansas among them. It is true, too, of the New 
York Medical College for Women, the University Medical College (Kansas City), 
the Starling-Ohio (Columbus), the University of Tennessee, Baylor University and 
Southwestern University (Dallas), Louisville, Little Rock, Memphis, etc. At Albany 
it was stated that the hospital has a pavilion for infectious diseases, which the school 
might use : " it does n't, because the students are afraid." But the very worst showing 
is made in the matter of obstetrics. Didactic lectures are utterly worthless. The 
manikin is of value only to a limited degree. For the rest, the student requires dis- 
cipline and experience. The safety and comfort of both patients mother and child 
depend on the trained care and dexterity of the physician. The practice is a fine art 
which cannot be picked up in the exigencies of out-patient work, poorly supervised 
at that. Principles, methods, technique, can be learned and skill acquired only in 
an adequately equipped maternity hospital ; only after that is the student fit to be 



118 MEDICAL EDUCATION 

trusted with the responsibilities of the out-patient department. Difficulties and limi- 
tations in such matters sit lightly on most of our medical schools. The hospitals of 
Atlanta and Los Angeles exclude students from the obstetrical ward; at Burling- 
ton there is no obstetrical ward, but the "students see more or less;" at Denver a 
"small amount" of material is claimed; at Birmingham it is "very scarce;" at Chat- 
tanooga there are " about ten cases a year," to which students are " summoned," how 
or by whom is far from clear. At the Hahnemann Medical College (Chicago) stu- 
dents "look on at internes who do the work;" a committee of the Missouri state 
board reports of the College of Physicians and Surgeons of St. Louis that it could 
find only incomplete records of 21 cases for a senior class of 57 ; at Augusta, Georgia, 
the cases " always come at night when you can't get students;" at Charlotte 15 cases 
were available from September 15 to February 4; the medical department of Lincoln 
Memorial University (Knoxville) has no out-patient department, but alleges "a few 
deliveries before the class;" Vanderbilt relies on out-patient work mostly. There is a 
senior class of almost 150 at the American School of Osteopathy (Kirksville, Mis- 
souri). In two months they had eight clinical cases in obstetrics. Perhaps most 
lamentable of all, the Woman's Medical College of Baltimore concedes its opportu- 
nities to be "inadequate." At Toledo, Louisville, the University of Tennessee, Kan- 
sas City, the University of Kansas, Albany, and Yale, obstetrics is practically alto- 
gether out-patient work ; that is to say, the student gets about the same training as 
a mid- wife. At Willamette (Salem, Oregon) he probably does not get even that: for 
"obstetrics depends on private practice and is very precarious. The student sees a 
delivery when the doctor is willing to take him." 

Not a few of the schools mentioned have elevated their entrance requirements 
until they already demand one or two years of college work for entrance, or expect 
to do so presently. 1 Meanwhile their clinical facilities remain what they were. 
Doubtless some of them will make haste to improve, Yale, for example. Others 
will probably recede from their announced elevation, as several have already done. 
Assuredly, students who improve their preparation will demand that the schools 
improve their facilities correspondingly. In the laboratory years this has generally 
taken place : he will be a dull fellow who does not quickly feel and resent the inferi- 
ority of the clinical end. In all fairness, the betterment of the facilities, the change 
of spirit and ideal, ought to have preceded as the warrant for the higher entrance 
standard. For the two-year college standard proclaims a university department. It 
still remains to be demonstrated that towns like Omaha, Washington, San Francisco, 
Toj>eka, Milwaukee, can recruit university faculties from the local profession. A univer- 
sity connection or a two-year college entrance requirement do not, of themselves, trans- 
form a medical school faculty. They merely impose upon it an additional strain. 

The strain to which high entrance standards and good laboratory teaching at 

1 Kansas Medical College, Dartmouth, Yale, Creighton, Denver and Gross, Hahnemann (Chicago), 
Starling-Ohio, Milwaukee Medical, Wisconsin College of Physicians and Surgeons, etc. 



HOSPITAL AND MEDICAL SCHOOL 119 

once subject the clinical end is distinctly apparent in the remote half of the divided 
school. We have already 1 considered the perplexities of the laboratory end without 
contact with clinics. They appeared not insoluble. Whether two clinical years given 
by themselves with practising physicians as teachers can ever form a substan- 
tial texture is highly problematical. The latter half of a divided school is given by 
the University of California at San Francisco, 2 by the University of Nebraska at 
Omaha, 3 by the University of Kansas in a suburb of Kansas City,* by Bowdoin Col- 
lege at Portland. 5 The American Medical Missionary College carries division still 
further. It is divided between Battle Creek and Chicago; but no single year is en- 
tirely given in either place. Every class is shifted in the course of the year from one 
town to the other. Nor does the division end here; for at Chicago, the clinical in- 
struction is divided so that different pieces are given at widely separated places. These 
pieces do not touch each other, and none of them ever touches the laboratory work 
given in Battle Creek. Indeed, none of the detached clinical departments is doing well. 
The vitality of the clinic depends on the closeness of its commerce with the laboratory 
branches; otherwise the clinical end is not rooted. Thus far none of these has achieved 
either executive or scientific intimacy. A certain degree of executive unity may per- 
haps be secured through a dean freely circulating between the two parts, though if 
he is attached as professor to one end of the department, the other is apt to resent 
intrusion. Scientific unity seems in any case unattainable. The clinical men at Omaha 
or San Francisco simply cannot be at home in the laboratories of Lincoln or Berkeley. 
Laboratories must be duplicated at the clinical site if the clinicians are to be in touch 
with them : in which case the divided type of school tends to turn into the whole re- 
mote type illustrated by the medical departments of the universities of Texas at 
Galveston, Indiana at Indianapolis, and of Cornell at New York. The truth is that an 
efficient medical school is a compact whole, in which geographic unity of labora- 
tories and hospital is essential to scientific and educational integrity. The wilted 
condition of the clinical ends of the divided schools is a warning that Michigan, 
now contemplating the removal to Detroit of the final year in medicine, may well 
weigh. Even separation of the two parts within one city is a disadvantage. 6 Division 
seems justifiable only as a temporary expedient to get clinical material, pending a 
choice between concentration of the entire school at one point or the other, or out- 
right abandonment of clinical instruction in favor of a two-year school. 7 

1 Page 74. 

2 First half given at Berkeley. The latter half will be duplicated at Los Angeles. Leland Stanford 
Junior will shortly give the latter half of its medical course at San Francisco, too ; its first half is 
given at Palo Alto. 

3 First half given at Lincoln. 

4 First half given at Lawrence. 
8 First half given at Brunswick. 

6 As at Rush (University of Chicago). 

7 Several of the southern state universities and the University of Colorado are in this position. 



120 MEDICAL EDUCATION 

Meanwhile we are not without schools that have practically no hospital connec- 
tion at all. The Mississippi Medical College (Meridian) has absolutely no hospital 
facilities or privileges of any sort whatsoever. The Georgia College of Eclectic Medi- 
cine and Surgery (Atlanta), the California Eclectic Medical College (Los Angeles), 
are in the same plight. Others are hardly better: for example, the three Chicago 
night schools, one of which, the National Medical University, had two lonely pa- 
tients on the top floor of the school-building, though claiming the usual relations 
with a private pay institution. Thrice happy for the nonce is the Hippocratean Col- 
lege of Medicine (St. Louis), a night school; it crosses no clinical bridges till it reaches 
them : as it is only three years old, it need not bother about hospital connections until 
next year! The Lincoln (Nebraska) Medical College deplores the fact that "there are 
no poor in Lincoln ; hence students have no regular hours at any hospital, but de- 
pend on cases as they turn up." The Hahnemann Medical College of Chicago has two 
surgeons on the Cook County Hospital staff and a hospital of 60 beds; but the lay 
superintendent "does n't believe in admitting students to the wards, so that there is 
no regular way for them to see common acute diseases." The College of Physicians and 
Surgeons, Denver, had access to a hospital of 28 beds, "certain ones free." The medi- 
cal school at Little Rock that trades on the name of the University of Arkansas, 
with which it is not even affiliated, is connected by a bridge with a city hospital 
that has a capacity of from twenty-five to thirty-five patients, some of whom are oc- 
casionally transported across into the amphitheater for operation or exhibition. The 
clinics of the medical department of Willamette University (Salem, Oregon) are some- 
what intangible: whether medical clinics are held, and where, "depends on the cases." 
Not infrequently, schools advertise varied hospital connections that prove on inves- 
tigation to be baseless or surreptitious. The Philadelphia College of Osteopathy claims 
"the freedom of every important surgical clinic in the great medical colleges and hos- 
pitals** of that city. Its hospital list is almost a page long; at the top stand the Uni- 
versity and Jefferson Hospitals, to which its students can gain access only by conceal- 
ing their identity. Rights or privileges they have none. The College of Physicians and 
Surgeons of Boston announces that "equal opportunities and privileges are available 
in the hospitals and institutions" of that city, a flagrant misstatement; for the stu- 
dents of that institution can on payment of fee attend only certain public clinics of 
little value. 

It is unnecessary to describe dispensary conditions in equal detail: naturally they 
parallel the hospital situation. The same clinicians are responsible for both; in general, 
the dispensaries would be likely, therefore, to reflect the samedegree of intelligence and 
conscientiousness. A teaching dispensary needs ample space, equipment for making the 
necessary diagnostic examinations and for taking simple therapeutic or surgical mea- 
sures on the spot, a well organized staff, and a thorough record system, in the keep- 
ing of which students serve as clerks. Voluminous attendance is an advantage, because 
it permits selection in the first place, repeated illustration of important conditions in 



HOSPITAL AND MEDICAL SCHOOL 121 

the second. It may be set down as fundamental that a good dispensary will not run 
itself; that nothing in the way of equipment will be used that is not actually there. 
Economy of time is of such importance to both teachers and students that makeshift 
inevitably means neglect. The well conducted dispensaries are the well equipped and 
well organized dispensaries. The moment that equipment and organization fail, omis- 
sion begins; no general rule prescribes where it will stop. 

Vanderbilt Clinic the dispensary attached to the College of Physicians and Sur- 
geons,New York (Columbia University) represents in respect to facilities the school 
dispensary at its best. Teaching and treatment rooms, ample in size and equipment 
from the standpoints of both students and patients, are provided; a clinical labora- 
tory, with working space for every student on duty, is part of the building; close 
correlation of physical examination and laboratory tests is feasible. An admirably 
kept card index facilitates the keeping and use of data; there was an attendance in 
1908 of almost 50,000 patients, making over 160,000 visits. The Johns Hopkins Dis- 
pensary and the Lakeside Dispensary, operated by Western Reserve, are equally ef- 
ficient. Less sumptuously housed, but adequate in all essential respects, are the dis- 
pensaries of Cornell, New York University, the three Philadelphia schools, and those 
open in Boston to Harvard and Tufts. The Polhemus Clinic controlled by the Long 
Island College Hospital, the Homeopathic Medical Dispensary controlled by the 
Boston University School of Medicine, must be included in the number of excel- 
lently housed, equipped, and organized institutions of this kind. 1 Yale has an excellent 
building, which the application of a few thousand dollars yearly will readily convert 
into an effective teaching adjunct. 2 

The first break comes in the care with which an abundant attendance is handled. 
It would seem probable that, where the records are careless and incomplete, the 
treatment of patients is likely to be hurried. The compilation and arrangement of 
data slow the pace. They conduce to, and usually indicate, thoroughness and de- 
liberation, of fundamental importance if the student is to acquire a cautious habit. 
Lack of system and superficiality tend to run together. Mere mass of material, swiftly 
handled, may be useful to experienced practitioners in affording a variety of cases 
among which occasionally something rare and interesting may turn up; but a stu- 
dent who is in such a dispensary initiated into the routine of practice will be fortu- 
nate ever to form methodical and thorough working habits. The Los Angeles clinical 
branch of the University of California possesses a thoroughly admirable dispensary 
building. Some of the rooms are well, some ill equipped ; the records are brief and 
non-significant; no report is compiled; and the clinical laboratory, indispensable to 
intelligent conduct of an out-patient department concerned to mould the student's 

1 A few institutions possess small, moderately well equipped dispensaries, the conduct of which in- 
dicates conscientious desire to do the best possible under the circumstances. Creditable examples are 
the dispensary of Drake University (Des Moines) and the South End Dispensary used by the Albany 
Medical School. 

2 Denver and Gross also has an excellent dispensary building. 



122 MEDICAL EDUCATION 

habits and to do well by its patients, is both defective and disorderly: the surgical in- 
strument case contained a tack-hammer, candle-ends, and other equally incongruous 
miscellaneous objects among its instruments. In the medical department of the Uni- 
versity of Cincinnati, there is a card index alphabetically arranged ; but the results 
of the physical examination are not given, nor is there any note of the treatment 
advised. The Starling-Ohio Medical College (Columbus) has a clean dispensary, with 
adequate attendance, but no records in a proper sense at all; Halifax Medical Col- 
lege requires attendance at a city dispensary that possesses little equipment for treat- 
ment, still less for teaching; besides, the college has no voice in its conduct. The 
students of Syracuse University also attend a city dispensary, but the head clinical 
professors know nothing about what they get, or fail to get, there. Utterly destruc- 
tive of good habits of observation or treatment must be a dispensary like the North 
End Dispensary, Kansas City, attended by the students of the state university; 
equipment and records are alike defective and confused. But there are others much 
worse. Dispensary suites are found at the Barnes Medical College and the College of 
Physicians and Surgeons (St. Louis). The former claims an annual attendance of 
10,000 cases. Several rooms are provided, those devoted to branches like gynecology 
and surgery being especially filthy. The equipment for internal medicine consists of 
a small dirty room and a few miscellaneous bottles of proprietary drugs scattered on 
the shelves of a bookcase. The dispensary of the College of Physicians and Surgeons 
is of the same general character: the gynecological room, for example, is without a 
window, water, or instruments; all is dark and dingy; there are no records of cases; 
evasive answers are made to all questions. The fact is that a dispensary, costing little 
to keep and nothing to run beyond the expense of a drug room, cannot answer for 
teaching. Nor can youthful volunteers be usually relied on to form an efficient staff. 
The expenditure on the score of dispensary must be greatly increased if the material 
that presents itself is to be effectively handled in the training of students. 

These schools shade off imperceptibly into those that make no pretense to a dis- 
pensary at all, passing on the way institutions like Birmingham Medical College, 
with a department both small and poor ; Augusta, without case records, not even 
prescriptions put up in the pharmacy being numbered ; Portland (Oregon), claiming 
two to seven a day; the Jenner (Chicago), claiming two to ten nightly; the Physio- 
Medical (Chicago), with perhaps 250 all of last year; the Eclectic (New York), using 
" what comes to the college ;" Charlotte, with loose unnumbered cards, mostly unin- 
telligible, the prescription files showing an average of four or five a day. At the De- 
troit Homeopathic College one finds prescriptions written on scraps of paper, envelope 
backs, etc., with neither numbers nor names ; at the Cleveland Homeopathic Medical 
College " medical cards are kept in pigeonholes that are cleaned out every spring." 
The Kansas City Eclectic school is hopeful, if not ambitious : its dispensary atten- 
dance averages now " about three daily ; " they hope to be able " to work it up to 
six." The medical department of Bowdoin College uses a dispensary at Portland that 



123 

has an attendance of eight or ten a day : there are no case records, not even a pre- 
scription file, no clinical laboratory, and not so much as a microscope on the premises. 
The University of Alabama (Mobile) is the only small southern school with decent dis- 
pensary quarters: an attractive wing has been recently built for the purpose by the 
state. 

There remains still the goodly number of schools that possess absolutely no dis- 
pensary provision at all. With some of them we are already familiar as destitute of 
hospital facilities. Without dispensary teaching of any kind, their students enter the 
homes of the poor, to officiate at childbirth, to care for wage- workers on whose well- 
being depends the independence of the family. Meridian, the Georgia Eclectic, Wil- 
lamette, the Lincoln Eclectic, the Hospital Medical College (Atlanta), the American 
Medical College 1 (St. Louis), the Chattanooga Medical College, Western University 
(London, Ontario), are representative schools of this description. It is painful to in- 
clude in essentially the same class the Medical College of the State of South Caro- 
lina, at Charleston, which in lieu of a school dispensary refers to the out-patient work 
of the Roper Hospital, with which its students have nothing at all to do. The two 
Dallas schools both long without a dispensary are now starting one; Ensworth 
Medical College at St. Joseph, Missouri, a city of 130,000, has practically no dis- 
pensary at all; Epworth University (Oklahoma City) is in the same plight. Not a few 
of these institutions might develop a fair dispensary service if their opportunities were 
intelligently cultivated. For example, the University of Buffalo, in a city of 400,000, 
has a wretched dispensary with a daily attendance of from twelve to fifteen, if one 
can judge by sampling ; for tabulated records there are none. Such notes as exist are 
brief and irregular. The poor do better to suffer in silence rather than to trust to the 
haphazard student medication that such institutions now supply. 

Astonishing to relate, the conditions that have been portrayed are defended. It is 
alleged in extenuation that "our graduates pass state board examinations, get hos- 
pital appointments, succeed in practice."" It is quite true: what of it? The argument 
if valid would commit every school above the lowest to deliberate deterioration of 
its facilities. Bowdoin makes light of a wretched dispensary on the grounds above 
cited ; Dartmouth men succeed by the same tests without any dispensary at all ; ergo, 
Bowdoin may safely forego dispensary teaching altogether. Is it not obvious that 
both are mistaken? that they take hold of the situation at the wrong end? Medical 
education is nowadays a definite problem, the factors to which, the end of which, 
may be specifically stated. We know exactly what it drives at; we can determine to 
a nicety the means necessary to reach the goal thus set up. It will shortly be demon- 
strated that the number of doctors needed can in most sections be supplied with- 
out material departure from the conditions agreed on. Why, then, should they be 
abandoned ? In order that local doctors may continue to develop their professional 

1 At this school one is naively told that they have "a dispensary room, and almost every day some 
one comes." 



124 MEDICAL EDUCATION 

business? In order that "historic" schools may continue to produce a slightly amel- 
iorated type of didactically trained physician? 

As a matter of fact, many of the schools mentioned in the course of this recital 
are probably without redeeming features of any kind. Their general squalor consorts 
well with their clinical poverty: the class-rooms are bare, save for chairs, a desk, and 
an occasional blackboard; the windows streaked with dust and soot. In wretched 
amphitheaters students wait in vain for "professors," tardy or absent, amusing the 
interval with ribald jest and song. The teaching is an uninstructive rehearsal of text- 
book or quiz-compend : one encounters surgery taught without patient, instrument, 
model, or drawing; recitations in obstetrics without a manikin in sight, often 
without one in the building. Third and fourth year men are frequently huddled to- 
gether in the same classes. At the Memphis Hospital Medical College the students 
of all four years attend the same classes in many of the subjects taught. 

So much for the worst. It may be, however, that in the case of some schools with 
weak hospitals and no dispensaries, the didactic instruction is vigorous, clean cut, in 
its way effective. Such is the claim made at Dartmouth and at Bowdoin. Let us con- 
cede its justice: what of it? Logically, the position of these institutions would be 
stronger if they stuck to didactic instruction altogether. The moment that they 
offer a course in clinical microscopy, they are committed to an entirely different scale 
of values. For that they require patients whom they can observe closely and contin- 
uously in order that laboratory data and bedside data may be put together as the 
basis of a specific judgment. In other words, teaching must henceforth be concrete, 
not abstract; clinical, not didactic. Good didactic instruction may indeed to some 
extent accompany clinical teaching. We are not especially concerned to determine its 
actual extent. 1 Let it earn the school an extra credit, if you please. But its excellence 
is no substitute for missing, defective, or badly balanced clinical opportunities. 



1 The subjoined comparative schedule indicates the distribution between clinical and didactic work in 
schools of various grades. This table is not alone conclusive ; for schools with weak clinical resources 
are not infrequently without illustrative material, so that a clinical lecture may perforce turn into a 
didactic lecture. Moreover, clinical instruction of the amphitheater type may, if the students are 
few and the conditions good, be as useful as a bedside demonstration ; where, however, the students 
are many and the conditions poor, it may be no better than a didactic exposition. 



COMPARATIVE SCHEDULE, THIRD AND FOURTH YEARS 

THIRD YEAR 



WESTERN RESERVE UNIVERSITY 



NEW YORK UNIVERSITY 



MEDICO-CIURUROICAL COLLEGE UNIVERSITY or ALABAMA 



Subject 


Hours 


Subject 


Hours 


Subject 


Hours 


Subject 


Hours 


Inatomy 


Did. 


Lab. 


Clin. 


Pathology 


Did. 


Lab. 


Clin. 


Anatomy 


Did. 


Lab. 


Clin. 


Anatomy 


Did. 


Lab. 


Chn. 


Applied anatomy 


96 






Demonstrations 




64 




Applied anatomy 


48 






Anatomy of the 








*athology and Preven- 
tive Medicine 








Applied patholo- 
gy 


32 


64 




Path. <t Bacteriology 
Pathology 


96 






eye, ear, nose, 
and throat 


14 






Gross pathological ana- 








Bacteriology 




64 




Bacteriology 


32 






Pathology 








tomy 
Autopsy technique 
Hygiene and preven- 
tive medicine 
y harmacology, Materia 
Medico. <6 Therapeutics 
Pharmacology 
Therapeutics 
Advanced prescription 
writing 
fedicine 
Physical diagnosis 
Medicine and clinical 
medicine 
Clinical microscopy 


40 

84 
32 

64 
35 


32 
10 

20 
6 

105 


68 
96 


Pharmacology 
Lectures 
Therapeutics 
Lectures and re- 
citations 
Medicine 
Lectures and re- 
citations 
Section work : "J 
hospital, ills- 1 
pensary, and f 
bedside J 
Clinics 
Diseases of chil- 
dren 


16 
96 
192 

64 




96 
96 


Surgical pathology 
Autopsies 
Therapeutics 
Lectures and recita- 
tions 
Therapeutic clinics 
Prescription dis- 
pensing 
Medicine 
Med. & clinical med. 
Pathological physi- 
cal diagnosis 
Children's diseases 
Nervous and mental 
diseases 


32 
128 

64 

32 
32 


i 

16 
64 


32 

64 
i 
32 

32 


Lectures, reci- 
tations, and 
laboratory 
Therapeutics 
Lectures and 
recitations 
Electro - thera- 
peutics 1 
Medicine 
Lectures and 
clinics 1 
Physical diag- 
nosis 
Clinical diag- 
nosis 


28 
56 

56 
28 


112 
56 

56 


112 


Medical dispensary 
forgery 
History taking 
Surgical diagnosis 
Fractures and disloca- 
tions 
Genito-urinary surgery 


12 

20 

18 
12 




24 


Surgery 
Lectures and re- 
citations 
Section work : ^ 
hospital, dis- 1 
pensary, and f 
bedside J 


192 




96 
96 


History taking 
Surgery 
Lectures and recita- 
tions 
Clinics 
Operative surgery & 
bandaging 


192 


i 
50 


128 


Surgery 
Lectures and 
clinics 1 
Obstetrics 
Lectures and 
recitations 1 


38 
112 




112 


Principles of surgery 
Clinical surgery 
Surgical pathology 


64 


60 


64 


Olinics 
Operative sur- 
gery 

Dhatfifri fa 




32 




Orthopaedic surgery 

Obstetrics and Oyne- 
cology 






32 










Surgery dispensary 
Eye, ear, nose, & throat 


32 




36 
24 


\jusiei 'iics 
Lectures and re- 
citations 


96 






Obstetrics 
Gynecology 


96 
32 




i 
32 










Obstetrics db Gynecology 








Manikin work 




8 




Specialties 
















Obstetrics 


64 






Lying-in hospital 






3 
wks. 


Ophthalmology 






32 










Gynecology 


32 




12 


Oynecology 








Laryngology 






16 


















Recitations and 








Otology 






16 


















demonstrations 


32 






Dermatology 






32 


1 On clou ichedule 
























Medical Jurispru- 
dence dk Toxicology ' 


32 






at " Eltctrieity." 
' Ciinict are the 
































tame for 3d and 
























1 Section work ; exact 








ith year clauet. 
























numberofhoun not given. 








3 Clatt tchedule 
























1 Part of thit teork it lab- 








slwtct only one reci- 
























oratory. 








tation per week. 









FOURTH YEAR 



WESTERN RESERVE UNIVERSITY 


NEW YORK UNIVERSITY 


MKDICO-CHIRUROICAL COLLEGE 


UNIVERSITY or ALABAMA 


Subject 


Hours 


Subject 


Hours 


Subject 


Hours 


Subject 


Hours 


^athology & Preventive Med. 


Did. 


Clin. 


Pathology 


Did. 


Clin. 


Pathology 


Did. 


Clin. 


Medicine 


Did. 


C/m. 


Hygiene 


24 




Conference 


32 




Autopsies 


i 




Medical clinics 1 




112 


Preventive medicine 


20 




Pathologic chemistry 


6 




Therapeutics 






Nervous and mental 






Medical jurisprudence 


20 




Autopsies 




8 


Applied therapeutics 




i 


diseases 


42 




fedicine 






Therapeutics 






Medicine 






Tropical medicine 


56 




Medicine and clinical med. 
Physical diagnosis 


96 


96 
50 


Conferences 
Hygiene 


32 
32 




Theory and practice 
Clinical medicine 


192 


96 


State medicine 
Dispensary, all sub- 

_j_ ] 


28 




Ward clinics 
Bedside work 




40 
32 


Special subjects 
Medicine 


30 




Medical dispensary 
Diseases of children 




i 
88 


jecis 
Dermatology 


28 


28 


Dispensary medicine 
Clinical microscopy 


i 


50 


Recitations & clinics 
Section work 


60 


96 
72 


Pediatrics dispensary 
Nervous and mental dis- 




i 


Surgery 
Lectures and recita 
lions 


TO 




Diseases of children 


32 


50 


Neurology 


32 


12 


eases 


16 


48 


Plini/*a * 


4 \f 




Diseases of nervous system 
Dermatology and syphilis 
Medical ethics, economics, 


32 
64 


23 
27 


Diseases of children 
Mental diseases 
Dermatology 


48 
16 
32 


20 
16 


Dermatology 
Dispensary dermatology 
Surgery 


16 


32 

a 


v^ 11I11C9 

Operative surgery 
Genito-urinary sur- 
gery 




112 
84 

OS 


and Roentgenology 


1 




Surgery 






Lectures and recitations 


192 




Hospital section 




v 


Surgery 






Recitations & clinics 


92 


96 


Clinics 






work 1 




70 


Surgical diagnosis 


12 




Section work 




72 


Genito-urinary surgery 


16 




Obstetrics and Oyn- 






Recitations 


20 




Genito-urinary sur- 






Orthopaedic surgery 






ecology 






Clinical surgery 




192 


gery 


32 


24 


Ophthalmology 






Obstetrics lectures 


56 




Dispensary surgery 




50 


Orthopaedic surgery 


32 


4 


Laryngology 






Gynecology lectures 


56 




Ward work, clinical mi-"| 
croscopy, and assign- - 
ment to cases J 
Ophthalmology 
Eye dispensary 
Ear, nose, and throat 
Obstetrics and Gynecology 
Obste tries 


32 
64 


64 

50 
50 

i 


Obstetrics and Gfyneco- 
logy 
Obstetrics 
Gynecology 
Specialties 
Ophthalmology 
Otology 


34 

32 

16 


52 

16 
16 


Otology 
Obstetrics and Oynecology 
Obstetrics 
Clinical obstetrics and' 
manikin work f 
Gynecology 
Gynecology ward clinics 


64 
64 


i 

32 

> 


Other Subjects 
Hygiene and medi- 
cal jurisprudence 
Ear & nose diseases 
Eye and throat dis- 
eases 
Ophthalmology 


28 
56 

84 


28 




i 




Laryngology 


16 


20 














Clinical gynecology 




64 








1 Whfn material it available. 






1 Clinics open to 3d ith 
year clattet. 






Dispensary gynecology 




50 








1 Section work; number of 






-' Ciinict only for iih year 






Number of hours varies. 












hours not given. 






clatt. 







CHAPTER VIII 
THE FINANCIAL ASPECTS OF MEDICAL EDUCATION 

AN examination of the financial aspects of the American medical school will com- 
pletely account for the conditions that have been described. 1 It is universally con- 
ceded that medical education cannot be conducted on proper lines at a profit, 
or even at cost; but it does not follow that it has therefore ceased to "pay." It is 
commonly represented that medical schools are benevolent enterprises, to which self- 
ish financial considerations are nowadays quite alien. Such is not even generally the 
case. Our best medical schools are indeed far from self-supporting ; they absorb the 
income of large endowments or burden seriously the general resources of their respec- 
tive universities. But these institutions constitute but a small fraction of the medi- 
cal schools of the country. The others pay in one or more of several ways, if " pay- 
ing" is understood to mean that the fees do more than meet the expense of running 
the school. This use of terms is entirely justifiable; for if fees alone are inadequate 
to meet the running expenses of an up-to-date medical school, then the difference 
between actual expenditure on instruction, with its essential incidentals, and the 
total fee income of the school is profit, whatever the use to which it is applied. In 
the worst cases this sum is great and goes into the pockets of the teachers ; in many 
others, it may not be large in any single year, though its total over a stretch of 
years may be quite sufficient to have altered materially the complexion of the in- 
stitution. In these schools an annual balance to the good is obtained for distribu- 
tion by slighting general equipment, by overworking laboratory teachers, by wholly 
omitting certain branches, by leaving certain departments relatively undeveloped, 
or by resisting any decided elevation of standards. In one or more of these ways, for 
example, not to go outside the Empire State, the Albany Medical School is enabled 
to pay some $500 a year apiece to otherwise well-to-do clinicians; the University of 
Buffalo to distribute "nominal sums" of $1000 to a number of professors in large 
regular practice ; the Long Island College Hospital to apportion a substantial sum 
out of the fee income in tithes among the faculty; and the University and Bellevue 
Hospital Medical College to pay out of fees salaries to some of the most successful 
practitioners in New York city, while the laboratory branches still lack anything 
like uniform development. More favorable, but still by no means beyond the reach 
of legitimate criticism, is the case of schools that, admitting the impossibility of 
providing satisfactory instruction at cost, nevertheless save from current use a not 
inconsiderable amount to be applied to paying for buildings or plant instead of 
dividends. Every such saving is necessarily at the expense of instruction ; that is 
to say, if every dollar taken in were consumed in current teaching, unfortunate make- 
shifts would still have to be employed. With every dollar less than total fee income 
1 See appendix for table showing income of medical schools. 



FINANCIAL ASPECTS 127 

used in providing teaching, the quality of instruction is still further impaired. As 
the country becomes able and willing to support at a loss the number of schools 
needed, the ethical justification of other schools that must pay a profit even though 
that profit go into buildings and equipment becomes decidedly dubious. 

Most of the existing medical school plants have been provided in this manner ; 
quite commonly those who have participated in the operation fail to reflect on its 
significance. For if a good medical education costs more than the student pays in 
fees, then, even though an adequate plant has been provided in advance, his instruc- 
tion must at some essential points be curtailed if additional income is not availa- 
ble. If, however, fees must provide either initial plant or plant extension, it is clear 
that proper teaching must be still further refused during the years when fees are 
employed to accumulate equipment. Historically that is the explanation of our 
extensive medical school plants in New York, Philadelphia, Baltimore, Louisville, 
Chicago: instruction far below what was at the moment scientifically feasible was 
given to the current student body, in order that their fees might be used to provide 
a better basis for a body of students that would come along in the future. Didactic 
lectures were given in 1890, to pay for a building in which laboratory instruction 
could be given in 1900. As conditions improved, one laboratory was put into opera- 
tion, while a fee surplus was accumulated to install a second. Before the day of 
medical school support by endowment or taxation, such procedure compared very 
favorably indeed with the more common practice of doing nothing for the student 
of to-day and as little as possible for the student of to-morrow. The point now to 
aim at is the development of the requisite number of properly supported institutions 
and the speedy demise of all others. 

In varying degrees, contented acceptance of these conditions goes along with the 
survival, however insidiously, of the notion that medical education, whatever else it 
may be, is something of a business, too. It is questionable whether this notion can ever 
be uprooted, so long as several competing schools in the same or in adjacent towns 
solicit patronage that can never again be sufficient in volume to satisfy them all. 
The essence of a business transaction consists in spending less in producing an article 
than is paid for it over the counter, how much less depending now on the proximity 
and competitive eagerness of other dealers, now on the wariness and number of the 
customers. It matters not that in this instance the article is education, the counter 
the registrar's latticed window, the profit going in extreme cases in large sums into 
a doctor's pocket, in the best cases in smaller sums into bricks and microscopes. If, 
in other words, medical education is a social function, it is not a proper object for 
either institutional or individual exploitation. Society ought to provide means for 
its support according to the best light obtainable ; and the law should make it im- 
possible for any person or institution to engage in it on any other than the best 
terms that society is in position to enforce. Great departures from this principle were 
at one time inevitable: the country was bound to have doctors; it had to take them 



128 MEDICAL EDUCATION 

as it could get them. They need never have been so badly trained as most of them 
were. But on that point it is useless to dwell. Important for us it is to ascertain 
whether in this year of grace, 1910, it is still necessary to put up with schools that 
are seriously defective; and if so, to what extent, and how much longer. 

What does it really cost to carry on a medical school that construes its duty in 
social terms? Initial investment may be put to one side. That, the college income 
cannot furnish; fees cannot provide buildings and equipment in the first place, or pay 
for them subsequently in instalments. The medical school must start with an ade- 
quate plant, laboratory and clinical, debt free. The value of these plants may vary 
within very wide limits; size, style, the ratio of teaching to research, all bear on the 
problem of initial cost. In a measure it is a question of taste, how much one will ex- 
pend on buildings and equipment. Essential, however, to every venture are class-rooms 
with the essential teaching paraphernalia, class laboratories in each of the sciences 
with individual equipment, private quarters with requisite appurtenances for each 
member of the teaching staff. These facilities cannot be dispensed with because the 
numbers to be handled are small. The several items may be scaled down, but they 
do not disappear. Fee income, confessedly inadequate to keep such a plant running, 
cannot be called on to provide it. The plant, therefore, is taken for granted before 
we even begin to consider what it costs to teach medicine. 

For the sake of simplicity we shall continue the demarcation between laboratory 
and clinical branches. At present the cost of maintaining the hospital is not usually 
a school encumbrance. Whether or not it ought to be must be decided as the case 
arises. Western Reserve is in position to avoid the expense; the University of Michi- 
gan must carry it. In general, the school obligation on this point has been shirked. 
The intolerable compromises described in the preceding chapter are employed in con- 
sequence. Nothing will perhaps go further towards destroying superfluous schools or 
preventing new ones than correct ideas as to necessary hospital conditions. It is quite 
impossible that most schools should either possess their own hospitals or effect a satis- 
factory relation with hospitals belonging to other people. At the moment, possession 
rather than diplomacy seems in most places to furnish the only satisfactory solution, 
and possession necessitates an immense increase of the school budget. Meanwhile, 
this point will not be obscured by provisional separation of the two budgets ; for this 
manner of presentation an additional reason is found in the fact that, to a varying 
extent, the hospital may be made to carry itself without derogating from its peda- 
gogical purpose. 

A schematic outline of the laboratory years calls for at least five departments, 
(1) anatomy, (2) physiology and pharmacology, (3) chemistry, (4) pathology, (5) bac- 
teriology and hygiene, subject, within limits, to rearrangement. The ultimate cost of 
the entire school will not be greatly affected by such redistribution. In their internal 
economy the departments will follow the same general lines. There will be a profes- 
sor, devoting himself wholly to teaching and research, and in position to do both; 



FINANCIAL ASPECTS 129 

assistants varying in number with the size of the classes and the extent to which the 
institution is minded to encourage original activity ; a departmental helper attached 
to each department ; preferably, too, a technician and a mechanic, who will, however, 
in the end more than save their cost. 

The budget of a department thus organized in a medical school of, say, 250 stu- 
dents, favorably situated, would assign $3000 to $5000 a year to its head, $2000 to 
$2500 to a first assistant, $1000 to $2000 to additional assistants, $750 to a helper, 
and $2500 to $5000 to maintenance, including books, new apparatus, material, ani- 
mals, etc. The total, ranging from $9250 to $15,250, still omits a proportionate 
share of the general overhead expense of administering the institution. A university 
department in one of the fundamental medical sciences, none too elaborately pro- 
vided, cannot, then, on the average be effectively maintained for less than $10,000 to 
$15,000 per annum. At the moment, of course, the departments are not all equally 
expensive. Anatomy and pathology cost more than pharmacology and bacteriology. 
But the average is not thus seriously disturbed ; for the former will extend above the 
line as much as the latter can be reduced below it. All of them, as they are devel- 
oped, tend to cost more. Where the sum named has not yet been reached, the ten- 
dency towards it is unmistakable. It is, of course, true that fairly good instruction is 
at times furnished more cheaply. In the small two-year schools situated in small 
towns, the professors receive less, sometimes much less, than the sums stated; and the 
expense of maintenance does not at times exceed a few hundred dollars per annum. 
But these departments cannot continue on this makeshift basis: they are now manned 
by young men, who, finding themselves doomed to routine and sterility, begin fight- 
ing at once to get away. The teacher who is content under such circumstances will 
soon be out of date; and the instruction, however conscientious, will be decidedly 
limited in range. To live, these departments must be much more liberally supported; 
and in the small two-year schools where this has been the case notably at Cornell 
and Wisconsin the departmental budgets correspond pretty closely to our present 
estimate. The organization of a department of, say, physiology on the minimum 
basis of efficiency, for 25 students or less, would require, after providing the initial 
plant, $3000 for the professor, $1000 for his assistant, $750 expense on the score of 
material for class use, $250 to keep some little research going, $300 for books and 
periodicals, $600 for a janitor, a total of $5900 for the routine teaching of a few 
students under undesirable limitations. As it is clear that there is no justification 
just now for the existence of medical schools that are incapable of greatly bettering 
the type, it follows that schools unable or indisposed to spend the requisite sums lack 
a valid reason for being. We may then assume that the five departments of a properly 
organized medical school, capable of handling 125 students, in its first two years can 
hardly be properly sustained on a total budget of less than from $50,000 to $75,000 
annually. If, now, the student pays $150 a year for tuition, there will be an annual 
deficit ranging from $31,250 to $56,250 a year. Not all the medical schools that are 



ISO MEDICAL EDUCATION 

alive to their responsibility are, as we shall see, at this moment able to provide on this 
scale for each of the fundamental departments; but they are in no doubt that these 
departments need such support; and they are straining every effort to procure it for 
them. 1 

On the clinical side, the problem is more complicated. We have seen that the re- 
lation of the medical school to its hospital must be of the same kind as its relation 
to its laboratories. But laboratories exist only for school purposes; the hospital dis- 

1 A comparison of the estimates above given with corresponding budgets in German universities is 
highly suggestive. Despite the fact that the cost of apparatus, supplies, etc., is much lower in Germany 
than here, the sums spent in various universities on laboratory maintenance are as follows : 
KONIGSBERG (170 medical students) BBESLAU (189 medical student*) 

Anatomy 16,349 marks Anatomy 26,618 marks 

Pathology 9,860 Pathology 14,932 

BERLIN (1107 medical students) GOTTINGEN (189 medical students) 

Anatomy 57,436 marks Anatomy 19,850 marks 

Physiology 89,766 Physiology 9,606 

(From Etat des Ministeriums der Unterrichts- und Medizinal Angelegenheiten, 1909, Beilage 6.) 

Still more significant is the ratio between expenditure for salaries and that for laboratory main- 
tenance, and the steady encroachment of the latter : out of every 100 marks spent in German uni- 
versities, there went in 

1868 45.95 marks to salaries 37.07 marks to laboratories 

1878 41.94 40.46 

1888 36.00 47.18 

1902 29.46 53.77 " 

1906 27.93 55.45 

(From Preussische Statistik, 204: Slatistik der preuuischen Landes Universitdten, 1908, p. 7.) 

Finally, the actual sums spent on salaries and laboratories respectively tell the same significant 
story: 
Total expenditure in Prussian universities in 

1868 1,786,108 marks for salaries 1,440,955 marks for laboratories 

1878 2,959,187 2,959,103 

1888 3,305,125 4,331,649 

1898 3,499,785 6,094,316 

1906 4,308,980 " 8,554,581 " 

(Ibid., p. 14.) 

That is, in 38 years, total salaries have increased 141 per cent, total laboratory expense, 490 per cent. 
In the same period, the total attendance of medical students in the same universities has risen 113 
per cent (from 2771 in winter semester, 1868, to 5903, winter semester, 1906). 

Paulsen (German Universities, translated by Thilly, p. 219, note) quotes from the Rector's Address 
of Adolph Wagner in 1896 : 

"Expenditures for salaries and institutes in the University of Berlin show the following growth : 
Year Salaries Institutes 

1811 116,550 marks (71.8 per cent) 39,294 marks (24.0 per cent) 

1834 193,650 (64.6 " " ) 78,434 (26.2 " ' ) 

1880 321,000 (52.8 " " ) 267,000 (40.1 ' ' ) 

1896-7 865,000 (30.9 " " ) 1,481,000 (52.9 " ' )" 

All the seminaries in the mental sciences (there are 18) cost 17,650 marks annually; the 15 natural- 
scientific institutes and collections cost 379,798 marks; the 10 medical-scientific institutes 190,054 
marks; the 10 clinical institutes, 617,691 marks. 

The publications of the Prussian government mentioned above are models, which we would do well 
to adopt. They enable us to follow in minute detail the educational developments of the last seventy- 
five years, with their social implications. The American student of similar problems deals with chaos. 
It is difficult to obtain definite and complete statements from any one institution ; and quite impos- 
sible to compare data from several institutions without exhaustive inquiry by way of ascertaining 
whether they cover the same ground. The German statistics prove clearly, however, the point at 
issue, i.e., the rapidly increasing cost of properly organized medical education. 



FINANCIAL ASPECTS 131 

charging simultaneously a philanthropic office may, as we have seen, be provided for 
independently of school funds and yet be as intimately a part of the educational or- 
ganization as if teaching were its main purpose. The school will invariably have to 
equip and maintain its laboratories; the hospital may be separately financed without 
burden to the medical school. Further, the initial cost of the hospital establishment 
may vary within large limits : a plain, but serviceable structure, capable of accommo- 
dating 200 patients, with proper teaching facilities, may be erected for a few hundred 
thousand dollars; or it may cost millions. The cost of maintenance also fluctuates 
considerably according to situation and scale of support. In the city of New York, it 
is roughly estimated that it takes $1000 to maintain one bed for one year; a 200 bed 
hospital may thus readily involve an annual expenditure of $150,000 and upwards. 
This sum may be reduced by profits derived from pay patients, or by small contribu- 
tions from charity patients. The extent to which the provision of proper clinical 
opportunities falls upon the medical school varies, then, from place to place. It is 
therefore not included in the schematic school budget we are preparing; but it is 
important to emphasize clearly that where independent endowment or state support 
does not furnish the medical school with a hospital in which it is thoroughly at home, 
the burden falls at once upon the school. The substitutes, makeshifts, and compromises 
now so widely employed in the United States do not relieve the medical schools of 
their responsibility. 

From the standpoint of the medical school, it is perhaps immaterial how its hos- 
pital is supported. But it would be unfair not to point out briefly in passing 
that certain larger considerations give great importance to the source of hospital sup- 
port. The hospital in the United States is not necessarily privately managed because 
privately supported, or publicly managed because publicly supported : it may be pri- 
vately managed, even though in large measure publicly supported. The teaching hos- 
pitals connected with the Philadelphia schools and with the proprietary schools of 
Baltimore are of this description. In respect to management they are private con- 
cerns; but they have received large lump subsidies from the state for both buildings 
and support. It is not the sole objection to this policy that it strengthens proprie- 
tary medical schools, though that is surely a legitimate criticism. More serious is the 
general demoralization that log-rolling always entails. Schools and hospitals, com- 
peting in all other matters, join hands in assaulting the state treasury; for coopera- 
tive action increases the total largess to be divided. The state or city can indeed 
legitimately aid medical education by completely handing over to high-grade medi- 
cal schools the ward service in hospitals financially managed by the proper state or 
municipal authorities. The public interest would be promoted, not injured, if, for 
example, Cornell, Columbia, and New York University were each left in unfettered 
possession of its division at Bellevue (New York) ; there is no possible source of de- 
moralization there. The Pennsylvania plan, however, tends to transfer the making of 
appropriations and the accounting for the same from the hands of state officials to 



132 MEDICAL EDUCATION 

private parties whose common interest it is to increase appropriations and to reduce 
oversight. 1 The size of the appropriation is determined to greater or less degree by 
the violence of the onset There is no fixed relation between the charity work done 
and the amount asked or secured.* In pursuance of that policy the state of Pennsyl- 
vania last year granted out of the public treasury to private and semi-private hos- 
pitals $4,404,500. 

However the hospital and dispensary are supported, the teaching budget of the 
clinical years is necessarily a charge upon the funds of the medical school. The pro- 
fessor of medicine in the medical school will be physician-in-chief to the hospital; 
surgeon, obstetrician, pediatrist, will likewise occupy the same dual relation. The 
university hospital will be their laboratory ; their salaries will protect them against 
the distractions of successful practice, be that practice general or consultant, for 
a thriving consultation business may prove just as fatal to scientific productivity as 
any other form of immersion in routine. The clinical departments must embody the 
same ideals as pathology or physiology in respect to teaching and research; they 
require, then, the same organization and support. The laboratory service must be ex- 
tended for them. For the investigator in internal medicine needs not only a clinic, 
but a laboratory, in whose activities the bedside problem and the fundamental 
sciences are brought together. The professors of pathology, physiology, physiologi- 
cal chemistry, work on broad lines. The clinician applies what he obtains from them 
to problems that are narrower in compass. Neither the clinical laboratories, where 
routine examinations are carried on, nor the fundamental scientific laboratories, 
serve precisely the needs of the investigating clinician, though the latter are in the 
most intimate cooperation with him. 

What may be called the theory of virtual endowment deserves a word at this 
point. Let us suppose that ten practitioners give their professorial services gratis. 
Undoubtedly their ethical position is better than that of practitioner teachers who 
draw dividends. They contend, however, that their services constitute an endowment. 
Paid teachers would get, say, $3000 each. The $30,000 saved represents five per cent 
on $600,000. It is argued that the school is just where it would be if it had an en- 
dowment of something more than a half-million. Sanguine calculators of this type 
occasionally run the virtual endowments up to two or three millions. But virtual 
endowment is a poor substitute for good bonds. The volunteer teacher may begin 
well ; but as between teaching and practice, the former must always get the worst of 
it. Slipshod dispensaries, imperfect hospital records, general clinical barrenness, tell 
the tale. 

1 Experts are of one mind as to the viciousness of this policy. See, for example. Report on Subtidiet, 
National Conference of Charities and Corrections, hem at Washington, D.C., May 9-15, 1901. 

The amounts secured vary from 12 cents to $2 a day for free patients, according to the efficacy of 
the hospital "pull." In New York city " pull " is eliminated : the hospital is paid a fixed sum for ser- 
vice rendered. Nevertheless, even this method of procedure may have unfortunate educational con- 
sequences, for it enabled the Brooklyn Post-Graduate Medical School to start. 



FINANCIAL ASPECTS 133 

The modern medical establishment that spends $50,000 or $75,000 upon its fun- 
damental laboratories will, if it is to be equally productive in clinical medicine, 
spend an equal sum on teaching and investigation during the latter two years, 
quite apart from the current maintenance of hospital and dispensary. That is to 
say, $100,000 to $150,000 will be required at the start to pay the minimum cost of 
a four-year school of medicine accommodating 250 students and consistently organ- 
ized along sound lines on both laboratory and clinical sides. The outlay will increase, 
not decrease, as the school grows, not in number, but in scope and power. The pro- 
posed budget may look formidable just now, when compared with the scant provision 
that has been generally made for medical education in this country under men many 
of whom have had no real appreciation of what good medical training is, or costs; 
but as public sentiment and educational intelligence develop, the suggested scale will 
appear not only modest, but insufficient. 

The fees received from such a student body would amount to some $40,000; so 
that it may be fairly estimated that in such an institution fees will at the utmost 
pay little more than one-third of the expense, provided that proper hospital and 
dispensary facilities are already supported by endowment or otherwise. A com- 
forting notion is prevalent that "in time" this proportion will rise, and that losses 
in attendance due to elevation of standards will eventually be " made up." There is 
no warrant for this belief. Institutions which have always, or long, operated on a 
high standard, and thus command an established public, find that expense tends to 
increase more rapidly than fee income. They persistently seek additional funds that 
may enable them to push ahead. The number of high standard schools supported 
will tend to be in some definite relation to the public need; there will be no such 
disproportion between number and need on a high, as there has been on the low, 
basis. In other words, the total enrolment will shrink; it will tend to concentrate 
in fewer schools. Under these circumstances schools which have long enjoyed a com- 
paratively low-grade patronage must cut loose from their past, and begin to culti- 
vate a new clientele. They will probably make slow headway in recovering from the 
initial shock. Most of them must expire or "merge" before their independent salva- 
tion can possibly be worked out. Our conclusion is that established schools, secure of 
their public on a sound basis, may count on fees to the extent of one-third to one- 
half of the expenditure required to conduct a good school of modern medicine; and 
that as the department becomes more homogeneously developed, the fees will tend 
to do even less. 

It is interesting to compare this hypothetical budget as a whole, and by separate 
departments, with the actual outlay of our best schools. The Johns Hopkins most 
nearly represents desirable conditions; for there a teaching hospital belonging to 
the medical school is supported by adequate and separate endowment, so that clinical 
facilities impose no burden on the funds of the medical school proper. Moreover, 
there from the first clinical teachers have been salaried and, in a measure, withdrawn 



184 MEDICAL EDUCATION 

from general practice. The actual cost of conducting the Johns Hopkins Medical 
School, with 297 students, is something over $100,000 a year, not including, how- 
ever, the salaries of clinical professors, which are in this case paid out of the hospital 
funds. Including these, the total outlay would considerably exceed our estimate. 
Tuition fees are about one-half of this amount. The Harvard budget runs higher, 
$251,389, much more than double the income in fees from its 285 students; Michigan, 
with 389 students, spends $83,000 on its department of medicine and surgery, and 
$70,000 more on the university hospital; Columbia, with 312 students, requires 
$239,072 for the College of Physicians and Surgeons, including the Sloane Maternity 
Hospital and the Vanderbilt Clinic; Cornell (207 students) expends $209,888 at 
New York and $32,840 more at Ithaca, and gets back $24,410 in fees. The Toronto 
(592 students) medical budget is about $85,000, as against $64,500 received in fees; 
McGill (328 students), $77,000, as against $43,750 received in fees; the University 
of Minnesota, $71,336, as against $16,546 received in fees. More modest establish- 
ments, working towards the same ideals, make a similar exhibit: eighteen years ago 
the total budget of the Yale Medical School was $10,000^ it is now $43,311, three 
times the amount received in tuition fees and confessedly inadequate to the aspira- 
tions and capacity of the medical faculty. Cornell spends at Ithaca, on a two-year 
course, $32,840, not including the cost of heating, lighting, administration, etc. 

Few of these institutions have developed all departments equally. Even the labo- 
ratory branches are not as yet all of the same type. Relatively few even of the best 
schools are able to cultivate pharmacology to any considerable extent ; the same is 
true of preventive medicine. On the clinical side, makeshifts of which we cannot be 
too impatient are all but universal. In general, even where intelligent ideals prevail, 
resources do not suffice for an all-round organization. Wherever a department has 
been acceptably cared for, the expenditure is apt to exceed our schematic estimate : a 
Johns Hopkins now spends $16,750 a year on anatomy, $14,171 on pathology (not 
counting $4791 spent on the clinical laboratory), $13,246 on physiology and phy- 
siological chemistry. Columbia spends $29,259 on anatomy, $18,400 on pathology, 8 
$17,838 on physiology. Cornell (New York) spends $37,000 on pathology,* histology, 
and bacteriology, $15,895 on anatomy, $14,940 on physiology. These appropriations 
are not extravagant. On the contrary, they are closely approached sometimes ex- 
ceeded wherever modern methods are effectively employed: at Ithaca, Cornell (18 
students) spends $9500 on anatomy and $13,500 on physiology and pharmacology; 
New York University (408 students) spends $15,000 on pathology; Washington 

1 Graham Lusk: "Medical Education," Journal Amor. Med. Ann., vol. Hi. p. 1230. 

1 The budgets that follow are not exactly comparable, for the lines are not always drawn in exactly 
the same way. Nevertheless they represent nearly enough the same thing to illustrate the point under 
discussion. Unfortunately college accounting does not as yet enable us to say how much goes into 
ordinary undergraduate teaching, how much into research, etc. 

* Including clinical pathology, $26,800. 
4 Excluding clinical pathology. 



FINANCIAL ASPECTS 135 

University, St. Louis (178 students), spends $9640 for anatomy, $8550 for physio- 
logy and pharmacology; the University of Wisconsin (49 students) spends SI 0,000 
for anatomy and $8100 for physiology. Anatomy costs the University of Michigan 
$14,300 a year, and the University of Iowa $13,525. Champions of cheapness allege 
that large sums are needed only for research, where medicine is taught to college 
graduates who afterwards practise in large cities ; but Michigan and Iowa spend these 
sums in behalf of high school boys who after graduation from the medical school re- 
turn to the simple surroundings amidst which they grew up. New York University 
operates also with high school boys, and is mainly a teaching school. Where clinical 
medicine is on the proper basis, the same result emerges: at Tulane, for example 
(439 students), the department, recently reorganized on modern lines, requires $9100 
for its support. The University of Michigan uses $7830 in medicine, $9405 in 
surgery. Every one of the important subjects must of course very soon be pro- 
vided on an adequate scale; for in every acceptable medical school, though large 
individual variations must occur, the movement to treat the main clinical divisions 
similarly will not stop. A simple process of multiplication will then give the mini- 
mum cost of maintaining a medical establishment in which all the essential sub- 
jects are adequately, even though not homogeneously, developed. Endowment 
or taxation alone can meet this burden, and endowment and taxation are feasi- 
ble only if medical education is carried on not only in, but by the university. For 
of course a medical school supported by fees is just as fettered inside, as it would 
be outside, the university. Its ideals may be higher ; its fee income may be more in- 
dependently expended. But in no case are the fees adequate to support all the es- 
sential departments on a substantial basis. As a rule, these schools "feature" one or 
two branches ; the others pine. The best developed departments show what all ought 
to be: pathology at New York University, anatomy at Jefferson Medical College, 
are really strong departments; they belong to institutions dependent on fees; but to 
provide them, other departments must be denied anything like equal opportunity to 
expand. 

Of course it is not to be supposed that the most expensive teaching is the best; 
that a department that costs $20,000 is necessarily twice as good as one that spends 
$10,000; it may be both scientifically and pedagogically inferior. It remains true, 
however, that in general the equipment and conduct of laboratories are costly ; that 
professorial salaries are rising; that a productive teacher needs competent assistants, 
expensive apparatus, material, etc., and a certain margin, in case an unforeseen turn 
necessitate an unusual outlay. The scientist financially hampered so as to be in- 
capable of following out surprises may miss the most valuable result of his tedious 
labors. 

Important is it to observe that the expense does not diminish pan passu with the 
attendance. The formation of two-year schools has recently proceeded apace, many 
of them feebly equipped and poorly sustained; their initial plant costs little; their 



1S6 MEDICAL EDUCATION 

total budgets are but a few thousand dollars. 1 A few dollars are expended for books; 
animals are provided in a gingerly manner; pathological material is small in amount, 
and comes as a gratuity from distant schools whose needs have been previously sup- 
plied; apparatus barely suffices for routine work; no helpers relieve the single de- 
partmental teacher of menial drudgery. These schools are of course scientifically 
sterile; as such, they must rapidly become antiquated, for they are situated in out- 
of-the-way places and their staff has but little intercourse with active centers. It 
seems hardly justifiable to start such ventures merely to meet institutional com- 
petition. The two-year school can doubtless make good where, as in Wisconsin, 
liberal support overcomes at many points the defects due to isolation; the heavy 
charges incurred, however, ought to be seriously pondered by those whose less ample 
means forbid anything like so adequate an appropriation. 

It is now clear that medicine cannot be, and is not, properly taught on the basis 
of receipts. We have at this date 30-odd schools, all university departments, whose 
annual budgets call, for sums considerably in advance of their receipts from fees. As 
these institutions will in number and facilities undoubtedly soon be equal to the 
task of producing physicians enough to supply the need, the coil is tightening 
around schools not yet in position to devote even all their fees to instruction. Well 
known institutions can still be cited, whose instruction as offered costs the school 
less than the fees paid in, a balance being available for buildings, improvements, 
or for debt originally incurred for plant. Large receipts mean in most instances* 
low standards, standards below the four-year high school basis. In order to secure 
a balance, economies must be effected, as has been already pointed out, at the expense 
of teaching, by inadequate equipment, uneven development, lack of full-time profes- 
sors, reliance upon necessarily incompetent student assistants, absence of helpers, 
employment of volunteers in the dispensary, etc. Tufts College Medical School, with 
an income of 859,093, is paying off in annual instalments a debt incurred for the 
building it now occupies; Jefferson Medical College, with receipts of SI 02,995, must 
incidentally accumulate a fund to retire a large mortgage. The medical department 
of Northwestern University must apply its surplus to the discharge of debts incurred 
for buildings and plant. Vanderbilt University, having invested $83,000 in a medi- 
cal department, compels the department out of its fees (about $25,000 a year) to 
pay all its own running expenses, something on the original purchase price, and six 
per cent interest on the unpaid balance. The University of Maryland, the College of 
Physicians and Surgeons of Baltimore, the Starling-Ohio (Columbus), pursue substan- 
tially the same policy. 

1 The minimum outlay, ordinary working efficiency being considered, for a department of physiology 
is given on page 199. It is questionable whether just now an institution is justified in undertaking the 
work if it is unable to do more than this minimum. Only a decided probability of increased resources 
in the future warrants the step. 

2 Rush (Chicago) is the only exception. No other high standard school contains over 300 students ; 
most of them have a comparatively small enrolment 



FINANCIAL ASPECTS 137 

Of our 155 medical schools, 120-odd depend on fees alone. Of these, there are better 
and worse : the former using the fees as far as they go to provide either several labo- 
ratory branches decently, or two or three well; the latter devoting but a part, often 
a small part, of the fee income to pedagogical use, distributing the rest among the 
teachers, who are in such cases always practising physicians. 

The ethics of the case are clear. Let us grant that in the hope of ultimately get- 
ting to a sounder basis, it may have been justifiable for the more prosperous fee- 
supported schools, whose total income is large enough to do something, to fight for 
survival. Surely they were, and are, morally bound meanwhile to furnish the best 
medical teaching procurable with such income as they enjoy. Their practitioner 
teachers were all the time profiting indirectly by their school connection; and this 
would suffice, if their motives were really as altruistic as is commonly alleged. 
Meanwhile, laboratories can be kept decent and laboratory teaching can as a rule be 
thorough only if full-time instructors are employed. These teachers have no income 
but their salaries. The medical school must therefore devote its fees primarily to 
paying them and to giving them the necessary facilities. Though the fee-supported 
school do this unreservedly, it will none the less omit part of its duty, because fees can- 
not support a complete set of laboratories efficiently organized. The school is therefore 
not justified in cutting out one or more of its possible laboratories in order to pay its 
clinical teachers. It must not only use its fees to pay for the right kind of laboratory 
instruction, but it must organize as many such laboratories as fees will support before 
paying anything to the clinical teachers, who profit indirectly nevertheless. A school 
may not be justified in existing even on this basis; that is, if the demand for doctors 
can be met by institutions that can do better for their students, there is no need to 
put up with even so altruistic a compromise. Surely an institution that is not will- 
ing to do so much as this has absolutely no defense unless a section is so hard run 
for doctors that it must take them on any terms upon which they can be procured. 
Such is not the case at this writing in any part of the United States or Canada. The 
younger men utilized in the dispensary ought probably to be treated on the same basis. 
For the dispensary is usually turned over to young men still struggling for a liveli- 
hood. A small annual stipend would go far to get from them the best service they 
are capable of rendering. To these two purposes the fee-supported school is in 
conscience bound to apply its income. As far as fees reach, orderly, even though 
modest, scientific departments and a well conducted dispensary service should be pro- 
vided and paid for. 

A few schools have squarely met their responsibility in this matter, and with re- 
sults that prove them deserving of additional support. The medical department of 
Syracuse University has a total fee income of $28,861, which is spent on the sci- 
entific branches ; the plant is not elaborate, but it is effective, attractive, and con- 
scientiously managed. Within less than a year, the medical department of the 
University of Pittsburgh has come under complete university control. Prior to that 



138 MEDICAL EDUCATION 

time it was a highly prosperous concern to its managers; nowhere in the country 
were worse conditions found. Now, as then, the school has only its fees for support; 
but they have this year gone into laboratories instead of into professorial pockets: 
with a result that is hardly less than a transformation. Full-time professors of pa- 
thology, physiology, and other branches have brought order out of chaos. The entire 
atmosphere of the institution has been clarified : students may be found actually 
studying, in the room in which under other conditions last year "four dozen wooden 
chairs were broken up "in boisterous horse-play. The medical department of Boston 
University, with a total income of $12,762, makes a decent and attractive showing 
in a simple way in its laboratories of bacteriology, pathology, physiology, etc. 
Highly creditable is the record of Meharry Medical College, the colored school at 
Nashville ; for there the teachers, though practising physicians, are poor men : of the 
total income of $23,946, the salary list gets only $9665. A violent contrast is af- 
forded by Shaw University (Raleigh, N. C.), another school for colored men, whose 
teachers are, however, white physicians: its income from fees is $2846; a few contri- 
butions increase the total income (not counting the board of students) to $4721 ; 
the teachers just referred to draw out $4737. In consequence the school has practi- 
cally no outfit. 

In the majority of the larger schools dependent on fees, an opposite policy is pur- 
sued. The laboratories are slighted or starved; the dispensary is neglected in order 
that dividends or salaries, running sometimes as high as $1000, may be paid to pre- 
cisely those faculty members who need it least. The Albany Medical School nomi- 
nally affiliated with Union College has a fee income of $20,276. Associated with 
it is the Bender Laboratory, where practically all its laboratory teaching except 
chemistry and anatomy is carried on. The school appropriates niggardly sums to 
provide for the teaching of pathology and bacteriology by the overworked and under- 
helped chief of the Bender Laboratory ; the laboratory has struggled hard, and not 
unsuccessfully, to be productive at the same time; but it has accomplished, whether 
in teaching or in research, but a fraction of what it would have achieved, had not a 
large part of the college receipts been distributed in sums approximating $500 each 
to fifteen members of the school faculty. At Buffalo similar conditions exist. The 
dispensary is utterly neglected ; some laboratory subjects are unprovided, others are 
slighted, in order that a "nominal" salary of $1000 may be paid in real money to 
some of the leading practitioners in the town. This institution collects $4608 in 
laboratory fees and spends $1105 in carrying the laboratories on. Brooklyn fairly 
repeats Albany. There the Hoagland Laboratory relieves the Long Island College 
Hospital of certain subjects ; the rest are omitted, for the fees that might furnish 
them are distributed among well-to-do clinical teachers. Bowdoin, with a total avail- 
able income of $15,230, appropriates $200 for the maintenance of the bacteriologi- 
cal laboratory, $50 for the physiological laboratory, $200 for chemistry, and $200 
for books, as against $12,225 for salaries to men, not one of whom gives his whole 



FINANCIAL ASPECTS 139 

time to medical education. At Halifax, the fee income is some $5000 a year and the 
government makes an appropriation of $1200, a total of $6200. The faculty ap- 
portions this sum as follows : three-fourths of the fees are divided among the teach- 
ers; one-fourth of the fees plus the government subsidy must carry all other expense, 
heat, light, janitor service, laboratory maintenance : the disgraceful condition of the 
premises follows as a matter of course. The Hahnemann of Philadelphia, with esti- 
mated receipts of $18,500, distributes $11,000 among teaching practitioners and 
spends perhaps $1500 on equipment and $500 for laboratory material. Advertising 
and commencement exercises the latter only another form of advertising often 
cost these institutions more than their laboratories. One large eastern institution 
expends $4700 on publicity, as against $3500 on its laboratories; another a New 
York school, this $1500 on publicity, $1100 on laboratories; another, $2100 on ad- 
vertising, $1160 on laboratories; another this time in the south $1000 on adver- 
tising, $500 on laboratories, "including repairs." 1 

The conclusion, then, is irresistible that these schools, far from being the benevo- 
lent enterprises that they are alleged to be, still "pay, 1 " both directly and indirectly; 
nor can a genuine altruistic motive be made out for any medical school which does 
not consistently devote its entire income to providing decent facilities and adequate 
instruction in the laboratories, where the teachers, if competent, must rely wholly on 
their salaries. Clinical teachers ought undoubtedly be paid, but not out of fees 
at the expense of laboratories and laboratory men. Institutions that supplement their 
fee income out of special endowments or out of their general funds very properly go 
ahead to pay their clinical teachers; otherwise the practitioner teacher must be subor- 
dinated. That these schools have been persistently used for pecuniary advantage is 
clear when an inventory of their belongings is contrasted with the annual income 
that has in some cases been earned for many years. They have little or nothing to 
show in the way of equipment. The medical department of the University of Arkan- 
sas is thirty years old; its annual receipts are now $14,100; 2 except fora small recent 
investment, it is practically bare. The medical department of Georgetown Univer- 
sity (Washington, D.C.) has been in operation almost sixty years; its annual income 
is now estimated at $11,000. Its plant can represent only a small fraction of its re- 
ceipts during its lifetime. The Medical College of Georgia is seventy years old ; it has 
accumulated no plant worthy the name. The medical department of the University 
of Oregon, started in 1887, with a present fee income of $8000 and state aid of $1000 
a year, has only one small laboratory that represents any investment at all. The 
medical department of the University of Chattanooga twenty-one years old with 
an income now of $4290, of which the dean draws $1800, would not, if sold under 

1 Additional examples to prove that the schools are operated for the profit of their faculties may be 
given if necessary : University of Alabama, fee income $19,788, salaries $14,000; University of Ver- 
mont, fee income, $22,730, salaries and dividends, $17,489 (laboratories, supplies, etc., $1941, publicity. 

$1289). 

2 Estimated. 



140 MEDICAL EDUCATION 

the hammer, bring $500. The St. Louis College of Physicians and Surgeons, with an 
estimated income of SI 6,035, cannot afford the simplest equipment for its squalid 
dispensary and its hopeless laboratories. The osteopaths bid fair to repeat the worst 
offenses of the medical practitioners : their schools are fairly booming. The receipts 
of the Kirksville institution probably reach $89,600 a year. The instruction fur- 
nished is exceedingly cheap in quality. All in all, there are annually paid in the 
United States and Canada about $3,000,000 in medical student fees. An equal sum 
has been paid annually for years. It is obvious that only a small part of the total 
fee income of our medical schools has been devoted to upbuilding and equipping the 
schools, though just the reverse is pretended. Undoubtedly, the disfavor with which 
educational benefactors have regarded medical education is justified by the merce- 
nary record reflected in these figures. But it is highly important that henceforth 
distinctions be made. 

There are in the United States and Canada 56 l schools whose total annual avail- 
able resources are below $10,000 each, so small a sum that the endeavor to do any- 
thing substantial with it is of course absurdly futile; a fact which is usually made 
an excuse for doing nothing at all, not even washing the windows, sweeping the floor, 
or providing a disinfectant for the dissecting-room. There is not a shred of justifica- 
tion for their continuance: for even if there were need of several thousand doctors 
annually, the wretched contribution made by these poverty-stricken schools could 
well be spared. Among them may be mentioned the California Eclectic (Los Angeles), 
estimated income $1060; Pulte Medical College (Cincinnati), estimated income $1325 ; 
Toledo Medical College, with $3240 ; Willamette University, with $3580; and South- 
western Homeopathic College, with $1100. 

Responsibility for the conditions described does not rest on medical men alone; 
colleges and universities have not infrequently become accessory after the fact. We 
have repeatedly urged that the proper place for a medical school is within a univer- 
sity; but there is no saving grace in the mere name. Three services may be specified 
as comprised in the duty of a university which makes itself responsible for a me- 
dical school : the definition and enforcement of entrance standards, the upholding 
of scientific ideals, and responsibility for adequate support. Wehave mentioned univer- 
sities that fail in the first or the second or in both; and as a rule these are the in- 
stitutions that fail likewise in the third. Of the 155 medical schools of the continent, 
82 are university departments, actual or so-called. With few exceptions the connec- 
tion of these universities with medical education began at a time when no one took 
obligations in the matter seriously. Some of those that entered the field thus lightly 
have made amends. Others, awakening late to a sense of their obligations, are con- 
fronted by an apparently hopeless situation. Their total annual income would not 
alone suffice for a good medical school, and it must carry the burden of the entire 

1 There are thirteen more whose fee income is likewise below 10,000 apiece, but they are university 
departments whose budgets, greatly in excess of fees, are carried by the respective universities. 



FINANCIAL ASPECTS 141 

institution. Their medical departments will, unless discontinued, prove sources of 
weakness and reproach, until their income is augmented far beyond their immediate 
expectations. As a matter of fact, few university administrators yet grasp clearly the 
fundamental principles of modern medical education. Twenty-seven colleges and 
universities of the United States and Canada have nominal or affiliated medical de- 
partments which they do not control and which they do not help to support. The 
state universities of Arkansas, Georgia, Illinois, and Oregon are in this position. 
Among endowed institutions that lend their names to proprietary medical schools, 
for which they can hope to do nothing and which they cannot possibly control as 
long as they do nothing, are the University of Denver, Washburn College, Cotner 
University, Epworth, Baylor, Western, and Dalhousie Universities. Some of these 
institutions are very poor. Among those that are capable of leading respectable 
lives as colleges, but are little less than absurd as universities, may be mentioned 
Union University, in New York state, which is the appellation given to the super- 
ficial combination of Union College and the Albany Law and Medical Schools. The 
chancellor of the University of Denver, aMethodist institution, affiliated with the 
Denver and Gross Medical College, finds a strange reason for self-congratulation in 
the connection. "The University of Denver," he says in a recent report, "has always 
had a form of organization that is peculiar to itself. From the beginning the profes- 
sional schools have had autonomous life. The church has never expended one penny 
for equipment or for buildings or for maintenance of the professional schools. ... It 
has made a notable extension of its influence in very many ways through the profes- 
sional schools of the university without the expenditure of a penny for any purpose 
whatsoever." A highly diverting illustration of the seriousness with which these ties 
are regarded has been recently furnished at Los Angeles ; there a local school, affili- 
ated with the University of Southern California, saw a chance of improving its lot 
by contracting an alliance with the University of California. A divorce was speedily 
agreed on, and the University of California, protected by contract, however, against 
any expenditure for two years, promptly became sponsor for a second clinical school. 
The University of Southern California, however, enjoyed only a brief widowhood. Into 
the vacant place, the Los Angeles College of Physicians and Surgeons promptly 
stepped. The University of Southern California was thus again made whole by the 
addition of a medical department which, enjoying an estimated total fee income of 
$4075, will ask nothing for support and still less for supervision. 

The strength of the argument advanced in this chapter is not dependent on the 
absolute accuracy of the figures cited. Actual income may vary from our estimates 
a few thousand dollars up or down; we may have failed to consider this offset or 
that. It has been, as a matter of fact, utterly impossible to get figures that represent 
exactly the same items in all, or even in many, institutions. An improvement in 
institutional book-keeping would have to be effected in order to make accurate com- 
parison possible. None the less, the picture is on the whole fair and reliable. Medi- 



142 MEDICAL EDUCATION 

cine is expensive to teach. It can in no event be taught out of fees. Reputable insti- 
tutions with no other outlook should combine with better favored schools or stop 
outright. Legal enactment should terminate the career of the others. Abundant bene- 
faction should strengthen up to our need the relatively small number of schools re- 
quired to deal effectively with the subject. No greater error can be made than to sup- 
pose that endowment and university ideals are necessary only to medical schools 
with high entrance standards. Vanderbilt and Tulane, trying to make intelligent 
physicians out of high school boys in the south, need the same means and ideals as 
Harvard and Johns Hopkins, working with college material in another section. In- 
deed, the more defective the material or the more unfavorable the environment, the 
greater must be the resources and the higher must be the purposes of those who have 
undertaken to look after this vital social function. 



CHAPTER IX 

RECONSTRUCTION 

THE necessity of a reconstruction that will at once reduce the number and improve 
the output of medical schools may now be taken as demonstrated. A considerable 
sloughing off has already occurred. It would have gone further but for the action of 
colleges and universities which have by affiliation obstructed nature's own effort at 
readjustment. Affiliation is now in the air. Medical schools that have either ceased 
to prosper, or that have become sensitive to the imputation of proprietary status or 
commercial motive, seek to secure their future or to escape their past by contracting 
an academic alliance. The present chapter undertakes to work out a schematic re- 
construction which may suggest a feasible course for the future. It is not supposed 
that violent measures will at once be taken to reconstitute the situation on the basis 
here worked out. A solution so entirely suggested by impersonal considerations may 
indeed never be reached. But legislators and educators alike may be assisted by a 
theoretical solution to which, as specific problems arise, they may refer. 

This solution deals only with the present and the near future, a generation, at 
most. In the course of the next thirty years needs will develop of which we here take 
no account. As we cannot foretell them, we shall not endeavor to meet them. Certain 
it is that they will be most effectively handled if they crop up freely in an unen- 
cumbered field. It is therefore highly undesirable that superfluous schools now exist- 
ing should be perpetuated in order that a subsequent generation may find a means 
of producing its doctors provided in advance. The cost of prolonging life through 
this intervening period will be worse than wasted; and an adequate provision at 
that moment will be embarrassed by inheritance and tradition. Let the new founda- 
tions of that distant epoch enjoy the advantage of the Johns Hopkins, starting with- 
out handicap at the level of the best knowledge of its day. 

The principles upon which reconstruction would proceed have been established in 
the course of this report: (1) a medical school is properly a university department; 
it is most favorably located in a large city, where the problem of procuring clinical 
material, at once abundant and various, practically solves itself. Hence those univer- 
sities that have been located in cities can most advantageously develop medical 
schools. (2) Unfortunately, however, our universities have not always been so placed. 
They began in many instances as colleges or something less. Here a supposed solici- 
tude for youth suggested an out-of-the-way location ; elsewhere political bargaining 
brought about the same result. The state universities of the south and west, most 
likely to enjoy sufficient incomes, are often unfortunately located: witness the Univer- 
sity of Alabama at Tuscaloosa, of Georgia at Athens, of Mississippi at Oxford, of 
Missouri at Columbia, of Arkansas at Fayetteville, of Kansas at Lawrence, of South 
Dakota at Vermilion; and that experience has taught us nothing is proved by the 



144 MEDICAL EDUCATION 

recent location of the State University of Oklahoma at Norman. Some of these insti- 
tutions are freed from the necessity of undertaking to teach medicine by an endowed 
institution better situated; in other sections the only universities fitted by their large 
support and their assured scientific ideals to maintain schools of medicine are handi- 
capped by inferiority of location. We are not thereby justified in surrendering the 
university principle. Experience, our own or that of Germany, proves, as we have 
already pointed out, that the difficulty is not insuperable. At relatively greater ex- 
pense, it is still feasible to develop a medical school in such an environment : there is 
no magnet like reputation ; nothing travels faster than the fame of a great healer; dis- 
tance is an obstacle readily overcome by those who seek health. The poor as well as 
the rich find their way to shrines and healing springs. The faculty of medicine in 
these schools may even turn the defect of situation to good account; for, freed from 
distraction, the medical schools at Iowa City and Ann Arbor may the more readily 
cultivate clinical science. An alternative may indeed be tried in the shape of a remote 
department. The problem in that case is to make university control real, to impregnate 
the distant school with genuine university spirit. The difficulty of the task may well 
deter those whose resources are scanty or who are under no necessity of engaging 
in medical teaching. As we need many universities and but few medical schools, a 
long-distance connection is justified only where there is no local university qualified 
to assume responsibility. A third solution division may, if the position taken 
in previous chapters is sound, be disregarded in the final disposition. 1 

(3) We shall assign only one school to a single town. As a matter of fact, no 
American city now contains more than one well supported university, 2 and if we 
find it unnecessary or impolitic to duplicate local university plants, it is still less neces- 
sary to duplicate medical schools. The needless expense, the inevitable shrinkage of 
the student body, the difficulty of recruiting more than one faculty, the disturbance 
due to competition for hospital services, argue against local duplication. It is some- 
times contended that competition is stimulating: Tufts claims to have waked up 
Harvard; the second Little Rock school did undoubtedly move the first to spend 
several hundred dollars on desks and apparatus. But competition may also be de- 
moralizing; the necessity of finding students constitutes medical schools which ought 
to elevate standards the main obstacles to their elevation : witness the attitude of 
several institutions in Boston, New York, Philadelphia, Baltimore, and Chicago. 
Moreover, local competition is a stimulus far inferior to the general scientific compe- 
tition to which all well equipped, well conducted, and rightly inspired university 
departments throughout the civilized world are parties. The English have experi- 
mented with both forms, a single school in the large provincial towns, a dozen 
or more in London, and their experience inclines them to reduce as far as possible 

1 We shall omit the half-school because it may be considered to divide with the whole school the work 
of the first two years ; it does not greatly affect the clinical output, with which this chapter is mainly 
concerned. 

2 Chicago is almost an exception, as Northwestern University is situated at Evanston, a suburb. 



RECONSTRUCTION 145 

the number of the London schools. Amalgamation has already taken place in cer- 
tain American towns : the several schools of Cincinnati, of Indianapolis, and of Louis- 
ville have all recently "merged." This step is easy enough in towns where there is 
either no university or only one university. Where there are several, as in Chicago, 
Boston, and New York, the problem is more difficult. Approached in a broad spirit 
it may, however, prove not insoluble; cooperation may be arranged where several 
institutions all possess substantial resources; universities of limited means can retire 
without loss of prestige, on the contrary, the respect in which they are held must 
be heightened by any action dictated by conscientious refusal to continue a work 
that they are in no position to do well. 

(4) A reconstruction of medical education cannot ignore the patent fact that stu- 
dents tend to study medicine in their own states, certainly in their own sections. In 
general, therefore, arrangements ought to be made, as far as conditions heretofore 
mentioned permit, to provide the requisite facilities within each of the characteris- 
tic state groups. There is the added advantage that local conditions are thus heeded 
and that the general profession is at a variety of points penetrated by educative in- 
fluences. New Orleans, for example, would cultivate tropical medicine ; Pittsburgh, 
the occupational diseases common in its environment. In respect to output, we may 
once more fairly take existing conditions into account. We are not called on to 
provide schools enough to keep up the present ratio. As we should in any case 
hardly be embarrassed for almost a generation in the matter of supply, we shall do 
well to produce no doctors who do not represent an improvement upon the present 
average. 

The principles above stated have been entirely disregarded in America. Medical 
schools have been established regardless of need, regardless of the proximity of com- 
petent universities, regardless of favoring local conditions. An expression of surprise 
at finding an irrelevant and superfluous school usually elicits the reply that the 
town, being a "gateway " or a " center," must of course harbor a " medical college." 
It is not always easy to distinguish "gateway"" and "center:" a center appears to be 
a town possessing, or within easy reach of, say 50,000 persons; a gateway is a town 
with at least two railway stations. The same place may be both, in which event 
the argument is presumably irrefragable. Augusta, Georgia, Charlotte, North Caro- 
lina, and Topeka, Kansas, are "centers," and as such are logical abodes of medical in- 
struction. Little Rock, St. Joseph, Memphis, Toledo, Buffalo, are "gateways." The ar- 
gument, so dear to local pride, can best be refuted by being pursued to its logical 
conclusion. For there are still forty-eight towns in the United States with over 
50,000 population each, and no medical schools : we are threatened with forty-eight 
new schools at once, if the contention is correct. The truth is that the fundamental, 
though of course not sole, consideration is the university, provided its resources are 
adequate; and we have fortunately enough strong universities, properly distributed, 
to satisfy every present need without serious sacrifice of sound principle. The Ger- 



146 MEDICAL EDUCATION 

man Empire contains eighty-four cities whose population exceeds 50,000 each. Of its 
twenty-two medical schools, only eleven are to be found in them : that is, it possesses 
seventy-three gateways and centers without universities or medical schools. The re- 
maining eleven schools are located in towns of less than 50,000 inhabitants, a uni- 
versity town of 30,000 being a fitter abode for medical study than a non-university 
town of half a million, in the judgment of those who have best succeeded with it. 

That the existing system came about without reference to what the country 
needed or what was best for it may be easily demonstrated. Between 1904 and 1909 
the country gained certainly upwards of 5,000,000 in population; during the same 
period the number of medical students actually decreased from 28,142 to 22,145, i.e., 
over 20 per cent. The average annual production of doctors from 1900 to 1909 was 
5222; but last June the number dropped to 4442. Finally, the total number of 
medical colleges which reached its maximum 166 1 in 1904 has in the five years 
since decreased about 10 per cent. Our problem is to calculate how far tendencies 
already observable may be carried without harm. 

We have calculated that the south requires for the next generation 490 new doc- 
tors annually, the rest of the country, 1500. We must then provide machinery for the 
training of about 2000 graduates in medicine yearly. Reckoning fatalities of all kinds 
at ten per cent per annum, graduating classes of 2000 imply approximately junior 
classes of 2200, sophomore classes of 2440, freshman classes aggregating 2700, 
something over 9000 students of medicine. Thirty medical schools, with an average 
enrolment of 300 and average graduation classes of less than 70, will be easily equal 
to the task. As many of these could double both enrolment and output without 
danger, a provision planned to meet present needs is equally sufficient for our growth 
for years to come. It will be time to devise more schools when the productive limit 
of those now suggested shall come in sight. 

For the purpose here in mind, the country may be conceived as divided into sev- 
eral sections, within each of which, with due regard to what it now contains, medical 
schools enough to satisfy its needs must be provided. 8 Pending the fuller develop- 
ment of the states west of the Mississippi, the section east will have to relieve them 
of part of their responsibility. The provisional nature of our suggestions is thus 
obvious; for as the west increases in population, as its universities grow in number 
and strength, the balance will right itself: additional schools will be created in the 
west and south rather than in the north and east. It would of course be unfortunate 
to over-emphasize the importance of state lines. We shall do well to take advantage 
of every unmistakably favorable opportunity so long as we keep within the public 
need; and to encourage the freest possible circulation of students throughout the 
entire country. 

1 Not including osteopathic schools. 

a This chapter now recapitulates and summarizes the more detailed accounts contained in Part II, in 
which the schools of each state are described and the general state situation discussed. 



RECONSTRUCTION 147 

(1) New England represents a fairly homogeneous region, comprising six states, 
the population of which is increasingly urban. Its population increased, 1908-9, 
somewhat less than 75,000, requiring, on the basis of one doctor to every increase 
of 1500 in population, 50 new doctors. About 150 physicians died. Seventy-five 
men would replace one-half of these. In all, 125 new doctors would be needed. 
To produce this number two schools, one of moderate size and one smaller, readily 
suffice. Fortunately they can be developed without sacrificing any of our criteria. 
The medical schools of Harvard and Yale are university departments, situated in 
the midst of ample clinical material, with considerable financial backing now and 
every prospect of more. It is unwise to divide the Boston field; it is unnecessary to pro- 
long the life of the clinical departments of Dartmouth, Bowdoin, and Vermont. They 
are not likely soon to possess the financial resources needed to develop adequate cli- 
nics in their present location ; and the time has passed when even excellent didactic 
instruction can be regarded as compensating for defective opportunities in obstetrics, 
contagious diseases, and general medicine. The historic position of the schools in 
question counts little as against changed ideals. Dartmouth and Vermont can, how- 
ever, offer the work of the first two years with the clinical coloring made feasible 
by the proximity of a hospital, as is the case with the University of Missouri at Co- 
lumbia; with that they ought to be content for the time being. 

(2) The middle Atlantic states comprise for our purpose New York, New Jersey, 
Pennsylvania, Delaware, Maryland, and the District of Columbia. Their population 
grows at the rate of 300,000 annually, for whom 200 doctors can care; 230 more would 
fill one-half the vacancies arising through death : a total of 430 needed. Available 
universities are situated in New York city, Syracuse, Philadelphia, Pittsburgh, 
Baltimore. The situation is in every respect ideal; the universities located at New 
York, Philadelphia, and Baltimore are strong and prosperous; those of Syracuse 
and Pittsburgh, though less developed, give good promise. Without sacrifice of a 
single detail, these five university towns can not only support medical schools for 
the section, but also to no small extent relieve less favored spots. The schools of 
Albany, Buffalo, Brooklyn, Washington, 1 would, on this plan, disappear, certainly 
until academic institutions of proper caliber had been developed. Whether even in 
the event of their creation they should for some years endeavor to cultivate medicine 
is quite doubtful. Appreciation of what is involved in the undertaking might well 
give them pause. Meanwhile, within the university towns already named there would 
be much to do : better state laws are needed in order to exterminate the worst schools ; 
merger or liquidation must bring together many of those that still survive. The 
section under consideration ought indeed to lead the Union; but the independent 
schools of New York and Pennsylvania are powerful enough to prove a stubborn 
obstacle to any progressive movement, however clearly in the public interest. 

1 Except Howard University which, patronized by the government, is admirably located for the 
medical education of the negro. 



148 MEDICAL EDUCATION 

(3) Greater unevenness must be tolerated in the south; 1 proprietary schools or nom- 
inal university departments will doubtless survive longer there than in other parts of 
the country because of the financial weakness of both endowed and tax-supported in- 
stitutions. All the more important, therefore, for universities to deal with the subject 
in a large spirit, avoiding both overlapping and duplication. An institution may well 
be glad to be absolved from responsibilities that some other is better fitted to meet. 
Tulane and Vanderbilt, for example, are excellently situated in respect to medical 
education ; the former has already a considerable endowment applicable to medicine. 
The state universities of Louisiana and Tennessee may therefore resign medicine to 
these endowed institutions, grateful for the opportunity to cultivate other fields. 
Every added superfluous school weakens the whole by wasting money and scattering 
the eligible student body. None of the southern state universities, indeed, is wisely 
placed : Texas has no alternative but a remote department, such as it now supports 
at Galveston; Georgia will one day develop a university medical school at Atlanta; 
Alabama, at Birmingham, the university being close by, at Tuscaloosa. The Uni- 
versity of Virginia is repeating Ann Arbor at Charlottesville; whether it would do 
better to operate a remote department at Richmond or Norfolk, the future will deter- 
mine. Six schools are thus provided: 2 they are sufficient to the needs of the section 
just now. The resources available even for their support are as yet painfully inade- 
quate: three of the six are still dependent upon fees for both plant and maintenance. 
It is doubtful whether the other universities of the south should generally offer even 
the instruction of the first two years. The scale upon which these two-year depart- 
ments can be now organized by them is below the minimum of continuous efficiency; 
they can contribute nothing to science, and their quota of physicians can be better 
trained in one of the six schools suggested. Concentration in the interest of effective- 
ness, team work between all institutions working in the cause of southern development, 
economy as a means of improving the lot of the teacher these measures, advisable 
everywhere, are especially urgent in the south. 

(4) In the north central tier Ohio, Indiana, Michigan, Wisconsin, Illinois 
population increased 239,685 the last year: 160 doctors would care for the increase; 
190 more would replace one-half of those that died: a total of 350. Large cities with 
resident universities available for medical education are Cincinnati, Columbus, Cleve- 
land, and Chicago. Ann Arbor has demonstrated the ability successfully to combat 
the disadvantages of a small town. The University of Wisconsin can unquestionably 
do the same, with a slighter handicap, at Madison whenever it chooses to complete 
its work there. Indiana University has undertaken the problem of a distant connec- 
tion at Indianapolis. Four cities thus fulfil all our criteria, two more develop the 
small town type, one more is an experiment with the remote university department. 

l Tbe south includes eleven states, riz., Virginia, Kentucky, North Carolina, South Carolina, Florida, 
Georgia, Tennessee, Mississippi, Louisiana, Arkansas, Texas. 

*A seventh, Meharry, at Nashville, must be included for the medical education of the negro. 



RECONSTRUCTION 149 

Surely the territory in question can be supplied by these seven medical centers. Chi- 
cago alone is likely to draw a considerable number of students from a wider area. It 
has long been a populous medical center. Nevertheless the number of high-grade stu- 
dents it just now contains is not large. If the practice of medicine in this area rested 
on a two-year college basis, as it well might, there would to-day be perhaps 600 
students of medicine in that city. Cooperative effort between the two universities 
there and the state university at Urbana would readily provide for them. 

(5) The middle west comprises eight states, Minnesota, Iowa, Missouri, Okla- 
homa, Kansas, Nebraska, South Dakota, North Dakota, with a gain in popula- 
tion last year of 216,036, requiring 140 more physicians, plus 160 to replace half 
the deaths : a total of 300. To supply them, urban universities capable of conduct- 
ing medical departments of proper type are situated in Minneapolis and St. Louis; 
and both deserve strong, well supported schools. For Minneapolis must largely carry 
the weight of the Dakotas and Montana; St. Louis must assist Texas and have an 
eye to Arkansas, Oklahoma, and the southwest. The University of Nebraska, now 
dispersing its energies through a divided school, can be added to this list; for it 
will quite certainly either concentrate the department on its own site (Lincoln, pop- 
ulation 48,232), or bring the two pieces together at Omaha, only an hours distance 
away. The University of Kansas will doubtless combine its divided department at 
Kansas City. The State University of Iowa emulates Ann Arbor at Iowa City. 
These five schools must produce 297 doctors annually. Their capacity would go 
much farther. Oklahoma 1 and the Dakotas might well for a time postpone the entire 
question, supporting the work of the first two years, which they have already under- 
taken, on a much more liberal basis than they have yet reached. With the exception of 
St. Louis, all these proposed schools belong to state universities, and even at St. 
Louis the cooperation of the state university may prove feasible. A close relation 
may thus be secured between agencies concerned with public health and those devoted 
to medical education. The public health laboratory may become virtually part of the 
medical school, a highly stimulating relation for both parties. The school will 
profit by contact with concrete problems ; the public health laboratory will inevitably 
push beyond routine, prosecuting in a scientific spirit the practical tasks referred to 
it from all portions of the state. The direct connection of the state with a medical 
school that it wholly or even partly maintains will also solve the vexed question of 
standards : for the educational standard which the state fixes for its own sons will be 
made the practice standard as well. Private corporations, whether within or without its 
borders, will no longer be permitted to deluge the community with an inferior product. 

(6) Seven thinly settled and on the whole slowly growing states and territories 
form the farther west: New Mexico, Colorado, Wyoming, Montana, Idaho, Utah, 
Arizona. Their increase in population was last year about 45,000. They contain now 

1 Should it be possible for the State University of Oklahoma, by engaging in clinical work at Okla- 
homa City, to get and to retain a monopoly of the field, the step would doubtless be advisable even now. 



150 MEDICAL EDUCATION 

one doctor for every 563 persons. In view of local conditions, let us reckon one addi- 
tional doctor for every additional 750 persons : 60 will be required. And, further, 
let us make up the death-roll man for man: 60 more would be needed altogether 
120. There are at the moment in this region only two available sites, Salt Lake 
City and Denver. At the former the University of Utah is situated ; the latter could 
be occupied by the University of Colorado, located at Boulder, practically a suburb. 
The outlying portions of this vast territory will long continue to procure their doc- 
tors by immigration or by sending their sons to Minneapolis, Madison, Ann Arbor, 
Chicago, or St. Louis. 

(7) The three states on the Pacific coast, California, Oregon, Washington, are some- 
what self-contained. They increased last year by 53,454 persons, requiring 36 more 
physicians; 50 more would repair one-half the losses by death: a total of 86. Avail- 
able sites, filling the essential requirements, are Berkeley and Seattle. The former, 
with the adjoining towns of Alameda and Oakland, controls a population of 250,000 
or more; the medical department of the University of California concentrated there 
would enjoy ideal conditions. At present the clinical ends of two divided schools share 
San Francisco, and the outlook for medical education of high quality is rendered du- 
bious by the division. With unique wisdom the University of Washington and the 
physicians of Seattle 1 have thus far refrained from starting a medical school in 
that state. They have held, and rightly, that in the present highly overcrowded con- 
dition of the profession on the coast, there is no need for an additional ordinary 
school ; and the resources of the university are not yet adequate to a really creditable 
establishment. The field will therefore be kept clear until the university is in posi- 
tion to occupy it to advantage. 

(8) In Canada the existing ratio of physicians to population is 1 :1030. The esti- 
mated increase of population last year was 239,516, requiring 160 new physicians; 
losses by death are estimated at 90. As the country is thinly settled and doctors 
much less abundant than in the United States, let us suppose these replaced man for 
man : 250 more doctors would be annually required. The task of supplying them 
could be for the moment safely left to the Universities of Toronto and Manitoba, to 
McGill and to Laval at Quebec. Halifax, Western (London), and Laval at Montreal 
have no present function. At some future time doubtless Dalhousie University at 
Halifax will need to create a medical department. The future of Queen's depends on 
its ability to develop halfway between Toronto and Montreal, despite comparative 

1 Copy of Extract of Minute* 

Of the King County Medical Society (State of Washington), June 20, 1904. 

Committee. On motion a committee consisting of F. H. Coe, P. W. Willis, and R. W. Schoenle was 
appointed to draw up suitable resolutions regarding the establishment of any medical preparatory 
course in the University of Washington, condemning the same and directed to the regents of the 
institution. 

Committee. A committee, consisting of H. M. Read, L. R. Dawson, J. E. : Harris, N. D. Pontius, 
C. A. Smith, and I. A. Parry, was also appointed with directions to visit Dr. Kane personally and 
urge the importance of our position upon the same subject. 



RECONSTRUCTION 151 

inaccessibility, the Ann Arbor type of school. As for the rest, the great northwestern 
territory will, as it develops, create whatever additional facilities it may require. 

In so far as the United States is concerned, the foregoing sketch calls for 31 medi- 
cal schools 1 with a present annual output of about 2000 physicians, i. e., an average 
graduating class of about 70 each. They are capable of producing 3500. All are 
university departments, busy in advancing knowledge as well as in training doc- 
tors. Nineteen are situated in large cities with the universities of which they are 
organic parts; four are in small towns with their universities; eight are located in 
large towns always close by the parent institutions. Divided and far distant depart- 
ments are altogether avoided. 

Twenty states 8 are left without a complete school. Most of these are unlikely to 
be favorably circumstanced for the next half century, so far as we can now judge. 
Several may, however, find the undertaking feasible within a decade or two. The 
University of Arkansas might be moved from Fayetteville to Little Rock ; Oklahoma, 
if its rapid growth is maintained, may from Norman govern a medical school at 
Oklahoma City; Oregon may take full responsibility for Portland. Unfortunately, 
of the three additional schools thus created, only one, that at Little Rock, would 
represent conditions at their best. There is therefore no reason to hasten the others; 
for their problem may, if left open, be more advantageously solved. 

To bring about the proposed reconstruction, some 120 schools have been apparently 
wiped off the map. As a matter of fact, our procedure is far less radical than would 
thus appear. Of the 120 schools that disappear, 37 are already negligible, for they con- 
tain less than 50 students apiece; 13 more contain between 50 and 75 students each, 
and 16 more between 75 and 100. That is, of the 120 schools, 66 are so small that 
their student bodies can, in so far as they are worthy, be swept into strong institu- 
tions without seriously stretching their present enrolment. Of the 30 institutions 
that remain, several will survive through merger. For example, the Cleveland College 
of Physicians and Surgeons could be consolidated with Western Reserve; the amal- 
gamation of Jefferson Medical College and the University of Pennsylvania would make 
one fair-sized school on an enforced two-year college standard; Tufts and Harvard, 
Vanderbilt and the University of Tennessee, Creighton and the University of Ne- 
braska, would, if joined, form institutions of moderate size, capable of considerable 
expansion before reaching the limit of efficiency. 

In order that these mergers may be effective, not only institutional, but personal 
ambition must be sacrificed. It is an advantage when two schools come together; 
but the advantage is gravely qualified if the new faculty is the arithmetical sum of 
both former faculties. The mergers at Cincinnati, Indianapolis, Louisville, Nashville, 

1 The accompanying maps contrast the existing with the suggested number and distribution. Meharry 
and Howard are included. 

2 They are Maine, New Hampshire, Vermont, West Virginia, North Carolina, South Carolina, Florida, 
Mississippi, Kentucky, Arkansas, Oklahoma, North Dakota, South Dakota, Montana, Wyoming, 
Idaho, New Mexico, Arizona, Nevada, Oregon. One school will not long content the state of Texas. 



154 MEDICAL EDUCATION 

have been arranged in this way. The fundamental principles of faculty organization 
are thus sacrificed. Unless combination is to destroy organization, titles must be 
shaved when schools unite. There must be one professor of medicine, one professor 
of surgery , etc., to whom others are properly subordinated. What with superabundant 
professorial appointments, due now to desire to annex another hospital, and again 
to annexation of another school, faculties have become unmanageably large, viewed 
either as teaching, research, or administrative bodies. 

Reduction of our 155 medical schools to 31 would deprive of a medical school 
no section that is now capable of maintaining one. It would threaten no scarcity of 
physicians until the country's development actually required more than 3500 physi- 
cians annually, that is to say, for a generation or two, at least. Meanwhile, the out- 
line proposed involves no artificial standardization: it concedes a different standard 
to the south as long as local needs require; it concedes the small town university 
type where it is clearly of advantage to adhere to it; it varies the general ratio in 
thinly settled regions; and, finally, it provides a system capable without overstraining 
of producing twice as many doctors as we suppose the country now to need. In other 
words, we may be wholly mistaken in our figures without in the least impairing the 
feasibility of the kind of renovation that has been outlined ; and every institution 
arranged for can be expected to make some useful contribution to knowledge and 
progress. 

The right of the state to deal with the entire subject in its own interest can as- 
suredly not be gainsaid. The physician is a social instrument. If there were no disease, 
there would be no doctors. And as disease has consequences that immediately go 
beyond the individual specifically affected, society is bound to protect itself against 
unnecessary spread of loss or danger. It matters not that the making of doctors 
has been to some extent left to private institutions. The state already makes certain 
regulations; it can by the same right make others. Practically the medical school is a 
public service corporation. It is chartered by the state; it utilizes public hospitals on 
the ground of the social nature of its service. The medical school cannot then escape 
social criticism and regulation. It was left to itself while society knew no better. But 
civilization consists in the legal registration of gains won by science and experience; 
and science and experience have together established the terms upon which medicine 
can be most useful. "In the old days," says Metchnikoff, 1 "anyone was allowed to 
practise medicine, because there was no medical science and nothing was exact. Even 
at the present time among less civilized people, any old woman is allowed to be a 
midwife. Among more civilized races, differentiation has taken place and childbh-ths 
are attended by women of special training who are midwives by diploma. In case of 
nations still more civilized, the trained midwives are directed by obstetric physicians 
who have specialized in the conducting of labor. This high degree of differentiation 
has arisen with and has itself aided the progress of obstetrical science.' 1 Legislation 
l Tht Nature of Man (translated by Chalmers), p. 300. 



RECONSTRUCTION 155 

which should procure for all the advantage of such conditions as is now possible 
would speedily bring about a reconstruction quite as extensive as that described. 

Such control in the social interest inevitably encounters the objection that indi- 
vidualism is thereby impaired. So it is, at that level; so it is intended. The commu- 
nity through such regulation undertakes to abridge the freedom of particular indi- 
viduals to exploit certain conditions for their personal benefit. But its aim is thereby 
to secure for all others more freedom at a higher level. Society forbids a company of 
physicians to pour out upon the community a horde of ill trained physicians. Their 
liberty is indeed clipped. As a result, however, more competent doctors being trained 
under the auspices of the state itself, the public health is improved ; the physical 
well-being of the wage- worker is heightened; and a restriction put upon the liberty, 
so-called, of a dozen doctors increases the effectual liberty of all other citizens. Has 
democracy, then, really suffered a set-back? Reorganization along rational lines in- 
volves the strengthening, not the weakening, of democratic principle, because it tends 
to provide the conditions upon which well-being and effectual liberty depend. 



CHAPTER X 

THE MEDICAL SECTS 

Lv the reconstruction just sketched, no allusion has been made to medical sectarianism. 
We have considered the making of doctors and the increase of knowledge; allopathy, 
homeopathy, osteopathy, have cut no figure in the discussion. Is it essential that we 
should now conclude a treaty of peace, by which the reduced number of medical schools 
shall be so pro-rated as to recognize dissenters on an equitable basis? 

The proposition raises at once the question as to whether in this era of scientific 
medicine, sectarian medicine is logically defensible; as to whether, while it exists, 
separate standards, fixed by the conditions under which it can survive, are justifi- 
able. Prior to the placing of medicine on a scientific basis, sectarianism was, of 
course, inevitable. Every one started with some sort of preconceived notion; and 
from a logical point of view, one preconception is as good as another. Allopathy 
was just as sectarian as homeopathy. Indeed, homeopathy was the inevitable retort 
to allopathy. If one man "believes" in dissimilars, contrary suggestion is certain 
to provide another who will stake his life on similars; the champion of big doses 
will be confronted by the champion of little ones. But now that allopathy has sur- 
rendered to modern medicine, is not homeopathy borne on the same current into the 
same harbor? 

The modern point of view may be restated as follows: medicine is a discipline, in which 
the effort is made to use knowledge procured in various ways in order to effect cer- 
tain practical ends. With abstract general propositions it has nothing to do. It har- 
bors no preconceptions as to diseases or their cure. Instead of starting with a finished 
and supposedly adequate dogma or principle, it has progressively become less cock- 
sure and more modest. It distrusts general propositions, a priori explanations, gran- 
diose and comforting generalizations. It needs theories only as convenient sum- 
maries in which a number of ascertained facts may be used tentatively to define a 
course of action. It makes no effort to use its discoveries to substantiate a principle 
formulated before the facts were even suspected. For it has learned from the previ- 
ous history of human thought that men possessed of vague preconceived ideas are 
strongly disposed to force facts to fit, defend, or explain them. And this tendency both 
interferes with the free search for truth and limits the good which can be extracted 
from such truth as is in its despite attained. 

Modern medicine has therefore as little sympathy for allopathy as for homeopathy. 
It simply denies outright the relevancy or value of either doctrine. It wants not 
dogma, but facts. It countenances no presupposition that is not common to it with 
all the natural sciences, with all logical thinking. 

The sectarian, on the other hand, begins with his mind made up. He possesses in 
advance a general formula, which the particular instance is going to illustrate, verify, 



MEDICAL SECTS 157 

reaffirm, even though he may not know just how. One may be sure that facts so 
read will make good what is expected of them; that only that will be seen which 
will sustain its expected function ; that every aspect noted will be dutifully loyal to 
the revelation in whose favor the observer is predisposed: the human mind is so 
constituted. 

It is precisely the function of scientific method in social life, politics, engineering, 
medicine to get rid of such hindrances to clear thought and effective action. For 
it, comprehensive summaries are situate in the future, not in the past; we shall at- 
tain them, if at all, at the end of great travail; they are not lightly to be assumed 
prior to the beginning. Science believes slowly; in the absence of crucial demonstra- 
tion its mien is humble, its hold is light. "One should not teach dogmas; on the 
contrary, every utterance must be put to the proof. One should not train disciples 
but form observers : one must teach and work in the spirit of natural science." 1 

Scientific medicine therefore brushes aside all historic dogma. It gets down 
to details immediately. No man is asked in whose name he comes whether that 
of Hahnemann, Rush, or of some more recent prophet. But all are required to 
undergo rigorous cross-examination. Whatsoever makes good is accepted, becomes 
in so far part, and organic part, of the permanent structure. To plead in advance 
a principle couched in pseudo-scientific language or of extra-scientific character 
is to violate scientific quality. There is no need, just as there is no logical justifi- 
cation, for the invocation of names or creeds, for the segregation from the larger 
body of established truth of any particular set of truths or supposed truths as es- 
pecially precious. Such segregation may easily invest error with the sanctity of truth; 
it will certainly result in conferring disproportionate importance upon the fact or pro- 
cedure marked out as of pivotal significance. The tendency to build a system out of 
a few partially apprehended facts, deductive inference filling in the'rest, has not in- 
deed been limited to medicine, but it has nowhere else had more calamitous conse- 
quences. 

The logical position of medical sectarians to-day is self-contradictory. They have 
practically accepted the curriculum as it has been worked out on the scientific basis. 
They teach pathology, bacteriology, clinical microscopy. They are thereby com- 
mitted to the scientific method ; for they aim to train the student to ascertain and 
interpret facts in the accepted scientific manner. He may even learn his sciences in 
the same laboratory as the non-sectarian. But scientific method cannot be limited 
to the first half of medical education. The same method, the same attitude of mind, 
must consistently permeate the entire process. The sectarian therefore in effect con- 
tradicts himself when, having pursued or having agreed to pursue the normal scien- 
tific curriculum with his student for two years, he at the beginning of the third year 
produces a novel principle and requires that thenceforth the student effect a com- 
promise between science and revelation. 
1 Johannes Orth : Berliner Klinische Wochenschrift, vol. xliii. p. 818. 



158 MEDICAL EDUCATION 

Once granted the possibility of medical dogma, there can be no limit to the num- 
ber of dissenting sects. As a matter of fact, only three or four are entitled to serious 
notice in an educational discussion. The chiropractics, the mechano- therapists, and 
several others are not medical sectarians, though exceedingly desirous of masquerading 
as such ; they are unconscionable quacks, whose printed advertisements are tissues of 
exaggeration, pretense, and misrepresentation of the most unqualifiedly mercenary 
character. The public prosecutor and the grand jury are the proper agencies for 
dealing with them. 

Sectarians, in the logical sense above discussed, are (1) the homeopathists, (2) the 
eclectics, (3) the physiomedicals, (4) the osteopaths. All of them accept in theory, 
at least, the same fundamental basis. They admit that anatomy, pathology, bac- 
teriology, physiology, must form the foundation of a medical education, to use the 
words broadly so as to include all varieties of therapeutic procedure. They offer no 
alternative to pathology or physiology; there is, they concede, only one proper 
science of the structure of the human body, of the abnormal growths that afflict it. 
So far, they make no issue as against scientific medicine. Much is involved in agree- 
ment up to this point. The standards of admission to the medical school, the facili- 
ties which the schools must furnish in order effectively to teach the fundamental 
branches, are the same for all alike. A student of homeopathy or of osteopathy needs 
to be just as intelligent and mature as a student of scientific medicine; and he is no 
easier to teach; for during the first and second years, at least, he is supposed to be 
doing precisely the same things. 

At the beginning of the clinical years, the sectarian interposes his special princi- 
ple. But educationally, the conditions he needs thenceforth do not materially differ 
from those needed by consistently scientific medicine. Once more, whatever the ar- 
bitrary peculiarity of the treatment to be followed, the student cannot be trained to 
recognize clinical conditions, to distinguish between different clinical conditions, or 
to follow out a line of treatment, except in the ways previously described in deal- 
ing with scientific medicine. He must see patients and must follow their progress, so 
as to discover what results take place in consequence of the specific measures employed. 
A sectarian institution, being a school in which students are trained to do particular 
things, needs the same resources and facilities on the clinical side as a school of scien- 
tific medicine. 

Sectarian institutions do not exist in Canada ; in the United States there are 32 
of them, of which 15 are homeopathic, 8 eclectic, 1 physiomedical, and 8 osteopathic. 
Without attempting to indicate the peculiar tenets of each, we shall briefly review 
them as schools, seeking to ascertain how far they are in position effectively to teach, 
quite regardless of the individual doctrine each sect may desire to promote. 

None of the fifteen homeopathic schools 1 requires more than a high school educa- 

1 Hahnemann (San Francisco), Hahnemann and Hering (Chicago), state universities of Iowa and 
Michigan, Southwestern Homeopathic (Louisville), Boston University, Detroit Homeopathic, Kan- 



MEDICAL SECTS 159 

tion for entrance ; only five 1 require so much. The remaining eleven get less, how 
much less depending on their geographical locations rather than on the school^ own 
definition. The Louisville, Kansas City, and Baltimore schools cannot be said to have 
admission standards in any strict sense at all ; Pulte at Cincinnati is bound to be care- 
ful in dealing with Ohio candidates: outsiders are responsible for themselves. The 
minimum at Boston University, to judge from the examinations which, in default of 
acceptable credentials, the candidate must pass, covers less than two years of a good 
high school course. 

On the laboratory side, though the homeopaths admit the soundness of the sci- 
entific position, they have taken no active part in its development. Nowhere in homeo- 
pathic institutions, with the exception of one or two departments at Boston Uni- 
versity, is there any evidence of progressive scientific work. Even "drug proving" is 
rarely witnessed. The fundamental assumption of the sect is sacred; and scientific 
activity cannot proceed where any such interdict is responsible for the spirit of the 
institution. The homeopathic departments at Iowa and Michigan are in this respect 
only half-schools, clinical halves. For their students get their scientific instruction 
in pathology, anatomy, etc., in the only laboratories which the university devotes to 
those subjects, under men none of whom sympathizes with homeopathy. Their dis- 
advantage is increased by the fact that the instruction is adapted to students who 
have had one or two years of college work. The general argument in favor of higher 
standards is here reinforced by the consideration that the homeopathic students 
should certainly qualify themselves for the only grade of scientific instruction that 
the two universities offer. 

Of complete homeopathic schools, Boston University, the New York Homeopathic 
College, and the Hahnemann of Philadelphia alone possess the equipment necessary 
for the effective routine teaching of the fundamental branches. None of them can 
employ full-time teachers to any considerable extent. But they possess fairly well- 
equipped laboratories in anatomy, pathology, bacteriology, and physiology, 1 a mu- 
seum showing care and intelligence, and a decent library. Boston University deserves 
especial commendation for what it has accomplished with its small annual income. 

Of the remaining homeopathic schools, four are weak and uneven: the Hahnemann 
of San Francisco and the Hahnemann of Chicago have small, but not altogether in- 
adequate, equipment for the teaching of chemistry, elementary pathology and bac- 
teriology ; the Cleveland school offers an active course in experimental physiology. Be- 
yond ordinary dissection and elementary chemistry, they offer little else. There is, 
for example, no experimental physiology in the San Francisco Hahnemann: "the 
instructor does n't believe in it;" the Chicago Hahnemann contains a small outfit and 

sas City (Kansas) Hahnemann, New York Medical College for Women, New York Homeopathic, 
Pulte (Cincinnati), Cleveland Homeopathic, Hahnemann (Philadelphia), Atlantic Medical (Baltimore). 

1 State universities of Iowa and Michigan, Detroit Homeopathic, and the two New York schools. 

2 The Philadelphia Hahnemann is defective in experimental physiology. 



160 MEDICAL EDUCATION 

a few animals for that subject; the Cleveland equipment for pathology and bacteri- 
ology is meager. The New York Homeopathic College for Women is well intentioned, 
but its means have permitted it to do but little in any direction. 

Six schools remain all utterly hopeless: Hering (Chicago), because it is with- 
out plant or resources; the other five, 1 because in addition to having nothing, their 
condition indicates the total unfitness of their managers for any sort of educational 
responsibility. The buildings are filthy and neglected. At Louisville no branch is 
properly equipped ; in one room, the outfit is limited to a dirty and tattered mani- 
kin; in another, a single guinea pig awaits his fate in a cage. At Detroit the dean 
and secretary "have their offices downtown;" the so-called laboratories are in utter 
confusion. At Kansas City similar disorder prevails. At the Atlantic Medical ap- 
pearances are equally bad ; to make matters worse, the school has lately omitted the 
word "homeopathic" from its title so as to gather in students dropped from other 
Baltimore schools. 

In respect to hospital facilities, the University of Michigan, Boston University, and 
the New York Homeopathic alone command an adequate supply of material, under 
proper control, though modern teaching methods are not thoroughly utilized even by 
them. The Iowa school controls a small, but inadequate, hospital. All the others are 
seriously handicapped by either lack of material or lack of control, and in most instances 
by both. The Hahnemann of San Francisco relies mainly on 30 beds supported by the 
city and county in a private hospital ; the Detroit school is cordially welcome at the 
Grace Hospital, but less than 60 beds are available, and they are mostly surgical ; the 
Woman's Homeopathic of New York 2 controls a hospital of 35 available beds, mostly 
surgical ; the Southwestern (Louisville) and the Cleveland school get one-fifth of the 
patients that enter the city hospitals of their respective towns, but these hospitals are 
not equipped or organized with a view to teaching. The Kansas City school holds 
clinics one day a week at the City Hospital ; Pulte (Cincinnati) and the Atlantic 
(Baltimore) have, as nearly as one can gather, nothing definite at all. Several of the 
schools appear to be unnecessarily handicapped. The Chicago Hahnemann adjoins 
a hospital with 60 ward beds. But as the superintendent " does n't believe in admitting 
students to wards," there is little or nothing beyond amphitheater teaching. A 
bridge connects Hering (Chicago) with a homeopathic hospital, but "students are 
not admitted." The Cleveland school is next door to a hospital with which it was once 
intimate ; their relations have been ruptured. An excellent hospital is connected with 
the building occupied by the Philadelphia Hahnemann, but there is no ward work. 

The dispensary situation is rather worse. Iowa and Ann Arbor have little oppor- 
tunity. Of the others, Boston University alone has a really model dispensary, com- 
paring favorably in equipment, organization, and conduct with the best institutions 

'Southwestern (Louisville), Pulte (Cincinnati), Atlantic (Baltimore), and the Detroit and Kansas 
City schools. 

'This school has scattered supplementary facilities, as is the way of New York schools. 



MEDICAL SECTS 161 

of the kind in the country. The New York Homeopathic, the Chicago Hahnemann, 
and the Philadelphia Hahnemann command material enough. The others lack material, 
equipment, or care ; in some instances, Atlantic Medical, Pulte, Detroit, Kansas 
City, they lack everything that a dispensary should possess. 

Financially, the two state university departments and the New York Homeo- 
pathic school are the only homeopathic schools whose strength is greater than their 
fee income. All the others are dependent on tuition. Their outlook for higher entrance 
standards or improved teaching is, therefore, distinctly unpromising. Only a few of 
them command tuition fees enough to do anything at all : the Chicago Hahnemann, 
Boston University, and the Philadelphia Hahnemann, with annual fees ranging be- 
tween $12,000 and $18,000.* Nine of them are hopelessly poor: the San Francisco 
Hahnemann, Hering (Chicago), the Detroit Homeopathic, and the Atlantic Medi- 
cal operate on less than $4000 J a year; the Southwestern (Louisville) and Pulte 
(Cincinnati) on less than S1500. 1 

In the year 1900 there were twenty-two homeopathic colleges in the United 
States ; to-day there are fifteen ; the total student enrolment has within the same 
period been cut almost in half, decreasing from 1909 to 1009 ; 2 the graduating 
classes have fallen from 413 to 246. As the country is still poorly supplied with 
homeopathic physicians, these figures are ominous ; for the rise of legal standard must 
inevitably affect homeopathic practitioners. In the financial weakness of their schools, 
the further shrinkage of the student body will inhibit first the expansion, then the 
keeping up, of the sect. 

Logically, no other outcome is possible. The ebbing vitality of homeopathic schools 
is a striking demonstration of the incompatibility of science and dogma. One may 
begin with science and work through the entire medical curriculum consistently, ex- 
posing everything to the same sort of test ; or one may begin with a dogmatic asser- 
tion and resolutely refuse to entertain anything at variance with it. But one cannot 
do both. One cannot simultaneously assert science and dogma; one cannot travel 
half the road under the former banner, in the hope of taking up the latter, too, at 
the middle of the march. Science, once embraced, will conquer the whole. Homeopathy 
has two options: one to withdraw into the isolation in which alone any peculiar 
tenet can maintain itself; the other to put that tenet into the melting-pot. Histor- 
ically it undoubtedly played an important part in discrediting empirical allopathy. 
But laboratories of physiology and pharmacology are now doing that work far more 
effectively than homeopathy; and they are at the same time performing a con- 
structive task for which homeopathy, as such, is unfitted. It will be clear, then, why, 
when outlining a system of schools for the training of physicians on scientific lines, 
no specific provision is made for homeopathy. For everything of proved value in 

1 Estimated. 

2 Journal of the American Institute of Homeopathy, vol. i., 1909, no. 11, p. 537. The Journal of the 
American Medical Association, Aug. 14, 1909 (pp. 556, 557), gives figures somewhat lower: 889 instead 
of 1009 ; 209 instead of 246. The discrepancy does not alter our interpretation. 



162 MEDICAL EDUCATION 

homeopathy belongs of right to scientific medicine and is at this moment incorpo- 
rate in it; nothing else has any footing at all, whether it be of allopathic or homeo- 
pathic lineage. "A new school of practitioners has arisen," says Dr. Osier, "which 
cares nothing for homeopathy and less for so-called allopathy. It seeks to study, ra- 
tionally and scientifically, the action of drugs, old and new." 1 

There are eight eclectic schools. 2 One of them that in New York City requires 
the Regents' Medical Student Certificate, i. e., a four-year high school education, 
for admission; the Cincinnati school must require an equal preliminary education of 
students expecting to practise in Ohio, others taking the matter into their own 
hands. Just how the instruction is thus accommodated to various levels is not clear. 
The remaining six schools have either nominal requirements or none at all. 

None of the schools has anything remotely resembling the laboratory equipment 
which all claim in their catalogues. The Cincinnati institution possesses a new and 
attractive building, thus far meagerly fitted out; the New York school has a clean 
building with a chemical laboratory in which elementary chemistry can be and ap- 
parently is taught properly. It has little else: a small room for the microscopic sub- 
jects, but no adequate equipment for teaching them; a few thousand books, mostly 
old ; a few models, a lantern, etc., and this is most satisfactorily equipped of all the 
eclectic institutions. The Hospital School at Atlanta, starting on four weeks' 1 notice, 
had time to get students, but not to get means of teaching them. The private labora- 
tory of the instructor in pathology and bacteriology was meanwhile at their service: 
other equipment there was, at the time of the visit, none. 

The remaining five eclectic schools are without exception filthy and almost bare. 
They have at best grimy little laboratories for elementary chemistry, a few micro- 
scopes, some bottles containing discolored and unlabeled pathological material, an 
incubator out of commission, and a horrid dissecting-room, when dissecting is in 
progress. The St. Louis school was the proud possessor of some new physiological 
apparatus, the state board having recently issued an edict requiring its purchase; but 
there was no place to use it and no sign of its use. The Kansas City institution had 
likewise made a recent investment to the same extent, having just taken on the fa- 
culty the "laboratory man" of the local homeopathic and osteopathic schools. The 
other Atlanta, the Los Angeles, and the Lincoln schools have even less. The Lin- 
coln institution alleges that its scientific training is given at Cotner University, where 
the only material available for medical instruction consists of a chemical laboratory, 
some microscopes, and a small collection of stuffed birds. 

Of the eight schools under discussion, none has decent clinical opportunities. The 
New York school can send three students twice weekly to the Sydenham Hospital; 
the Cincinnati school is affiliated with the Seton Hospital, with 24 available beds, 

l Loc. dt., p. 268. 

*One each at Los Angeles, Kansas City (Kansas), St Louis, Lincoln (Nebraska), Cincinnati, New 
York City, and two at Atlanta. 



MEDICAL SECTS 168 

80 to 90 per cent surgical, and can send its men to look on at the public clinics 
given in the City Hospital; the St. Louis students have a day a week at the City 
Hospital and profit occasionally elsewhere through professorial connection. All this 
is criminally inadequate, yet it is the best that the eclectics offer; for the other five 
schools have literally nothing at all. One of the Atlanta " colleges'" is connected with 
a private infirmary ; the other has not even such a semblance. The Los Angeles school 
claims " private hospitals only ; " the Kansas City school claims to give clinics at the 
new City Hospital, but the hospital authorities deny it. At Lincoln " there are no 
regular hours at any hospital ; they depend on cases as they turn up." 

The dispensaries may be even more briefly described. The Atlanta, Lincoln, and 
Los Angeles schools have none at all. The Cincinnati school uses poorly the small 
dispensary at the Seton Hospital. The New York school has three rooms in its own 
building and access to another dispensary. At St. Louis there is one room and " some 
one comes almost every day ; " at Kansas City, one room likewise, with a present daily 
attendance of three and a confident aspiration that this number can be swelled to six. 

The utter hopelessness of the future of these schools is apparent on a glance at 
their financial condition. All are dependent on fees. Only three of them the New 
York, the Cincinnati, and one Atlanta school enjoy an income between $5000 and 
$8500 J a year; the St. Louis, Lincoln, and second Atlanta schools have something 
over $3000 1 annually ; those at Los Angeles and Kansas City not much above $1000 ; 1 
and these modest sums are not always spent within the schools. Statistics confirm the 
unfavorable prognosis : the ten schools which the sect possessed in 1901 have now 
dwindled to eight ; a maximum enrolment of 1014 in 1904 has already shrunk to 413 ; 
graduates numbered 186 in 1906, 84 in 1909. 

So far as sectarian creeds go, there is, of course, no reason why these schools should 
be elaborately equipped for scientific instruction. They talk of laboratories, not be- 
cause they appreciate their place or significance, but because it pays them to defer 
thus far to the spirit of the times. Culpable indeed they are, however, for their utter 
failure to make good what their own tenets prescribe. The eclectics are drug mad ; 
yet, with the exception of the Cincinnati and New York schools, none of them can 
do justice to its own creed. For they are not equipped to teach the drugs or the drug 
therapy which constitutes their sole reason for existence. 2 

The eight osteopathic schools 3 fairly reek with commercialism. Their catalogues are 
a mass of hysterical exaggerations, alike of the earning and of the curative power of 
osteopathy. It is impossible to say upon which score the " science " most confidently 
appeals to the crude boys or disappointed men and women whom it successfully 

1 Estimated. 

2 The physio-medical sect can be dismissed in a note. It had three schools in 1907; only one, that in 
Chicago, is left. The reader will find it described in Part II, under Illinois, no. (11). There were 149 
physio-medical students in 1904; there are now 52; there were 20 graduates in that year, 15 in 1909. 

3 One school is found in each of the following cities: Chicago, Des Moines, Kirksville (Missouri), 
Kansas City (Missouri), Philadelphia, Cambridge (Massachusetts), and two at Los Angeles. 



164 MEDICAL EDUCATION 

exploits. "In no case has a competent osteopath made a failure in his attempt to build 
up a paying practice. . . . His remuneration, counted in dollars, will be greatly in excess 
of what he could reasonably expect in most other lines of professional work." l " It is 
only fair to say that many of our graduates are earning as much in single months 
as they were formerly able to earn by a full year's work." 8 " The average osteopath 
has a better practice than ninety out of every hundred medical practitioners. 1 " 8 " A 
lucrative practice is assured to every conscientious and capable practitioner." * "The 
graduate who does not make as much as the total cost of his osteopathic education 
in his first year of practice is the exception." 6 Standards these concerns have none ; 
the catalogues touch that point very tenderly. At the parent school at Kirksville an 
applicant will be accepted " if he pass examinations in English, arithmetic, history, 
and geography ;" but if he should fail to meet these lofty scholastic requirements, 
he may be admitted anyway. In Massachusetts the most homogeneously educated 
state in the Union the Cambridge school diplomatically posits that " a diploma 
may be accepted or an examination be required if deemed advisable by the directors," 
the word " is " being conspicuous by its absence ; the Pacific College, " chancing 
it," finds that " most make good." 

Whatever his notions on the subject of treatment, the osteopath needs to be trained 
to recognize disease and to differentiate one disease from another quite as carefully as 
any other medical practitioner. Our account of the sect proceeds wholly from this point 
of view. Whether they use drugs or do not use them, whether some use them while 
others do not, does not affect this fundamental question. Whatever they do, they must 
know the body, in health and disease, before they can possibly know whether there 
is an occasion for osteopathic intervention, and if so, at what point, to what extent, etc. 
All physicians, summoned to see the sick, are confronted with precisely the same crisis : 
a body out of order. No matter to what remedial procedure they incline, medical, 
surgical, or manipulative, they must first ascertain what is the trouble. There is only 
one way to do that. The osteopaths admit it, when they teach physiology, pathology, 
chemistry, microscopy. Let it be stated, therefore, with all possible emphasis that no 
one of the eight osteopathic schools is in position to give such training as osteopathy it- 
self demands. The entire course is only three years. In so simple and fundamental a mat- 
ter as anatomy assuredly the corner-stone of a "science" that relies wholly on local 
manipulation they are fatally defective. At Kirksville the accommodations are en- 
tirely unequal to the teaching of its huge student body. Hence the first year is devoted 
to text-book study of anatomy, part of the second year to dissection ; at Kansas City 
they consider that the student dissects better if he has learned anatomy first: hence 

1 Catalog**, Pacific College of Osteopathy, 1909-10, p. 9. 

1 Catalogue, Los Angeles College of Osteopathy, 1909-10, p. 9. 

^Catalogue, Central College of Osteopathy, 1908-9, p. 22. 

Catalog**, Philadelphia College of Osteopathy, 1909-10, p. 48. 

Catalogue, Massachusetts College of Osteopathy, 1909-10, p. 10. 



MEDICAL SECTS 165 

dissection comes in the latter half of the course, being completed just one-half year 
before graduation. The supply of material is also scant : the school had had one ca- 
daver early in the fall and was looking ahead to a second the latter part of the 
winter. The Los Angeles college has a small room with five tables for a student body 
numbering 250; it solves the difficulty by giving separate squads two hours a week 
each. At Philadelphia the department of anatomy occupies an outhouse, whence the 
noisome odor of decaying cadavers permeates the premises. Other subjects fare even 
worse. A small chemical laboratory is occasionally seen, at Philadelphia it happens 
to be in a dark cellar. At Kirksville a fair-sized room is devoted to pathology and 
bacteriology ; the huge classes are divided into bands of 32, each of which gets a six 
weeks 1 course, following the directions of a rigid syllabus under a teacher who is 
himself a student. At Cambridge pathology comes in the last year. A professor in 
the Kansas City school said of his own institution that it had practically no labora- 
tories at all ; the Still College at Des Moines has, in place of laboratories, laboratory 
signs; the Littlejohn at Chicago, whose catalogue avers that the "physician should 
be imbued with a knowledge of the healing art in its widest fields, and here is the 
opportunity," 1 has lately in rebuilding wrecked all its laboratories but that of chem- 
istry without in the least interfering with its usual pedagogic routine. 2 

Nowhere is there the faintest effort to connect the "laboratory teaching " with 
"clinical osteopathy ; " perhaps because no school has anything approaching the re- 
quisite clinical opportunities. Once more, their tenets are not in question. Much dif- 
ference of opinion prevails among them as to whether they should teach everything or 
only some things; as to whether they may use drugs in certain conditions or must 
confine themselves wholly to manipulation for " osteopathic lesions." Howeverthis may 
be, the osteopath cannot learn his technique and when it is applicable, except through 
experience with ailing individuals. And these, for the most part, he begins to see 
only when his prosperity begins after receiving his "D.O." degree. The Kirksville 
school (560 students) has indeed a hospital of 54 beds, of which, however, only 20 
are in the wards, and practically all are surgical. Eight obstetrical cases were obtained 
in April and May of last year. The Des Moines and Kansas City schools have no 
hospitals at all; the students see no acute cases "unless the doctors can take them 
along." The Pacific College has a hospital of from twelve to fifteen surgical and ob- 
stetrical beds, all pay ; " the students have no regular work at the hospital as there 
are so few acute cases; they don't see as much acute work as they should, but they 
treat everything." The Littlejohn (Chicago) has also a pay hospital, of 20 beds, 
mostly surgical. The Philadelphia school, whose "opportunities for practical work" 
are highly extolled in its catalogue, has an infirmary with three beds, occupied by 



1 Bulletin, June 15, 1909, p. 7. 

'This school teaches medicine as well as osteopathy. It offers instruction in materia medica and 

therapeutics, practice of medicine, and yet it is a three-year school. 



166 MEDICAL EDUCATION 

maternity cases if at all ; the Cambridge student must travel an hour or more to the 
Chelsea Hospital, a pay institution of from ten to fifteen rooms. 

The mercenary character of osteopathic instruction is nowhere more conspicuously 
displayed than in the dispensaries, designed in theory to turn a humanitarian im- 
pulse to educational account. The osteopathic schools insert a cash nexus : the patients 
almost always pay. At Kansas City students give treatment to patients who pay 
three dollars a month; those paying more are treated by the professors. At Kirks- 
ville two dollars a treatment is charged. The cases are mostly chronics, an instructor 
being present at the first treatment; afterwards, only if summoned. At Los Angeles 
the cheapest obtainable treatment is three dollars for " examination " and one month's 
treatment before the class; at Des Moines the "professor administers to high-priced 
patients, the students to others." 

The eight osteopathic schools now enroll over 1300 students, who pay some $200,000 
annually in fees. The instruction furnished for this sum is inexpensive and worthless. 
Not a single full-time teacher is found in any of them. The fees find their way di- 
rectly into the pockets of the school owners, or into school buildings and infirmaries 
that are equally their property. No effort is anywhere made to utilize prosperity as 
a means of defining an entrance standard or developing the "science." 1 Granting all 
that its champions claim, osteopathy is still in its incipiency. If sincere, its votaries 
would be engaged in critically building it up. They are doing nothing of the kind. 
Indeed, in none of the sectarian schools does one observe progressive effort even along 
the lines of its own creed. And very naturally : dogma is sufficient unto itself. It may 
not search its own assumptions ; it does well to adopt from the outside, after forced 
restatement in its own terms. 2 

In dealing with the medical sectary, society can employ no special device. Certain 
profound characteristics in one way or another support the medical dissenter : now, 
the primitive belief in magic crops up in his credulous respect for an impotent drug; 
again, all other procedure having failed, what is there to lose by flinging one's self 
upon the mercy of chance? Instincts so profound cannot be abolished by statute. But 
the limits within which they can play may be so regulated as to forbid alike their 
commercial and their crudely ignorant exploitation. The law may require that all 
practitioners of the healing art comply with a rigidly enforced preliminary educa- 
tional standard; that every school possess the requisite facilities; that every licensed 
physician demonstrate a practical knowledge of the body and its affections. To these 
terms no reasonable person can object; the good sense of society can enforce them 
upon reasonable and unreasonable alike. From medical sects that can live on these 
conditions, the public will suffer little more harm than it is destined to suffer any- 
how from the necessary incompleteness of human knowledge and the necessary defects 
of human skill. 

1 At the Pacific College of Osteopathy alone were two workers doing some research. 
3 In this fashion homeopathy handles serum-therapy as a case of similars. 



CHAPTER XI 

THE STATE BOARDS 

THE state boards are the instruments through which the reconstruction of medical 
education will be largely effected. To them the graduate in medicine applies for the 
license to practise. Their power can be both indirectly and directly exerted. They may 
after examination reject an applicant, an indirect method of discrediting the school 
which has vouched for him by conferring its M.D. degree. A small percentage of 
failures the doctrine of chance would lead one to expect ; an increasing proportion 
must cast increasingly serious doubt on any institution. A more direct and therefore 
more salutary method is needed, however, in dealing with schools bad beyond a 
reasonable doubt. In such instances the board should summarily refuse to entertain 
the applicant's petition because his medical education rests upon no proper prelim- 
inary training or was received under conditions that forbade thorough or conscientious 
instruction : the full weight of its refusal would fall with crushing effect upon the 
school which sent him forth. No institution can long survive the day upon which it 
is thus publicly branded as feeble, unfit, or disreputable. For the purpose, however, 
of saving the victims whose cruel disappointment will in time destroy these schools, 
the arm of the state boards should for the present go beyond the rejection of individ- 
uals to the actual closing up of notoriously incompetent institutions. The law that 
protects the public against the unfit doctor should in fairness protect the student 
against the unfit school. 

With the manifold duties and responsibilities of the state boards we cannot here 
fully deal. Our attention is necessarily confined to their educational function. They 
examine candidates for license ; but admission to examination should be granted only 
after a fair presumption of intellectual fitness in favor of the applicant has been es- 
tablished by the record of his preliminary education, and a fair presumption of suffi- 
cient professional training by his graduation from a recognized or reputable medical 
school. Neither of these points can for the present be overlooked. So long as the 
medical school has as such no determinate position in the school system, the public 
health authorities must be empowered to fix at least the lowest point to which it can 
safely be permitted to fall ; moreover, so long as any group of physicians may in most 
states incorporate a medical school under general laws that offer no safeguard at all, 
and license examinations are not yet deliberately constructed to frustrate their ac- 
tivity, summary protective power against mercenary and incompetent faculties must 
be lodged somewhere. The boards therefore touch at three points the problems with 
which this report has dealt : for they deal (1 ) with the preliminary educational require- 
ment, (2) with the facilities of medical schools, (3) with examinations for licensure. 

In all these respects, the scope of the state board is of course determined by statute. 
Let us consider briefly what powers in respect to each are needed if the boards are 



168 MEDICAL EDUCATION 

to be effective in the reconstruction to which we look forward. 

(1) However the educational prerequisite be defined, the board must be authorized 
to insist upon it as an educational, and not as a practice, preliminary. The sole reason 
for a preliminary requirement of any kind is as a method of restricting the study of 
medicine to those in whose favor an initial presumption of fitness exists. An ordi- 
nary secondary school education may be taken as indicating minimum competency 
only if it chronologically precede admission to the medical school. As a matter of 
fact, some state boards legally empowered to enforce the high school basis are often 
strangely careless as to the significance of dates ; so that a requirement whose sole 
value resides in its priority to medical education is held to be satisfied if fulfilled 
just prior to graduation or to licensure. 

The evaluation of preliminary credentials is a task requiring expert knowledge 
and experience. Certain boards have striven hard to discharge this function effectively ; 
but they lack an organization competent to deal with it. It may be that as the 
feasibility of federated action is increased by an approach to uniformity in laws and 
ideals, a central authority can be constituted by voluntary cooperation of the state 
boards, maintained by contributions from their several funds, and charged with the 
business of procuring first-hand information respecting secondary schools and col- 
leges. Such an agency could, by communication with the proper educational organi- 
zations engaged in the study and improvement of secondary schools, command reliable 
data for the evaluation of credentials prior to matriculation. In default thereof, the 
board of each state, instead of endeavoring to act on such knowledge as it can ob- 
tain, should get at once into effective relations with the state university, or with some 
endowed institution accustomed to pass upon questions of this kind ; and the medi- 
cal schools should be compelled to have a student's application " vised " by the state 
board before matriculation is regarded as complete. If neither time nor subject credit 
could be given by the medical school for any work prior to completed matriculation, 
an actual four-year high school preliminary requirement would be in force. 1 

(2) The enforcement of even the four-year high school standard will so far clean 
up the medical field that the state boards will at once be relieved of the duty of 
dealing with actually disreputable schools. Until that has been accomplished, these 
boards should be empowered to refuse applications from the graduates of schools 
scandalously defective in teaching facilities. The power here in question, if extended 
too far, would involve serious dangers. For boards authorized to decide whether 
schools are satisfactory may be led to specify the details which determine their judg- 
ment. In some quarters they have already shown a tendency to prescribe minutely 
the contents of a proper medical education. Their motive has been excellent ; they 
have tried to compel poor schools to give a good education. Unfortunately, that is 
quite impossible: teachers may sign a register showing due attendance upon their 
classes, just as students may scrupulously attend specified exercises in every essen- 
1 Thc same process can be employed in the south to enforce whatever standard is there decided on. 



THE STATE BOARDS 169 

tial branch for a fixed number of hours; but the instruction will probably be no 
whit improved by such police regulation. Meanwhile every competent and earnest 
instructor is seriously hampered by the vain effort to aid those who are beyond hu- 
man help. The fact is that an enforced entrance requirement at one end and a proper 
examination at the other will of themselves limit the survival of schools to those that 
are financially and educationally competent. Only so long as an entrance requirement 
cannot be enforced or a proper examination arranged, do the state boards need the 
power to close schools obviously and notoriously defective. 

(3) The examination 1 for licensure is indubitably the lever with which the entire 
field may be lifted ; for the power to examine is the power to destroy. At present, 
these examinations are not only without stimulating effect; they are actually depress- 
ing. There is only one sort of licensing test that is significant, viz., a test that ascer- 
tains the practical ability of the student confronting a concrete case to collect all 
relevant data and to suggest the positive procedure applicable to the conditions 
disclosed. A written examination may have some incidental value; it does not touch 
the heart of the matter. It tends, indeed, to do just the reverse. Written examinations 
are notably apt to follow beaten paths. A collection of state board examinations 
covering even a brief period of years will contain most of the questions that will be 
asked hereafter. An effective, but purely mechanical and entirely useless drill may be 
employed to make examination-proof a student who in the presence of a sick person 
would be quite helpless. As a matter of fact, prominent publishers put forth "State 
Board Questions" and "Quiz-compends" with " answers." These manuals, well conned, 
guarantee the candidate's safety. Do not the several states appear to do almost 
everything in their power to resist the production of a well trained body of physi- 
cians? In the first place, they permit a half-dozen men to start a medical school as 
lightly as they permit them to open a printing-shop; and they then offer them every 
inducement to furnish poor training by permitting the graduates to undergo an ex- 
amination for which they can satisfactorily prepare by an inexpensive drill that has 
no bearing on the practical ends for which doctors are needed. A proper examination 
would go far to correct all the defects that this report has sought to point out. For 
low entrance standards, deficient equipment, bad teaching, lack of clinical material, 
failure to correlate laboratory and clinic, would be detected and punished by a 
searching practical examination. 

If the written examination were relegated to a subordinate position, the weight of 
the test would fall upon the applicant's ability to do things; schools incapable for 
whatever reason of training students in the necessary technique would be rapidly ex- 
posed through the annual publication of statistics proclaiming their failure. The 
state board results, now so frequently misleading, would be a trustworthy index which 
the more intelligent students would carefully scan; and those schools only would sur- 

1 For an excellent discussion, see Councilman : " Methods and Objects of State Board Examinations," 
Journal of American Medical Association, Aug. 14, 1909, pp. 515-19. 



170 MEDICAL EDUCATION 

vive whose records entitle them to live. Of such overwhelming importance, indeed, 
is the character of the license examination that, if thorough practical examinations 
were instituted, all the other perplexing details we have discussed would become rel- 
atively immaterial. 

How far we now are from this ideal realized in other countries, hardly aspired 
to in America, a few facts make plain. In 1906, the worst of the Chicago schools 
a school with no entrance requirement, no laboratory teaching, no hospital connec- 
tions made before state boards the best record attained by any Chicago school in 
that year. This school, essentially the same now as then, has only recently been de- 
clared "not in good standing" with the state board of Illinois. Everywhere in Can- 
ada and the United States wretched institutions refute criticism by pointing to their 
successful state board records. Halifax and Western University candidates pass in 
Canada side by side with students from McGill and Toronto, though not in an equal 
proportion; for even in the written examination, better opportunities tell in the long 
run. Good didactic teaching at Bowdoin or Dartmouth proves capable of satisfying 
examinations that should strongly stress clinical experience. One or two of the states 
have latterly begun to introduce certain practical features into their examinations. 
These timid beginnings are hopeful signs, as yet, however, hardly extensive enough 
anywhere materially to affect either the kind of teaching employed or the outcome 
of the examination. The army and navy have gone a little further towards develop- 
ing a practical examination than has any state board; and their written tests are 
probably also more severe; with the result that between the years 1900 and 1909, 
46 per cent of graduated doctors applying for the naval medical corps failed; between 
1904 and 1909, 81 per cent of the applicants for the Marine Hospital service failed; 
and out of 1512 candidates for the army medical corps between 1888 and 1909, 
72 per cent failed: 1 this, although very few of the applicants examined came from 
the unmitigatedly bad schools. 

To do their duty fiilly, the state boards require to be properly constituted, orga- 
nized, and equipped. At present none of them fulfils all these conditions. In conse- 
quence it is difficult to know where to lodge responsibility. In some states the law 
is BO weak that a board can be successfully "mandamused" the moment it raises a 
finger. Elsewhere, a good law is practically negatived by the inactivity, if not worse, 
of a board that excuses itself by the apathy of the public or by the " pull " of the medi- 
cal schools. In general the boards have not been strongly constituted. In many states 
appointments are regarded as political spoils; quite generally teachers are ineligible 
for appointment. It happens, therefore, that the boards are sometimes weak, and 
either unwilling to antagonize the schools or legally incapable of so doing; again, 
well meaning but incompetent; in some cases unquestionably neither weak nor well 

1 For the records upon which these statements are based, acknowledgments are due to the Surgeon- 
General of the Navy, the Surgeon-General of the Marine Hospital Service, and to the Surgeon-Gen- 
eral of the Army, respectively. 



THE STATE BOARDS 171 

meaning, but cunning, powerful, and closely aligned with selfish and harmful politi- 
cal interests. In a few instances, that stand out, the boards are vigorous, intelligent, 
and public spirited, notably in Colorado, Michigan, and Minnesota. 

In the matter of organization they are decidedly defective. The whole weight rests 
usually upon a single executive officer, the secretary, whose sole staff consists of a 
stenographer, if that. As long as everything depends on the personality of a single 
individual, administration will be liable to marked fluctuations. There can be neither 
security nor continuity. For enlightened public opinion and accepted ideals have not 
as yet established definite and correct policy. Organization would within limits be 
independent of individuals ; for it embodies a routine that fortifies every gain won, 
and makes possible the division of labor that is indispensable to system and thor- 
oughness. 

A bureau properly organized cannot live on small fees. It requires liberal support ; 
for it must be in position to take trouble to secure information and to defend its 
rights. The power that validates the diploma with its license must have the strength 
to protect its issues against either debasement or infringement. The physician, like 
the lawyer, is an agent of the state. If he proves unworthy, the same board that 
vouched for him must have power to recall its act ; and its function must extend to 
the prosecution of fraudulent or unwarranted attempts to practise without its official 
sanction. Any effort to exercise powers of recall or restraint will of course be resisted. 
The state must therefore provide funds that will enable the board to defend its action 
in the courts. 

A model state board law must therefore guard the following points: the member- 
ship of the board must be drawn from the best elements of the profession, including 
not, as now, prohibiting those engaged in teaching; the board must be armed 
with the authority and machinery to institute practical examinations, to refuse 
recognition to unfit schools, and to insist upon such preliminary educational stand- 
ards as the state's own educational system warrants ; finally, it must be provided either 
by appropriation or by greatly increased fees with funds adequate to .perform effi- 
ciently the functions for which it was created. The additional powers needed in order 
to deal as effectively with the practice of medicine, lie outside the present discussion. 

Far-reaching legislative changes would be required in most states before the state 
boards could play the part here assigned to them. Yet for it they are clearly des- 
tined. As a matter of fact, recent legislation has been self-contradictory. The boards 
have been strengthened, their powers more satisfactorily defined ; and thereupon the 
end thus sought has been partially defeated by the creation of sectarian boards with 
lower standards and looser ideas. Minnesota, for example, obtained an excellent 
law, consolidated the medical schools of the state, established a high standard, and 
quarantined against invasion by a low-grade product from without ; and then, having 
fairly secured for the people of the state the best attainable conditions in the mat- 
ter of protecting the public health, it proceeded partly to undo the good work by es- 



172 MEDICAL EDUCATION 

tablishing a separate osteopathic board with power to license osteopaths who will 
treat all diseases, and quite possibly in all sorts of ways according to standards 
and methods fundamentally at variance with the main statute already outlined. The 
creation of separate boards is thus a roundabout method of recommitting the errors 
that the main currents of scientific thinking and effort are endeavoring to remedy. 
Our forty-nine states and territories have now eighty-two different boards of medi- 
cal examiners. The province of the state in this matter is plain. It cannot allow one 
set of practitioners to exist on easier and lower terms than another. It cannot indeed 
be a party to scientific or sectarian controversy. But it can and must safeguard the con- 
ditions upon which such controversy may be fought to its finish. The mooted points 
concern only therapeutics; in respect to all else there is complete agreement. If matters 
in dispute are omitted from the examination, enough is left for all essential pur- 
poses. A single board should subject all candidates, of whatever school, to the same 
tests at every point. The license of the state is a guarantee of knowledge, education, 
and skill. The layman is in no position to make allowances. The state's M.D. and 
the state's D.O. offer themselves for essentially the same purposes. The state stands 
equally as guarantor of both. No citizen can indeed be wholly protected by the state 
against his own ignorance, fanaticism, or folly. A man who does not "believe" in 
doctors cannot be forced to call them in or to heed them, any more than a man who 
does not "believe" in wearing rubbers can be compelled to don them in slushy 
weather. The state is powerless there. But having undertaken to vise practising physi- 
cians for the protection of those who summon them, it must see to it that the 
licenses to which it gives currency bear a fairly uniform value. Between the graduate of 
Harvard and the graduate of the Boston College of Physicians and Surgeons, the 
layman could not judge even if he knew the origin of each; as a matter of fact, he 
rarely knows so much. But in the act of licensing both for one purpose, the state 
assures its citizens of their substantial equality. It is shocking to reflect that, what 
with written examinations and separate boards, the divergencies run all the way from 
a high degree of competency to utter ignorance and unfitness. 

There is no question that in the end the medical sects will disappear. The dissenter 
cannot live on high entrance and educational standards. Pending his disappearance, 
the combination board is the least of the evils to which we are liable. The terms upon 
which these boards are now obtainable throw a strong light on the backward state of 
public opinion. In New York state, homeopaths, eclectics, and osteopaths, making 
together but a negligible proportion of the practising physicians of the state, have 
together a majority on the state examining board. 

Under existing conditions, though the state boards might well be constituted on 
a uniform plan and with the same powers, a certain degree of diversity is unavoid- 
able; but a certain degree of inevitable diversity is no excuse for hopeless confusion. 
The variations now found both in the laws and in their administration are fairly 
chaotic. In one state the board can and does fix entrance requirements; in the next 



THE STATE BOARDS 173 

it can, but does not; in a third it neither does nor can. Six boards 1 have announced 
the requirement of one or more years of college work preliminary to medical school- 
ing as the basis of practice in their respective states; but seventy-six remain to be 
converted. Their conversion, with the necessary changes in the state laws, must pre- 
cede the actual elevation of the entire medical profession. For though agreed eleva- 
tion of standard by individual schools improves their own product and indirectly 
leavens the mass, it does not stop the making of low-grade doctors. Temporarily it 
even assists the low-grade school. The ultimate improvement of the entire mass will 
come from control of all schools through the state boards, and not merely from vol- 
untary action on the part of the more self-respecting institutions. The middle west 
seems likely the osteopaths permitting first to realize this condition; for the 
states will surely not leave the practice of medicine within their borders open to 
strangers on terms denied to their own sons. 

Whether or not it will be left for the osteopaths to say, depends just now on mak- 
ing the public appreciate the fact that the point at issue is not a matter of business. 
A clever hue and cry has been raised to give the controversy the appearance of a 
competition between rival claimants for business patronage. The instinct for fair 
play, opposition to exclusive or aristocratic privileges, have thus won for the secta- 
rian a chance on his own terms. Unfortunately, this leaves the sick man wholly out 
of account. Medicine, curative and preventive, has indeed no analogy with business. 
Like the army, the police, or the social worker, the medical profession is supported for 
a benign, not a selfish, for a protective, not an exploiting, purpose. The knell of the 
exploiting doctor has been sounded, just as the day of the freebooter and the soldier 
of fortune has passed away. 

Despite imperfect and discordant laws and inadequate resources, the state board 
has abundantly justified itself. It is indeed hardly more than quarter of a century 
old ; yet, in summing up the forces that have within that period made for improved 
conditions, the state boards must be prominently mentioned. Their role is likely to 
be increasingly important. They have developed considerable esprit de corps. Their 
power of combined action on broad lines has distinctly increased even in the last few 
years. Reciprocity between states whose laws are measurably concordant and whose 
ideals are taking similar shape tends to demonstrate the fundamental sameness of 
the problems requiring solution. Out of these first cooperative efforts, a model law 
will emerge ; federated action may become possible. Perhaps the entire country may 
some day be covered by a national organization engaged in protecting the public 
health against the formidable combination made by ignorance, incompetency, com- 
mercialism, and disease. 



1 Minnesota, North Dakota, South Dakota, Connecticut, Colorado, Kansas. 



CHAPTER XII 

THE POSTGRADUATE SCHOOL 

THE postgraduate school as developed in the United States may be characterized 
as a "compensatory adjustment." It is an effort to mend a machine that was pre- 
destined to break down. Inevitably, the more conscientious and intelligent men 
trained in most of the medical schools herein described must become aware of their 
unfitness for the responsibilities of medical practice; the postgraduate school was 
established to do what the medical school had failed to accomplish. 

"When I graduated in the spring of 1869," says Dr. John A. Wyeth, 1 "I can 
never forget the sinking feeling that came over me when I realized how incompetent 
I was to undertake the care of those in the distress of sickness or accident. A week 
later, after arriving in my native village in Alabama, I rented a small office and at- 
tached my sign to the front door. Within two months, the tacks were withdrawn by 
the hand which had placed them there and the sign was stowed away in the bottom of 
my trunk. Two months of hopeless struggle with a Presbyterian conscience had con- 
vinced me that I was not fit to practise medicine, and that nothing was left for me 
but to go out into the world of business to earn money enough to complete my edu- 
cation. I felt the absolute need of clinical experience, and a conviction, which then 
forced itself upon my mind, that no graduate in medicine was competent to practise 
until he had had, in addition to his theoretical, a clinical and laboratory training, was 
the controlling idea in my mind when, in later years the opportunity offered, it fell 
to my good fortune to establish in this city the New York Polyclinic Medical School 
and Hospital." 

The postgraduate school was thus originally an undergraduate repair shop. Its 
instruction was necessarily at once elementary and practical. There was no time to 
go back to fundamentals; it was too late to raise the question of preliminary edu- 
cational competency. Urgency required that in the shortest possible time the young 
physician already involved in responsibility should acquire the practical technique 
which the medical school had failed to impart. The courses were made short, fre- 
quently covering less than a month ; and they aimed preeminently to teach the young 
doctor what to " do " in the various emergencies of general practice. 

As the general level of medical education has risen, the function of these insti- 
tutions has been somewhat modified. The general course, aiming to make good de- 
ficiencies at large, has tended to give way to special courses adapted to the needs of 
those inclined to devote themselves more or less exclusively to some particular line 
of work. Simultaneously, as the facilities of the schools have enlarged, they have be- 
come centers to which at intervals men practising in isolated places may return for 

1 Proceedingt of the Nineteenth Annual Meeting of the Atsociation of American Medical CoUeget, 
pp. 25, 26 (abridged). 



THE POSTGRADUATE SCHOOL 175 

brief periods in order to catch up with the times. Once more the training offered is 
of a practical, not of a fundamental or intensive, kind. It is calculated to "teach the 
trick" or, perhaps better, to exhibit an instructor in the act of doing it. For, as 
nothing is known of individuals in the stream of students who course through the 
schools, it is impossible to give them an active share in the work that goes on at the 
bedside or in the operating-room. Their part is mainly passive ; they look on at expert 
diagnosticians or operators. The danger of permitting an unknown student, tarrying 
for a brief stay, to participate at close range is prohibitive. In surgery the so-called 
practical courses are not usually worked out in such fashion that cadaver work, animal 
work, and service as dresser might prepare for actual participation : the school lacks 
means and facilities ; the students lack the time. In medicine the absence of sufficient 
material, the lack of proper hospital organization and equipment, the scrappiness of 
professional service, combine to prevent a systematic, thorough, and intimate discipline. 

Of the thirteen postgraduate schools, 1 the best of them reflect the conditions and 
purposes above described. The Postgraduate and Polyclinic of New York and the 
Polyclinic of Philadelphia command large dispensary services and considerable hos- 
pital clinics, partly in their own hospitals, partly in public and private hospitals in 
the city. No unkind criticism is intended when the teaching is characterized as too 
immediately practical to be scientifically stimulating: it has the air of handicraft, 
rather than science. Comparatively little is done in internal medicine: surgery and 
the specialties predominate. The courses, being practical and definite, are discon- 
nected ; the faculties are huge and unorganized. In the main, demonstrative instruc- 
tion is offered to small bodies of physicians, who come and go uninterruptedly through 
the year. Only one of the three the Philadelphia school has a laboratory build- 
ing, and in that no advanced work is in progress ; the two New York schools have 
laboratory space or equipment adequate only to routine clinical examinations. The 
teaching is in the main more elementary than the upper class instruction of a good 
undergraduate school of medicine. It is, of course, also at times more special in 
character. With the exception of the New York Postgraduate, these schools are with- 
out endowment: they live on fees, donations, and hospital receipts. 

Two departmental postgraduate schools are conducted by the government at 
Washington for those accepted for service in the army or navy medical corps. Eligible 
for these appointments are graduated physicians who have had a year of hospital 
experience or three years of practice. Excellent practical instruction is furnished by 
way of supplementing the usual undergraduate course. The needs of the services can 

1 Four are situated in Greater New York : (1) The New York Polyclinic Medical School, (2) New York 
Postgraduate Medical School, (3) Brooklyn Postgraduate Medical School, (4) Manhattan Eye, Ear, 
and Throat Postgraduate School ; four in Chicago : (5) Postgraduate Medical School, (6) The Chicago 
Polyclinic, (7) Illinois Postgraduate Medical School, (8} Chicago Ear, Eye, Nose, and Throat College; 
one each in Philadelphia, (9) The Philadelphia Polyclinic; Kansas City, (10) Postgraduate Medical 
School; New Orleans, (11) New Orleans Polyclinic (affiliated with Tulane University); and two in 
Washington, (12) Array Medical School, (13) Navy Medical School. A number of schools offer special 
courses to graduates, in special summer and regular winter sessions. 



176 MEDICAL EDUCATION 

be very definitely formulated ; the course worked out aims to meet them. The ac- 
cepted surgeons get in this way a concentrated practical drill in bacteriology, hygiene, 
and military surgery. The laboratories are excellently equipped, though cramped 
for space. The army school enjoys the advantage of contact with the great library and 
museum of the surgeon-general's office. The schools, as yet in their infancy, may not 
improbably develop into research laboratories dealing with the specific problems that 
crop up in naval and military service in various quarters of the globe. 

Postgraduate, like other schools, vary in character. We have spoken of the best. 
The others are weak concerns wearing a commercial hue. The Brooklyn Postgraduate 
School, for instance, entertains less than half a dozen students on the average at 
a time, in a wretched hospital, really a death-trap, heavily laden with debt, and 
without laboratory equipment enough to make an ordinary clinical examination ; the 
Kansas City affair had, when visited, no students in its improvised hospital contain- 
ing 25 ward beds, only 13 of them occupied ; it ekes out its opportunities with clinics 
at the public hospital. Chicago, varied and picturesque in this as in all else pertain- 
ing to medical education, supports four postgraduate institutions. None of them has 
a satisfactory plant. All are stock companies. Only unmistakable scientific activity 
could dislodge the unpleasant suspicion of commercial motive thus suggested. No such 
activity is in any of them observable. A cynical candor admits in one place that "it 
pays the teachers through referred cases ; " in another, " it establishes the reputation 
of a man to teach in a postgraduate school ; " in a third, " it pays through advertising 
teachers." In one a youth was observed working with a microscope. Inquiry elicited 
the fact that he was the teacher of clinical laboratory technique, lecturing in the 
absence of the "professor." The following dialogue took place: 

" Are you a doctor ? " 

"No." 

" A student of medicine ? " 

"Yes." 

"Where?" 

" At the Jenner Night School" 

" In what year ? " 

"The first" 

A first-year student of medicine in a night school was thus laboratory instructor and 
pro tempore lecturing professor in clinical microscopy in the Chicago Polyclinic. 

Improved medical education will undoubtedly cut the ground from under the in- 
dependent postgraduate school as we know it. This is not to say that the undergrad- 
uate medical curriculum will exhaust the field. On the contrary, the undergraduate 
school will do only the elementary work ; but that it will do, not needing subsequent 
and more elementary instruction to patch it up. Graduate instruction will be advanced 
and intensive, the natural prolongation of the elective courses now coming into 
vogue. For productive investigation and intensive instruction, the medical school will 



THE POSTGRADUATE SCHOOL 177 

use its own teaching hospital and laboratories; for the elaboration of really thorough 
training in specialties resting on a solid undergraduate education, it may use the 
great municipal hospitals of the larger cities. But advanced instruction along these 
lines will not thrive in isolation. It will be but the upper story of a university de- 
partment of medicine. The postgraduate schools of the better type can hasten this 
evolution by incorporating themselves in accessible universities, taking up univer- 
sity ideals, and submitting to reorganization on university lines. 



CHAPTER XIII 

THE MEDICAL EDUCATION OF WOMEN 

MEDICAL education is now, in the United States and Canada, open to women upon 
practically the same terms as men. If all institutions do not receive women, so many 
do, that no woman desiring an education in medicine is under any disability in find- 
ing a school to which she may gain admittance. Her choice is free and varied. She will 
find schools of every grade accessible : the Johns Hopkins, if she has an academic 
degree; Cornell, if she has three-fourths of one; Rush and the state universities, if 
she prefers the combined six years' course; Toronto on the basis of a high school 
education; Meridian, Mississippi, if she has had no definable education at all. 

Woman has so apparent a function in certain medical specialties and seemingly so 
assured a place in general medicine under some obvious limitations that the struggle 
for wider educational opportunities for the sex was predestined to an early success in 
medicine. It is singular to observe the use to which the victory has been put. The 
following tables show recent developments in coeducational and in women's medical 
schools taken separately: 

Number of Coeducational Number of Number of 

Year Medical School* Women Students Women Graduates 

1904 97 946 198 

1905 96 852 165 

1906 90 706 200 

1907 86 718 172 

1908 88 649 139 

1909 91 752 129 

Women's Number of Number of 

Year Medical Schools Students Graduates 

1904 3 183 56 

1905 3 221 54 

1906 3 189 33 

1907 3 210 39 

1908 3 186 46 

1909 3 169 33 

COMBINED 

Number of Number of Number of 

Year Schools Women Students Women Graduates 

1904 100 1129 254 

1905 99 1073 219 

1906 93 895 233 

1907 89 928 211 

1908 91 835 185 

1909 94 921 162 

Now that women are freely admitted to the medical profession, it is clear that 
they show a decreasing inclination to enter it. More schools in all sections are open 
to them ; fewer attend and fewer graduate. True enough, medical schools generally 
have shrunk ; but as the opportunities of women have increased, not decreased, and 
within a period during which entrance requirements have, so far as they are con- 



MEDICAL EDUCATION OF WOMEN 179 

cerned, not materially altered, their enrolment should have augmented, if there is 
any strong demand for women physicians or any strong ungratified desire on the part 
of women to enter the profession. One or the other of these conditions is lacking, 
perhaps both. 

Whether it is either wise or necessary to endow separate medical schools for 
women is a problem on which the figures used throw light. In the first place, eighty 
per cent of women who have in the last six years studied medicine have attended 
coeducational institutions. None of the three women^s medical colleges now existing 
can be sufficiently strengthened without an enormous outlay. The motives which 
elsewhere recommend separation of the sexes would appear to be without force, all 
possible allowance being made for the special and somewhat trying conditions in- 
volved. In the general need of more liberal support for medical schools, it would 
appear that large sums, as far as specially available for the medical education of 
women, would accomplish most if used to develop coeducational institutions, in 
which their benefits would be shared by men without loss to women students; but, it 
must be added, if separate medical schools and hospitals are not to be developed 
for women, interne privileges must be granted to women graduates on the same terms 
as to men. 



CHAPTER XIV 

THE MEDICAL EDUCATION OF THE NEGRO 

THE medical care of the negro race will never be wholly left to negro physicians. 
Nevertheless, if the negro can be brought to feel a sharp responsibility for the physi- 
cal integrity of his people, the outlook for their mental and moral improvement will 
be distinctly brightened. The practice of the negro doctor will be limited to his own 
race, which in its turn will be cared for better by good negro physicians than by poor 
white ones. But the physical well-being of the negro is not only of moment to the negro 
himself. Ten million of them live in close contact with sixty million whites. Not only 
does the negro himself suffer from hookworm and tuberculosis; he communicates them 
to his white neighbors, precisely as the ignorant and unfortunate white contaminates 
him. Self-protection not less than humanity offers weighty counsel in this matter ; 
self-interest seconds philanthropy. The negro must be educated not only for his sake, 
but for ours. He is, as far as human eye can see, a permanent factor in the nation. 
He has his rights and due and value as an individual ; but he has, besides, the tremen- 
dous importance that belongs to a potential source of infection and contagion. 

The pioneer work in educating the race to know and to practise fundamental 
hygienic principles must be done largely by the negro doctor and the negro nurse. 
It is important that they both be sensibly and effectively trained at the level at 
which their services are now important. The negro is perhaps more easily " taken in " 
than the white; and as his means of extricating himself from a blunder are limited, 
it is all the more cruel to abuse his ignorance through any sort of pretense. A well- 
taught negro sanitarian will be immensely useful ; an essentially untrained negro 
wearing an M.D. degree is dangerous. 

Make-believe in the matter of negro medical schools is therefore intolerable. 
Even good intention helps but little to change their aspect. The negro needs good 
schools rather than many schools, schools to which the more promising of the race 
can be sent to receive a substantial education in which hygiene rather than surgery, 
for example, is strongly accentuated. If at the same time these men can be imbued 
with the missionary spirit so that they will look upon the diploma as a commission 
to serve their people humbly and devotedly, they may play an important part in the 
sanitation and civilization of the whole nation. Their duty calls them away from 
large cities to the village and the plantation, upon which light has hardly as yet 
begun to break. 

Of the seven medical schools for negroes in the United States, 1 five are at this mo- 
ment in no position to make any contribution of value to the solution of the problem 

'Washington, D.C.: Howard University; New Orleans: Flint Medical College; Raleigh (N.C.): 
Leonard Medical School ; Knoxville : Knoxville Medical College ; Memphis : Medical Department of 
the University of West Tennessee ; Nashville : Meharry Medical College ; Louisville : National Med- 
ical College. 



MEDICAL EDUCATION OF THE NEGRO 181 

above pointed out ; Flint at New Orleans, Leonard at Raleigh, the Knoxville, Mem- 
phis, and Louisville schools are ineffectual. They are wasting small sums annually 
and sending out undisciplined men, whose lack of real training is covered up by the 
imposing M.D. degree. 

Meharry at Nashville and Howard at Washington are worth developing, and 
until considerably increased benefactions are available, effort will wisely concentrate 
upon them. The future of Howard is assured ; indeed, the new Freedman's Hospital 
is an asset the like of which is in this country extremely rare. It is greatly to be 
hoped that the government may display a liberal and progressive spirit in adapting 
the administration of this institution to the requirements of medical education. 

Meharry is the creation of one man, Dr. George W. Hubbard, who, sent to the 
south at the close of the war on an errand of mercy, has for a half-century devoted 
himself singly to the elevation of the negro. The slender resources at his command 
have been carefully husbanded ; his pupils have in their turn remembered their obli- 
gations to him and to their school. The income of the institution has been utilized 
to build it up. The school laboratories are highly creditable to the energy and in- 
telligence of Dr. Hubbard and his assistants. The urgent need is for improved clin- 
ical facilities a hospital building and a well equipped dispensary. Efforts now 
making to acquire them deserve liberal support. 

The upbuilding of Howard and Meharry will profit the nation much more than 
the inadequate maintenance of a larger number of schools. They are, of course, 
unequal to the need and the opportunity; but nothing will be gained by way of 
satisfying the need or of rising to the opportunity through the survival of feeble, ill 
equipped institutions, quite regardless of the spirit which animates the promoters. 
The subventions of religious and philanthropic societies and of individuals can be 
made effective only if concentrated. They must become immensely greater before 
they can be safely dispersed. 



PART II 

MEDICAL SCHOOLS OF THE UNITED STATES 
AND CANADA 

ARRANGED ALPHABETICALLY BY STATES AND PROVINCES 
AND SEPARATELY CHARACTERIZED 

NOTE : Facts given are at of date when the school wot visited, which 
is specified in each case. 

The estimates of population have, with the few exceptions noted, 
been kindly made by the Director of the Census, through the courtesy 
of the Secretary of Commerce and Labor. 



MEDICAL SCHOOLS 
OF THE UNITED STATES AND CANADA 

ALPHABETICALLY ARRANGED BY STATES AND PROVINCES 

ALABAMA 

Population, 2,112,465. Number of physicians, 2287. Ratio, 1: 924. 
Number of medical schools, 2. 

BIRMINGHAM: Population, 55,945. 

BIRMINGHAM MEDICAL COLLEGE. Organized 1894. A stock company, paying annual 
dividends of 6 per cent. 

Entrance requirement: Nominal. 

Attendance: 185, of whom 168 are from Alabama. 

Teaching staff: 32, 18 being professors, none of them whole-time teachers. 

Resources available for maintenance: Fees, amounting to $14,550 (estimated). 

Laboratory facilities: The teaching of anatomy, for which there is abundant ma- 
terial, is limited to dissecting on old-fashioned lines; there is the usual chemical 
laboratory and a small outfit for instruction in bacteriology and pathology ; the ma- 
terial used for the latter is purchased in the east, not obtained from autopsies or 
clinics. No animals are provided for experimental purpose beyond the use of dogs 
for surgical work. There are no physiological, pharmacological, or clinical labora- 
tories. The building is poorly kept, and there is neither library nor museum. 

Clinical facilities: The school adjoins the Hillman Hospital, 98 beds, of which the 
faculty has charge during term time. Bedside clinics are held, but the students 
make no blood or urine examinations; obstetrical cases are rare; the hospital is 
largely given over to surgical patients, gunshot and other wounds being decid- 
edly abundant. 

The dispensary service is as yet unorganized. 

Date of visit: January, 1909. 

MOBILE: Population, 56,335. 

MEDICAL DEPARTMENT OF THE UNIVERSITY OF ALABAMA. Established 1859. Now an 
organic department of the state university, with which, however, its connection is 
legal only. The two institutions are at opposite ends of the state, so that the 
medical department is practically a local school. 

Entrance requirement: Less than three-year high school education. 



186 MEDICAL EDUCATION 

Attendance: 204. 

Teaching staff: 25, of whom 8 are professors. No one devotes full time to medical 
instruction. 

Resources available for maintenance : The school receives from the state an annual ap- 
propriation of $5000, in return for which, however, sixty-seven free scholarships 
are given, one to each county ; the school is therefore in effect wholly dependent on 
tuition fees, amounting to $17,300, for its support, most of which is paid out in 
salaries. 

Laboratory facilities : The laboratory equipment is practically limited to inorganic 
chemistry, elementary bacteriology and pathology, and anatomy, taught by dis- 
secting first the goat, then the human cadaver. The school occupies a well kept 
old-fashioned building, recently remodeled. It possesses a few old books, but no 
funds with which to add to them ; and a small museum, mostly composed of an- 
tiquated wax or papier-mache models. 

Clinical facilities: For clinical instruction the school has access to the Sisters' Hos- 
pital, 100 beds, the faculty being the staff in term time. The senior students make 
blood and urine examinations in connection with clinical cases. 

Connected with the college building is a new, well arranged dispensary, for the 
conduct of which an appropriation of $50 a month is available. 

DaU ofvitit: January, 1909. 

General Considerations 

THE foregoing account makes it clear that really satisfactory medical education 
is not now to be had in Alabama. The entrance standards are low; the schools are 
inadequately equipped; and they are without proper financial resources. To get 
together their present numbers, standards must be kept low; in consequence, the 
medical schools do nothing to promote or to share the secondary school development 
of the state. To that and to any higher movement they are likely to be obstacles. 
Neither Alabama nor the rest of the south actually needs either school at this time ; 
but as the state has become a patron of medical education, it will hardly retire from 
the field. Under these circumstances, its policy should aim to bring about a genuine 
and effective connection between the medical department and the rest of the state 
university. The task of elevating entrance standards in the medical department and 
of furnishing a higher quality of scientific training would probably be assisted for the 
time being by removing the instruction in the first and second years to the university 
itself at Tuscaloosa; for in no other way can whole-time instructors be now procured. 
An improvement in the quality of training furnished in the scientific branches will 
ultimately compel a higher quality of clinical instruction. It is difficult to see how the 
influence or control of the university can in any event be made effective in Mobile, 
232 miles distant, at the opposite end of the state, and in a hospital in whose clinical 



ARKANSAS 187 

management there is no continuity. Birmingham is much closer, being only 56 miles 
distant, and promises to offer a larger supply of clinical material. If, therefore, the 
state is able to look at the question on its own merits, without regard to the rival 
claims of competing towns, it should establish a practice requirement that would 
automatically suppress proprietary instruction. For the present, the university might 
offer two years' work at Tuscaloosa, reserving to a more propitious time the entire 
question of organizing under effective university control a complete medical school 
at Birmingham, which is the nearest feasible location. As the state now contains one 
physician to every 924 inhabitants, the restriction or suspension of clinical teaching 
for some years to come involves no danger to the community. 



ARKANSAS 

Population, 1,476,582. Number of physicians, 2535. Ratio, 1 : 582. 
Number of medical schools, 2. 

LITTLE ROCK: Population, 44,931. 

(1) MEDICAL DEPARTMENT, UNIVERSITY OF ARKANSAS. Organized 1879. An indepen- 
dent institution, not even "affiliated" with the state university whose name it bears. 

Entrance requirement: Nominal. 

Attendance: 179, 81 per cent from Arkansas. 

Teaching staff: 35, 18 being professors. 

Resources available for maintenance: Fees, amounting to $14,100 (estimated). 

Laboratory facilities : After an existence of thirty years without any laboratory fa- 
cilities except a dissecting-room and a laboratory for inorganic chemistry, a frame 
building has recently been supplied with a meager equipment for the teaching of 
pathology and bacteriology. The session was, however, already well started and 
the new laboratory not yet in operation. No museum, no books, charts, models, 
etc., are provided. 

Clinical facilities: Hardly more than nominal. The school adjoins the City Hospital, 
with a capacity of 30 beds. Froin this hospital patients are brought into the amphi- 
theater of the school building. There are no ward visits. The students see no con- 
tagious diseases; obstetrical work is precarious; of post-mortems there is no mention. 
There is a small dispensary, of whose attendance no record is procurable. 

Date ofvirit: November, 1909. 

(2) COLLEGE OF PHYSICIANS AND SURGEONS. Organized 1906. An independent organi- 
zation, formed by men not in the older school. 



188 MEDICAL EDUCATION 

Entrance requirement: Nominal. 

Attendance: 81, 59 per cent from Arkansas. 

Teaching staff': 34, 25 being professors. 

Resources available for maintenance: Fees, amounting to $6450 (estimated). 

Laboratory facilities : Separate, recently organized, and very disorderly laboratories 
for pathology, bacteriology, and chemistry, which with pharmacy work are all in 
charge of a single teacher, who is also pathologist to the County Hospital, three 
miles off. He proposes shortly to add physiology. The usual wretched dissecting- 
room is also provided. None of the necessary illustrative paraphernalia are at hand 
in the shape of books, charts, museum, etc. 

Clinical facilities: The faculty of the school controls an adjoining hospital, from 
which patients are brought into the amphitheater for demonstration or operation. 
At operations it is claimed that students assist. No ward rounds are made. Occa- 
sional clinics are also held at two distant hospitals (county and penitentiary). 
Obstetrical and acute medical cases are rare; contagious diseases are not seen. 
There are no post-mortems. A small daily dispensary attendance is claimed. There 
is no adequate dispensary equipment. 

Dot* of visit : November, 1909. 

General Considerations 

BOTH the Arkansas schools are local institutions in a state that has at this date 
three times as many doctors as it needs; neither has a single redeeming feature. It is 
incredible that the state university should permit its name to shelter one of them. 
The general educational interests of the state require that the state university, now 
inconveniently located at Fayetteville, should be moved to Little Rock. Once there, 
it could probably get possession of both schools and organize something better than 
either, which it could improve as its resources increase with the general prosperity 
of the state. 

CALIFORNIA 1 

Population, 1,729,543. Number of physicians (exclusive of osteopaths), 4313. Ratio, 

1:401. 
Number of medical schools, 10. 

LOS ANGELES: Population, 116,420. 

(1) COLLEGE OF PHYSICIANS AND SURGEONS. Established 1903 as an independent 

1 The Director of the Census states: "The cities of Los Angeles, Oakland, Berkeley, and San Fran- 
cisco have had such an exceptionally rapid increase that no estimates of their population have been 
prepared." The figures given are taken from the census of 1900. 



CALIFORNIA 189 

school, it suddenly became, in 1909, nominally the medical department of the 
University of Southern California, when the former medical department of that 
institution cut loose in order to become the Los Angeles clinical department of 
the University of California. The seriousness with which the University of South- 
ern California treats medical education may be gathered from this amusing 
performance. 

Entrance requirement: High school graduation or "equivalent."" 
Attendance: 2%. 

Teaching staff": 41, 28 being professors. The teachers are practising physicians; no 
one gives his entire time to the school. 

Resources available for maintenance: Fees, amounting to $4075 (estimated). 

Laboratory facilities : The school is ordinary in type. It possesses a small chemical 
laboratory, a single laboratory in common for pathology, histology, and bacteri- 
ology, with meager equipment and supplies, and no animals; a dissecting-room 
with sufficient anatomical material, and clay for modeling bones ; a limited num- 
ber of wet specimens, and a small number of books in a room that is locked, though 
opened to students on request. There is no laboratory for physiology or pharma- 
cology. The building is new, attractive, and fairly well kept. 

Clinical facilities : A considerable part of one floor is used for a dispensary. The 
rooms are poorly equipped and cared for; there is no clinical laboratory. The at- 
tendance is very small, for the neighborhood is decidedly well-to-do. 

The school adjoins a private hospital in which many of the teachers are inter- 
ested. It is, however, of no teaching use. The catalogue describes it as "not a 
charity hospital by any means. ... In fact it is a twentieth century classy hospi- 
tal.'" For clinical instruction the students have access to the County Hospital, sev- 
eral miles distant, where the school has the use of 100 beds, holding clinics for 
senior students two days weekly. In surgery, students witness an operation with- 
out taking part in it; in medicine, the students make brief histories, which are, 
however, no part of the hospital records. Autopsies are done by the internes, who 
have no connection with the medical school. Students are not admitted to the ob- 
stetrical ward. Clinical facilities are thus extremely limited, for the management of 
the hospital is in no essential respect controlled by educational considerations. 

Date of visit: May, 1909. 

(2) UNIVERSITY OF CALIFORNIA : CLINICAL DEPARTMENT. Up to March, 1909, this 
school offered a four-year course as the medical department of the University 
of Southern California ; it has now become a second clinical department of the 
University of California, and will therefore offer after June, 1910, only the third 
and fourth years' work. See (6). 



190 MEDICAL EDUCATION 

Clinical facilities : Its present facilities for offering the instruction of the last two 
years are, for a university department on a two-year college basis, distinctly 
meager. It enjoys at the County Hospital the same facilities as the local College 
of Physicians and Surgeons, i.e., access to 100 beds, two or three days weekly 
being devoted to clinics for the senior class. Additional opportunities, depending 
on the personal connections of members of the faculty, are usually of slight peda- 
gogic value. The school has an excellent dispensary building, fairly equipped in 
certain respects, but indifferently conducted, though the attendance is good. It 
is also in close proximity to a good medical library. The clinical teachers are all 
local practitioners. The state university will incur no expense on account of this 
department for two years at least 

Date ofvitit : May, 1909. 

(3) CALIFORNIA MEDICAL COLLEGE. Eclectic. Organized at Oakland in 1879, this 
school has led a roving and precarious existence in the meanwhile. 

Entrance requirement: Nominal. 

Attendance: 9, of whom 7 are from California. 

Teaching staff": 27, of whom 26 are professors. 

Resources available for maintenance: Fees, amounting to $1060 (estimated). 

Laboratory facilities: The school occupies a few neglected rooms on the second floor 
of a fifty-foot frame building. Its so-called equipment is dirty and disorderly be- 
yond description. Its outfit in anatomy consists of a small box of bones and the 
dried-up filthy fragments of a single cadaver. A few bottles of reagents constitute 
the chemical laboratory. A cold and rusty incubator, a single microscope, and a 
few unlabeled wet specimens, etc., form the so-called "equipment" for pathology 
and bacteriology. 

Clinical facilities : There is no dispensary and no access to the County Hospital. 
The school is a disgrace to the state whose laws permit its existence. 

Datt ofvitit: May, 1909. 

(4) Los ANGELES COLLEGE OF OSTEOPATHY. Emigrated from Iowa in 1905. A stock 
company. 

Entrance requirement: Less than an ordinary grammar school education, with con- 
ditions. Many of the students are men and women of advanced years. 

Attendance: Began two years ago with 60, now claims "more than 250." 

Teaching staff: 19. All the teachers are practitioners. 

Resources available for maintenance: Fees, the annual income being about $37,500 



CALIFORNIA 191 

from tuitions and a considerable sum from "treatments" (see below). As the instruc- 
tion provided is inexpensive, the stock must be a very profitable investment. 

Laboratory facilities : The school occupies a five-story building containing a chemical 
laboratory, with meager equipment and limited desk space, and a single labora- 
tory for histology, pathology, and bacteriology. The dissecting-room contains 
five tables, but sufficient material. The rest of the building is mainly devoted to 
treatment rooms and the business office. 

Clinical facilities: There is no free dispensary. Patients who are willing to undergo 
treatment before a class pay not less than $3 a month; patients who are treated 
in the presence of a single student pay $5. A hospital is now under construction. 

The general aspect is that of a thriving business. An abundance of advertising mat- 
ter, in which the profits of osteopathy are prominently set forth, 1 is distributed. 
Date of visit: May, 1909. 

(5) PACIFIC COLLEGE OF OSTEOPATHY. A stock company, established in 1896. 

Entrance requirement: Ostensibly high school graduation; but "mature men and 
women who have been in business are given a chance and usually make good." 

Attendance: 85. 

Teaching staff: 38, 19 being professors. 

Resources available for maintenance: Fees, amounting to $12,750 (estimated). 

Laboratory facilities: The school has an ordinary chemical laboratory, a fairly 
equipped laboratory for pathology, histology, and bacteriology, with a private 
laboratory for the instructor in these branches adjoining, the usual dissecting- 
room, and a limited amount of apparatus for experimental work in physiology. 

Clinical facilities : A dispensary is carried on at the school, which also owns a hospital 
for obstetrical and surgical cases. The catalogue fails, however, to state that the 
students have no regular work in this hospital. They rarely see medical cases; 
"they don't have as much acute work as they should." Nevertheless, they are 
drilled to "treat gonorrhea by diet and antiseptics; syphilis with ointments and 
dietetics, and without mercury; typhoid, pneumonia, etc.," along the same lines. 

Date of visit : May, 1909. 

OAKLAND: Population, 73,812. 

(6) COLLEGE OF MEDICINE AND SURGERY. Established 1902 as a stock company, stock 
partly subscribed by merchants of the town. 

1 " People are ready to pay for relief from distress and sickness. It is only fair to say that many of 
our graduates are earning as much in single months as they were formerly able to earn by a full 
years work." (Catalogue, p. 9.) 



192 MEDICAL EDUCATION 

Entrance requirement: "High school or equivalent.** 

Attendance: 17. 

Teaching staff: 82, 13 being professors. There are no full-time teachers. 

Resources available for maintenance: The school lives on fees, amounting to $2760 
(estimated), and on contributions from the faculty. 

Laboratory facilities: It occupies a new, well kept building, has a small laboratory 
for experimental physiology, small separate laboratories for bacteriology, histo- 
logy, and pathology, a beautiful, though not extensive, collection of pathological 
specimens, a laboratory for chemistry, a dissecting-room with provision for model- 
ing, and a small library of slight value. Though there are no full-time teachers, 
there is evidence of active interest in pathology. Post-mortems are abundant and are 
intelligently used, through a fortunate connection of the instructor in pathology. 

Clinical facilities : In respect to both dispensary and hospital, the clinical facilities 

are decidedly inadequate. 
Date ofvitit: May, 1909. 

SAN FRANCISCO: Population, 355,919. 

(7) UNIVERSITY OF CALIFORNIA MEDICAL DEPARTMENT. Established as such 1872. An 
organic department of the university. The first and second years' work is given 
at Berkeley. See (2). 

Entrance requirement: Two years of college work, strictly enforced. 
Attendance: 36, all but 2 from California, 

Teaching staff: 60, of whom 12 are professors. The laboratory courses at Berkeley 
are given by full-time teachers. 

Resources available for maintenance: The department shares the university funds, its 
budget calling for $33,396. The total receipts from fees are $7004. 

Laboratory facilities: The equipment and instruction are of the highest quality. The 
laboratories, though temporary in structure, are completely fitted up, in charge 
of high-grade teachers, abundantly provided with assistants and helpers. The sole 
question to be raised concerns the medical atmosphere, which, in several depart- 
ments, is not strongly in evidence. In consequence, post-mortem work has not 
been hitherto cultivated, though abundant opportunities for it exist. The bio- 
logical point of view prevails. This is not the case with anatomy, the teaching 
of which thoroughly scientific in method and spirit frankly meets the main 
purpose of the students. 

Clinical facilities : Clinical instruction is given in San Francisco. The university hos- 
pital, its main reliance, is small but modern. It contains 75 beds, practically all 



CALIFORNIA 198 

available for instruction. 1 Bedside teaching is carried on; but post-mortem work 
for the benefit of the students is meager. Some additional clinical work is procured 
at hospitals maintained by the city and by the United States government. In 
general, the laboratory and clinical departments are not as yet effectively correlated. 
The teachers of the third and fourth years are, excepting the dean, practitioners 
who are not in touch with the laboratory work and ideals as realized at Berkeley. 
Efforts are, however, making to bridge the gap. 

The hospital is unfortunately situated from the standpoint of a dispensary; such 
material as there is, is not well used from a teaching point of view. The students 
do not in all departments take an active part in the dispensary work. For example, 
in some of them they have nothing to do with making up the records, which are 
separately kept in the several departments. No report, showing the number of the 
distribution of cases, is obtainable. 
Date of visit: May, 1909. 

(8) LELAND STANFORD JUNIOR UNIVERSITY SCHOOL OF MEDICINE, ON THE COOPER MEDI- 
CAL COLLEGE FOUNDATION. Until 1908, the Cooper Medical College offered a four- 
year course based on high school graduation. Its property has now been deeded 
to Stanford University, its buildings being the seat of the clinical department of 
Stanford University School of Medicine, the instruction of the last five semesters 
being given in Cooper Hall and Lane Hospital. That of the first three semesters 
is given at Palo Alto. As its present classes graduate, the Cooper Medical College 
passes out of existence and its faculty disbands. 

Entrance requirement : Three years of college work. 

Attendance: 16 in first year (fourth collegiate year). No other year's work has yet 
been given. 

Teaching staff: 21, of whom 16 are professors. Six professors and one assistant pro- 
fessor give their entire time to medical work. The clinical professors thus far 
chosen have been taken from the former faculty of the Cooper Medical College. 

Resources available for maintenance : The department will share in the general in- 
come of the university. A special library endowment amounts to about $250,000. 

Laboratory facilities : These are provided at Palo Alto on the same scale as other 
departments there (anatomy, pharmacology, bacteriology, physiology, physio- 
logical chemistry). The school has an unusually valuable library of some 85,000 
volumes and receives the main current medical periodicals, American and foreign. 

Clinical facilities: Clinical work on the part of Stanford University is not yet begun. 
The university now owns the Lane Hospital of 125 beds, which has hitherto been 
conducted as a pay institution. Patients paying $10 a week are used for clinical 

1 During four months of 1909, there was a daily average of 44 free patients. 



194 MEDICAL EDUCATION 

teaching ; seventy -odd beds are thus available, part of these being temporarily 
supported by the city. 1 The hospital is now under temporary control of Cooper 
Medical College until needed by the university. Its organization at present, from 
the teaching point of view, is seriously defective. Records are meager ; no surgical 
rounds are made in the wards ; obstetrical work exists only in the form of an out- 
patient department; post-mortems are scarce. No hospital report is obtainable. 
The catalogue statement that the hospital is a teaching hospital is hardly sus- 
tained by the facts. 

The dispensary in the college building adjoining had in 1907 an attendance of 
20,000, including both old and new cases. But the material, though adequate in 
amount, was not thoroughly used by the Cooper Medical College. 
Date ofvirit: May, 1909. 

(9) COLLEGE OF PHYSICIANS AND SURGEONS. Established 1896. An independent school. 
Entrance requirement: "High school education or equivalent." 

Attendance: 70. 

Teaching staff": 53, 23 being professors. There are no full-time teachers. 

Resources available for maintenance: The institution has no resources but fees, 
amounting to $7715 (estimated). 

Laboratory facilities : The school has no laboratories worthy the name. 
Clinical facilities: There are no adequate clinical or dispensary facilities. 
Date ofvitit: May, 1909. 

(10) HAHNEMANN MEDICAL COLLEGE OF THE PACIFIC. Established 1881. Homeopathic. 
An independent school. 

Entrance requirement: "High school graduation or equivalent." 

Attendance: 23. 

Teaching staff": 35, 13 being professors, none of them full-time teachers. 

Resources available for maintenance: The institution has practically no resources 
but fees, amounting to $2685 (estimated). 

Laboratory facilities: The school occupies a small, well kept building containing the 
usual dissecting-room, a laboratory for elementary chemistry, one fairly equipped 
laboratory in common for histology, bacteriology, and pathology, and a small 
orderly library. 

Clinical facilities : Several neatly kept but inadequately equipped rooms are set aside 
for a dispensary ; the attendance is fair, the records meager. The main clinical reli- 

1 During four months of 1909, there was a daily average of 60. 



CALIFORNIA 195 

ance now is on a small number of beds paid for by the city in the Hahnemann 
Hospital, a modern institution close by. 1 
Date of visit: May, 1909. 

General Cormderations 

CONSIDERATION of medical education in California may well start from the fact that, 
without taking into account the osteopaths who abound the state has now one 
physician to every 401 inhabitants, that is, in round numbers, about four times as 
many doctors as it needs or can properly support. Such an enormous disproportion 
can hardly be rectified within less than a generation ; it makes radical measures in the 
interest of sound medical education not only immediately feasible, but urgently 
necessary. 

Legal enactment fixing a sound basis for future practitioners, of whatever school, 
the grant of authority to the state board to close schools flagrantly defective in 
either laboratory or clinical facilities, or the institution of practical examinations 
for license, any one of these measures would at once wipe out at least seven of the 
ten existing schools, with distinct advantage to the public health of the state. As 
none of these schools has the resources indispensable to meet the rising tide in 
medical education, this outcome is in any case inevitable; legal regulation of the 
type indicated would merely hasten the day. 

Even then the situation of medical education in the state is not altogether clear. 
The University of California has not yet solved its problem. The sums it now devotes 
to medical education are relatively small; its clinical facilities in San Francisco are 
inadequate; it has not effectively organized what it there offers; it has not brought 
about team work between the two severed branches that constitute the department. 
If now it has proved difficult to perfect an organization covering two places separated 
by San Francisco Bay, what reason is there to be confident when the distance involved 
is five hundred miles ? Nor does any practical need compel a step educationally ques- 
tionable. The attendance in Los Angeles in the last two years on a high school or 
equivalent basis is less than thirty ; it will fall still lower when the two-year college 
basis is enforced and transplantation from Berkeley to Los Angeles is required at 
the beginning of the third year. Moreover, the clinical prospects are by no means 
up to university standard. The dispensary may indeed be adequately developed, but 
one hundred beds in the general medical and surgical wards of an old-fashioned 
public hospital, however supplemented by courtesies elsewhere, constitute a fragile 
support for a university department of medicine. The difficulty of controlling the 
teaching at Los Angeles by the scientific ideals of the university at Berkeley can 
hardly be overstated. Finally, with the present needs of the clinical department at 
San Francisco, it is not likely that the university can divert to Los Angeles the sums 
necessary to create a satisfactory department there. The move is explained on the 

1 During four months of 1909 there was a daily average of 55 city patients. 



196 MEDICAL EDUCATION 

ground that peculiar conditions exist in the state; it is, however, not clear why a 
long narrow state is educationally in any different plight from a short broad one; 
in either case, needless multiplication of medical schools is economically wasteful and 
professionally demoralizing. 

The university has undertaken to dominate two detached clinical departments, 
manned by local practitioners. There is nothing in the present status of detached 
clinical departments of this type to encourage confidence in the outcome. Before too 
far committing itself to this policy, it is at least worth inquiring into the advis- 
ability of concentrating its medical instruction across the bay, where a population of 
over two hundred thousand affords sufficient clinical material, and where a compact, 
effective, and organically whole university department of medicine, with a faculty, 
laboratory and clinical, selected on educational principles, could be readily developed. 

These considerations apply in some respects with equal force to the action of 
Stanford University in taking over the Cooper Medical College at San Francisco. 
It was well enough to offer the laboratory sciences at Palo Alto, where the resources 
and ideals of the university insure high-grade instruction ; but the entrance of the 
university into the San Francisco field in all probability portends the division and re- 
striction of whatever opportunities the city may hereafter create. Lane Hospital can 
be developed into a teaching hospital of adequate size only if very large sums are 
available for the purpose; its organization and conduct have been in the past peda- 
gogically very defective; and the clinical professors so far appointed have been taken 
with one exception from the former Cooper faculty. With one university medical 
school already on the ground, a second and a divided school at that is therefore 
a decidedly questionable undertaking. There is no need of it from the standpoint 
of the public ; it must, if adequately developed, become a serious burden upon the 
finances of Stanford University. If the experience of other schools and cities is to be 
heeded, the question arises whether Stanford would not do well to content itself with 
the work of the first two years at Palo Alto, and to cooperate with the state uni- 
versity in all that pertains to the clinical end. 

The situation just presented deserves to be studied carefully by all interested in 
medical education. What has happened in California is likely to happen elsewhere. 
Scores of schools are beginning a desperate struggle for existence. Their first impulse 
is to throw themselves into the lap of some prosperous university. The universities, 
not as yet themselves realizing that medical education is no longer either profitable 
or self-supporting, are prone to complete themselves by accepting a medical depart- 
ment as an apparent gift. From the standpoint of the university this blunder will 
soon prove a serious drain, as increased expenditure on instruction and reduced in- 
come from fees reveal the actual state of affairs. From the standpoint of medical edu- 
cation and practice, the tendency in question is still more deplorable. The curse of 
medical education is the excessive number of schools. The situation can improve 
only as weaker and superfluous schools are extinguished. 



COLORADO 197 

COLORADO 

Population, 653,506. Number of physicians, 1690. Ratio, 1: 328. 
Number of medical schools, 2. 

DENVER: Population, 158,329. 

(1) DENVER AND GROSS COLLEGE OF MEDICINE. Organized by consolidation 1902. No- 
minally the medical department of the University of Denver, with which institu- 
tion it has, however, only a six months' contract; to all intents and purposes, a 
proprietary school, managed by its own faculty. 

Entrance requirement; Less than high school graduation, loosely enforced. 
Attendance: 109, over one-half from Colorado. 

Teaching staff: 44 professors and 35 of other grade, none of them giving their 
whole time to teaching. 

Resources available for maintenance: The school has no resources but fees, amounting 
to $12,624 per annum (estimated). 

Laboratory facilities : Its equipment consists of a chemical laboratory of the ordinary 
medical school type, a dissecting-room, containing a few subjects as dry as leather, 
a physiological laboratory with slight equipment, and the usual pathology and 
bacteriology laboratories. There is atotal absence of scientific activity. The rooms are 
poorly kept. A few cases of books are found in the college office behind the counter. 

Clinical facilities: The college owns a new and exceedingly attractive dispensary 
building. Separate rooms nicely equipped are occupied by the various specialties. 
The attendance averages 90 a day; the records are inadequate. There is an out- 
patient obstetrical service. 

For hospital facilities the school depends largely on the County Hospital, the 
management of which is political. Clinics are held daily from 8.30 to 10, "purely 
through courtesy." Students from all schools merely "look on ;" they are "not much 
at the bedside." Obstetrical work is limited, post-mortems rare. Hospital staff ap- 
pointments are secured through "pull;" the college must take into the faculty 
the men who are already on the hospital staff. Supplementary opportunities are fur- 
nished by several local institutions. In several of these, however, the clinics are not re- 
gularly scheduled: "announcements appear upon the bulletin board of the college." 

Date of visit: April, 1909. 

BOULDER: Population, 9,652. 

(2) UNIVERSITY OF COLORADO SCHOOL OF MEDICINE. Organized 1883. An integral part 
of the university. 



198 MEDICAL EDUCATION 

Entrance requirement: A four-year high school education or its equivalent. Creden- 
tials are passed on by the dean. 

Attendance: 85. 

Teaching staff": 45, of whom 25 are professors, 20 of other grade. 

Resources available for maintenance: The school is supported out of the total uni- 
versity income of $200,000 per annum. Its fee income is $4043; its budget, $28,000. 

Laboratory facilities: The school is in general satisfactorily equipped to do under- 
graduate teaching in the medical sciences. Full-time men are in charge of patho- 
logy, bacteriology, and physiology, though the departments lack trained assistants. 
Histology and embryology are taught in the department of biology. The chair of 
anatomy is occupied by a non-resident surgeon. There is a good library, with a 
subscription list including the best German and English journals. A regular fund 
is available for the purchase of books and apparatus. 

Clinical facilities : The university hospital is entirely inadequate, even though the 
school is small. It contains 35 beds and averages 16 patients available for teaching. 
Its management has only recently been modernized. It now contains a clinical 
laboratory where students work, keeping excellent records of their findings. There 
are from 12 to 15 obstetrical cases annually in the hospital; these are supple- 
mented by an out-patient service. 
The dispensary is slight. 

Date ofvirit: April, 1909. 

General Considerations 

THE state is overcrowded with doctors. It can therefore safely go to a higher stand- 
ard; indeed, the new law provides that after 1912, all applicants for license must 
have had, previous to their medical education, a year of college work. As this is a 
practice, and not an educational, requirement, the Denver school may still continue 
to train low-grade men for adjacent states; 1 but it is probable that if it continues 
on a standard below the legal practice minimum, it will be too discredited, and if it 
arises to the aforesaid minimum, too much reduced, to continue. The state univer- 
sity alone, so far as we can now see, can hope to obtain the financial backing neces- 
sary to teach medicine in the proper way regardless of income from fees, and to it 
a monopoly should quickly fall. Its laboratory facilities are steadily increasing, but 
adequate clinical resources are not at present assured. It is important, therefore, that 
as a first step the state university gain access to the clinical facilities at Denver, 
from which it is now cut off, first, by a constitutional provision forbidding the state 
university to teach except at Boulder, second, by the fact that the City Hospital is 

1 It is. however, equally in the interest of these states that a further low-grade supply should be cut 
off. Though none of the following states has a medical school, all have too many doctors. The ratios 
are: Wyoming, 1 : 541 ; Arizona, 1 : 627 ; Idaho, 1 : 663; New Mexico, 1 : 618. 



CONNECTICUT 199 

in the hands of the local school. These conditions, so common in American cities, are 
plainly against the general interest of the community. It may be that an arrangement 
can be made by which the Denver and Gross school will be handed over to the uni- 
versity, thus clearing the field of all obstacles to the upbuilding of a creditable school ; 
for as Boulder is practically a suburb of Denver, the difficulties in the way of effective 
management at Denver are not insuperable. Whether the entire medical school shall 
be permanently concentrated at Denver or, following the Ann Arbor plan, a liberally 
supported hospital at Boulder be relied on to overcome the disadvantage of location 
in the matter of clinical material, need not be decided just now. The important steps 
to take at this moment comprise (1) passage of the constitutional amendment open- 
ing the clinical facilities of Denver to the state university, (2) more liberal state ap- 
propriations for the medical school, and (3) the consolidation of the Denver and 
Boulder schools as the medical department of the state university. 1 



CONNECTICUT 

Population, 1,054,366. Number of physicians, 1424. Ratio, 1 : 740. 
Number of medical schools, 1. 

NEW HAVEN -.Population, 130,027. 

YALE MEDICAL SCHOOL. Organized 1813. An organic part of Yale University. 

Entrance requirement: Two years of college work, enforced with such unusual con- 
scientiousness that in passing from the high school to the college standard this 
year, deficient members of last year's class were refused re-admission. Moreover, 
the advanced requirement has been actually exacted; out of an entering class of 
23, one only is conditioned, in part of biology. This is probably the lowest per- 
centage of "conditions" that the country affords. 

Attendance: 138; 72 per cent from Connecticut. 

Teaching- staff': 64, 14 being professors. Of these, the teachers in the fundamental 
branches devote full time to instruction, though they are overworked and without 
a proper force of assistants; in the clinical branches, the professor of medicine 
with two assistants is salaried. Small sums are also paid to a few other teachers in 
the clinical years. 

Resources available for maintenance: Fees amounting to $15,325, income from en- 
dowment amounting to $10,000, university appropriation of $17,986, making 
annual budget $43,311. 

Laboratory facilities: Well equipped student laboratories for organic chemistry, 

1 As this Report goes to press, announcement is made that a consolidation of the Denver and Gross 
School with the medical department of the state university has been arranged. 



200 MEDICAL EDUCATION 

physiology, and pharmacology; the provision for bacteriology, pathology, and 
anatomy is less satisfactory. In physiology alone is there internal evidence of pro- 
gressive activity. The instructors in other branches are overworked, being called 
on to carry the routine work of extensive subjects in all their parts without ade- 
quate assistance. Under such circumstances, the work, however conscientious, is 
bound to be limited. 

Clinical facilities : The New Haven Hospital, in which the school controls a small 
number of beds, is very intelligently employed. The obstetrical and gynecological 
wards, however, are not used for teaching; nor is there a contagious disease pa- 
vilion. Post-mortems are scarce. Clinical laboratories and teaching-rooms have 
been improvised close by the hospital; students are thereby enabled to do the 
clinical laboratory work in connection with assigned cases. Provision is also made 
there for the independent work of the professors of medicine and surgery. 

The dispensary occupies a new and excellent building, but lacks systematic 
organization as a teaching adjunct. The attendance is adequate; but as the staff 
service is gratis, it varies greatly in quality in various departments. 

Date of visit : January, 1910. 

General Considerations 

As the school now stands, it would, in point of facilities, still have to be classed with 
the better type of those on the high school basis; for, though it has advanced to a 
two-year college basis, there has been as yet no corresponding improvement of facili- 
ties. In order to deserve the higher grade student body which it invites, a more liberal 
policy ought to be pursued. The laboratory branches ought to be better manned, so 
that the instructors may create within them a more active spirit. A university depart- 
ment of medicine cannot largely confine itself to routine instruction, certainly 
not after requiring two years of college work for admission to its opportunities. 
For the same reason the clinical facilities should be extended, probably through a 
more intimate connection with the present hospital. Its wards should be more gener- 
ally used; more beds should be made accessible within them; and the missing pavilion 
for contagious diseases be provided. Enough money ought to be spent on the dispen- 
sary to ensure in every department systematic and thorough discipline, in examining 
patients, keeping records, etc. 

To make these improvements, larger permanent endowment is required. As the 
school is one of a very few in New England so circumstanced as to have a clear duty 
and opportunity, it behooves the university to make a vigorous campaign in behalf 
of its medical department. 

[For gtneral ditcutrion t4 " New England" p. 261.] 



DISTRICT OF COLUMBIA 201 

DISTRICT OF COLUMBIA 

Population, 322,212. Number of physicians, 1231. Ratio, 1 : 262. 
Number of medical schools 3, plus two postgraduate (Army and Navy Medical) 
schools. 

WASHINGTON: Population, 327,044. 

(1) GEORGE WASHINGTON UNIVERSITY, DEPARTMENT. OF MEDICINE. Organized 1825. 
Now an integral department of the university. 

Entrance requirement: Less than a four-year high school course. 
Attendance: 117. 

Teaching staff: 69 instructors, 25 being professors, none of whom is a full-time teacher; 
three instructors of other grade devote entire time to the school. 

Resources available for maintenance: The school budget calls for $23,779; its income 
in fees is $21,833; the hospital is self-supporting. 

Laboratory facilities: The laboratories of physiology, pathology, chemistry, and 
anatomy are well equipped ; the building is admirably kept, and there is evidence 
of independent activity on the part of the several instructors. Animals are pro- 
vided; there is a fair library enjoying a small annual appropriation, and a small 
but attractive museum. Post-mortems are scarce. 

Clinical facilities: The University Hospital and Dispensary, under complete control, 
adjoins the medical school; 56 beds are available for teaching purposes. The staff 
has been recently reorganized on modern lines in order to increase the scope of 
bedside work. Supplementary opportunities are furnished under the usual condi- 
tions by several other hospitals. 

The dispensary has an annual attendance of something over 1000. 

Date of visit: March, 1909. 

(2) GEORGETOWN UNIVERSITY SCHOOL OF MEDICINE. Organized 1851. A university 
department in name only. 

Entrance requirement: Less than a four-year high school course. 
Attendance: 89. 

Teaching staff : 74, of whom 20 are professors; no one gives whole time to the medi- 
cal school, except the dean, who has the chair of hygiene and is treasurer of both 
medical and dental schools. 

Resources available for maintenance: Fees only, amounting to $11,000 a year. 
Laboratory facilities : The equipment consists of a good dissecting-room, a single 



202 MEDICAL EDUCATION 

fairly well stocked laboratory for pathology, bacteriology, and histology, a fair 
equipment for experimental physiology, and an ordinary chemical laboratory. 
There is no library accessible to students, no museum, and no pharmacological 
laboratory. 

Clinical facilities: The school has recently built a hospital, in which there are 100 
ward beds, not free, but available for clinical use. It is several miles distant. The 
usual supplementary clinics are held in other places also. A few rooms at the hos- 
pital are set aside for a dispensary; the attendance is small. 

Datt ofvirit: March, 1909. 

(3) HOWARD UNIVERSITY MEDICAL COLLEGE. Organized 1869. An integral part of 
Howard University. 

Entrance requirement: A high school course or its equivalent. 

Attendance: 205, most of whom are working their way through. Practically all the 
students are colored. 

Teaching staff: 52, 22 being professors, 30 of other grade. 

Resources available for maintenance: The school budget calls for $40,000, of which 
26,000 are supplied by student fees, most of the remainder by government appro- 
priation. Though the school has been changed from a night to a day school, the 
fees raised from $80 to $100, and the admission requirements stiffened, the at- 
tendance has nevertheless increased. 

Laboratory facilities : The laboratory equipment includes anatomy, pathology, his- 
tology, bacteriology, and chemistry. There is no organized museum, though the 
school possesses a number of specimens, normal and pathological, charts, models, etc. 

Clinical facilities : Clinical facilities are provided in the new, thoroughly modern, and 
adequate government hospital of 278 free beds, with its dispensary, closely identi- 
fied with the medical school. A pavilion for contagious diseases alone is lacking. 

Datt of visit: January, 1910. 

(4) ARMY MEDICAL SCHOOL. Organized 1822. Offers laboratory courses, covering 
eight months, to candidates who have passed their preliminary examinations as 
army surgeons. 

Attendance: 57. 

Teaching staff: 10 instructors, detached from the army for the purpose. 

Laboratory facilities : Excellent teaching and working laboratories in cramped quar- 
ters are provided in the building occupied by the great library and museum of the 
Surgeon -General's office. 

DaU of vitit : January, 1910. 



GEORGIA 203 

(5) NAVY MEDICAL SCHOOL. Offers laboratory courses, covering six months, to candi- 
dates who have passed preliminary examinations as navy surgeons. 

Attendance: 20. 

Teaching staff": Several instructors, detached from the service for three years or less. 

Laboratory facilities: Good teaching and working laboratories are provided in the 

building formerly used for the naval observatory. 
Date of visit : January, 1910. 

General Considerations 

OF the medical schools in Washington, Howard University has a distinct mission 
that of training the negro physician and an assured future. The government 
has to some extent been the patron of the institution, and has done its medical de- 
partment an incalculably great service by the erection of the Freedman's Hospital. 
Sound policy educational as well as philanthropic recommends that this hospital 
be made a more intimate part of Howard University, so that students may profit 
to the uttermost by its clinical opportunities. Its usefulness as a hospital in its im- 
mediate vicinity will be thereby increased; and its service to the colored race at large 
will be augmented to the extent to which it is used to educate their future physicians. 
The other two schools lack adequate resources as well as assured prospects. They 
are surrounded by medical schools those of Richmond, Baltimore, Philadelphia 
whose competition they cannot meet. Finally, the District of Columbia has relatively 
more physicians than any other part of the country. Should the District require, as 
it ought, a higher basis, or even enforce an actual four-year high school standard, 
both would suffer seriously. Neither school is now equal to the task of training phy- 
sicians of modern type. 

GEORGIA 

Population, 2,557,412. Number of physicians, 2887. Ratio, 1 : 886. 
Number of medical schools, 5. 

ATLANTA: Population, 118,243. 

(1) ATLANTA COLLEGE OF PHYSICIANS AND SURGEONS. Organized through merger, 1898. 
An independent school. 

Entrance requirement: Nominal. 

Attendance: 286, about 63 per cent from Georgia. 

Teaching staff: 51, of whom 20 are professors. None of the teachers devotes full time 
to the school. 



204 MEDICAL EDUCATION 

Resources available for maintenance: The school has practically no resources but fees, 
amounting to $28,000. 

Laboratory facilities : It is perhaps the best equipped of all the schools of its grade; 
it has good buildings, containing a good dissecting-room, dissecting material, 
however, somewhat scarce, a fairly equipped laboratory for physiology and physio- 
logical chemistry, one of the same character for histology and pathology, and 
a separate laboratory, well equipped, for bacteriology. Unfortunately, the school 
has no full-time instructors in these branches, so that, what with practitioner 
teachers and an inferior student body, the equipment cannot be used at its real 
value. There is a small library, but no museum. 

Clinical facilities: Hospital facilities are furnished by the Grady (free city) Hospital, 
close by. Except in obstetrics, to which department students are not admitted, 
the clinical material is fairly abundant; but it cannot be effectively used, 1 and the 
students are so unappreciative of their opportunities that attendance in the 
wards is very irregular. 

In the school building a large suite of rooms is set aside for a dispensary. The 
attendance is ample, the methods old-fashioned. 

Date of visit : January, 1909. 

(2) ATLANTA SCHOOL OF MEDICINE. Organized 1905. An independent school. 
Entrance requirement: Nominal. 

Attendance: 230; not quite 70 per cent from Georgia. 

Teaching staff: 44, of whom 17 are professors, no one devoting whole time to the 
school. 

Resources available for maintenance: Fees and gifts, amounting together to $20,000- 
$25,000 annually. 

Laboratory facilities : Its laboratory equipment is slight, though it possesses some 
features uncommon in schools of its type, an excellent projectoscope, an X-ray 
machine, and a small, useful library. There is no museum. 

Clinical facilities: A suite of rooms in fair condition only is provided for a dispensary. 
Likewise, in the basement of the college, two wards, containing 20 beds, have been 
arranged ; so far as they go, they are fairly well used. For the rest of its clinical 
instruction the school depends mainly on the Grady Hospital, so far off, however, 
that the students do not conscientiously attend. 

Datt of visit: January, 1909. 

(3) GEORGIA COLLEGE OF ECLECTIC MEDICINE AND SURGERY. Organized 1877. An in- 
dependent institution. 

1 The consent of ward patients must be obtained before bedside instruction can be given. 



GEORGIA 205 

Entrance requirement: Nominal. 

Attendance: 66. 

Teaching staff: 20, of whom 14 are professors and 6 of other grade. 

Resources available for maintenance: Fees, amounting to $5655 (estimated). 

Laboratory facilities: The school occupies a building which, in respect to filthy con- 
ditions, has few equals, but no superiors, among medical schools. Its anatomy room, 
containing a single cadaver, is indescribably foul; its chemical "laboratory" is 
composed of old tables and a few bottles, without water, drain, lockers, or reagents; 
the pathological and histological "laboratory" contains a few dirty slides and 
three ordinary microscopes. 

Clinical facilities : The school is practically without clinical facilities. Its outfit in 
obstetrics is limited to a tattered manikin. 

Nothing more disgraceful calling itself a medical school can be found anywhere. 
Date of visit: February, 1909. 

(4) HOSPITAL MEDICAL COLLEGE. Eclectic. Organized 1908. This institution occupies 
the rear of a private infirmary. Started in 1908 "on four weeks' notice 11 by seceders 
from the Georgia College of Eclectic Medicine and Surgery (see (3) above\'\i gradu- 
ated 17 doctors at the close of its first year. 

Entrance requirement : Nominal. 

Attendance: 43. 

Teaching- staff: 16, all of whom are professors. 

Resources available for maintenance: Fees, amounting to $3950 (estimated). 

Laboratory facilities : In the matter of equipment, it is impossible to say what be- 
longs to the school and what to the infirmary. At any rate, there is only one lab- 
oratory with any equipment worthy the name, that of pathology and bacteriology. 

Clinical facilities: The clinical facilities comprise the infirmary above mentioned, con- 
taining 16 beds. It is, of course, a pay infirmary. 
Date of visit: February, 1909. 

AUGUSTA: Population, 45,582. 

(5) MEDICAL COLLEGE OF GEORGIA. Organized in 1828, it has been since 1873 nomi- 
nally the medical department of the state university ; but it is entirely controlled 
by its own separate board, and "no liability for its debts or expenses shall be in- 
curred by the university." 1 The institution is therefore in effect a proprietary school. 

1 Agreement between Medical College of Georgia and University of Georgia, article 4. 



206 MEDICAL EDUCATION 

Entrance requirement: Nominal. 

Attendance: 99, mostly from Georgia. Twenty-six of these hold free county scholar- 
ships, in addition to which number the dean admits as many more as he pleases, 
generally at the request of congressmen. Eighteen students were admitted free in 
this way last year. Hence 44 of the 99 students are free. 

Teaching staff*: 33, of whom 18 are professors. 

Resources available for maintenance: The institution has no resources but fees, 
amounting to $6835. 

Laboratory facilities : The school occupies a building which contains an exceedingly 
foul dissecting-room, a meager equipment for elementary chemistry, a fair equip- 
ment for histology and pathology, and practically nothing for bacteriology. There 
is a small museum and a collection of several thousand books of mainly anti- 
quarian interest. 

Clinical facilities: The city hospital adjoining, containing 100 beds, less than half 
of them occupied at the time of the inspection, offers most of the clinical facili- 
ties; the Lamar Hospital is also available, but is more than a mile off, though 
described in the official catalogue of the state university as "located only a short 
distance from the college." At the city hospital the students get no obstetrical 
work because "the cases mostly come at night and you can't get the students;" at 
the Lamar Hospital they get none because " they are too busy." There is no evi- 
dence anywhere of clinical laboratory work. It was learned that at the city hospital 
there had been "two post-mortems in six years." 

There is a dispensary at the city hospital, but no records are kept. 

Datt of visit: February, 1909. 

General Considerations 

THE situation to be dealt with in this state is so simple that there is no room for 
difference of opinion as to what ought to be done. That every state in the south is 
overcrowded with doctors is generally admitted. Florida alone of surrounding states 
lacks a medical school, and there is an excess of doctors there (ratio 1 : 865). The 
two eclectic schools, as utterly incapable of training doctors, should be summarily 
suppressed. The Augusta situation is hopeless. There is no possibility of developing 
there a medical school controlled by the university. The site is unpropitious, the dis- 
tance too great. The university ought not much longer permit its name to be exploited 
by a low-grade institution, whose entrance terms if the phrase can be used are 
far below that of its academic department. It should snap the slender thread; the 
medical school will not long survive amputation. 

Two schools remain at Atlanta, a growing city in close proximity to the univer- 
sity at Athens. It would be easy to consolidate these two institutions to form the 



ILLINOIS 207 

medical department of the University of Georgia. The department could immediately 
adopt the general entrance requirements of the university, to be enforced by the 
university authorities. The faculty should, of course, be reconstructed and governed 
without restriction on university lines. The city's growth ensures a fair clinic and 
probably material aid. 

ILLINOIS 

Population, 5,717,229. Number of physicians, 9744. Ratio 1 : 586. 
Number of medical schools, 14, plus 4 postgraduate schools. 

CHICAGO: Population, 2,282,927. 

(1) RUSH MEDICAL COLLEGE. A divided school. Since 1900 the instruction of the 
first and second years has been given wholly at the University of Chicago, of 
which it is an integral part; the third and fourth years, given at the Cook County, 
the Presbyterian, and the Children's Memorial Hospitals and in the laboratory 
buildings adjoining them, are merely affiliated with the university. Pedagogically, 
the two branches do not form an organic whole. 

Entrance requirement: Two years of college work, strictly enforced, though a consid- 
erable part of the entering class is conditioned in part of the scientific require- 
ment. 

Attendance: 488. 

Teaching staff: 89 professors and 141 of other grade: total 230. The laboratory 
work is in charge of men devoting their entire time to teaching and research. 

Resources available for maintenance: The instruction provided by the university is 
paid for out of the university funds and costs annually $45,738; the clinical divi- 
sion, carried by student fees and by contributions, costs $36,714: a total cost of 
$82,452. The total income in fees is $60,485. 

Laboratory facilities : The laboratory branches are most liberally provided for on 
the university grounds; the laboratories are complete in number and equipment, 
each manned by a full staff, all the members of which are engaged in investiga- 
tion as well as in teaching. There is considerable difference of opinion among 
those engaged in teaching the scientific subjects as to how far the presentation 
should be deliberately medical in aim. 

Clinical facilities: Clinical facilities are provided by the Presbyterian Hospital, the 
staff of which is the faculty of the Rush Medical School, by the Cook County 
Hospital, and by other connections. The Presbyterian Hospital is an important 
adjunct, though thus far it is not by any means a genuine teaching hospital. It 
contains about 150 beds available for instruction. The Cook County Hospital will 



208 MEDICAL EDUCATION 

be discussed in connection with the general state situation. It is sufficient to say 
here that its abundant material is in a high degree valuable, though serious limi- 
tations upon its use exist. Rush holds 21 staff appointments. 
Dispensary facilities are entirely adequate. 

Datt of visit: April, 1909. 

(2) NORTHWESTERN UNIVERSITY MEDICAL DEPARTMENT. Organized 1859, it has borne 
its present title since 1891. An integral part of the university. 

Entrance requirement: One year of college work, hitherto loosely enforced. 
Attendance: 522. 

Teaching staff: 54 professors and 89 of other grade: 143 in all, ten of whom devote 
their entire time to the school. 

Resources available for maintenance: Except for two professorships, endowed to the 
extent of $60,700, the department lives on and pays for plant addition out of its fees 
now amounting to $89,076. 

Laboratory facilities : The school has the necessary laboratories, well equipped for 
routine work ; more could be done but that the full-time teachers lack the neces- 
sary assistants. 

Clinical facilities: These are provided by Mercy Hospital, Wesley Hospital, the Cook 
County Hospital, and other institutions. The Wesley Hospital, the staff of which 
comes wholly from the faculty of this school, 1 contains 80 free beds. It is, however, 
not primarily a teaching hospital, though it might apparently be reorganized as 
such with much advantage both to itself and to the medical school. The Cook 
County Hospital will be discussed below; Northwestern holds 12 staff appoint- 
ments there. In general, material is abundant in amount and variety; the defects 
of the situation arise from the lack of financial resources and pedagogical control. 
Dispensary requirements are amply met. 

Data ofvititt: April, 1909; December, 1909. 

(8) COLLEGE OF PHYSICIANS AND SURGEONS. Organized in 1882; since 1896 nominally 
the medical department of the University of Illinois, with which, however, only a 
contractual relation exists. 

Entrance requirement : A high school education or its equivalent, the latter hitherto 
very loosely interpreted, though somewhat stricter action has been enforced this 
year. The policy of the institution had been to accept students who satisfied the 
Illinois law as administered by the present state board ; the requirement has, there- 
fore, been more or less nominal. Advanced standing has been accorded to stu- 
dents from decidedly inferior schools, some of them among the worst institutions 

1 Students from the American Medical Missionary College attend certain clinics. 



ILLINOIS 209 

in the country. These students were examined, only those who passed being ac- 
cepted; but the fact that, with the teaching they have had, they can pass is con- 
clusive as to the nature of the examination. 

Attendance: 517, about 60 per cent from Illinois. 

Teaching staff: 198, of whom 42 are professors, 156 of other grade. 

Resources available for maintenance : The institution is practically dependent on its 
fees, amounting to $80,155 (estimated), and has a large floating debt. 

Laboratory facilities : The school has the following laboratories: physiology, well 
equipped; pharmacology and chemistry, mediocre; anatomy, pathology, and bac- 
teriology, adequate. There are full-time professors of anatomy and physiology, 
without skilled assistants or helpers. Their work is limited to routine. The school 
has a large library. 

Clinkal facilities: For these the school relies on the Cook County Hospital, on the 
staff of which it holds 11 appointments, and on a number of other institutions to 
which its students are admitted under the usual limitations. Prominent among 
these is the so-called "University Hospital," which may be cited as a typical in- 
stance of the misleading character of catalogue representations. The title itself is 
a misnomer; for the hospital is a university hospital not in the sense that large 
teaching advantages exist for the benefit of the university, but only in the sense 
that to the existing opportunities, restricted as they are, students from other schools 
are not admitted at all. The catalogue states that "it contains one hundred beds, 
and its clinical advantages are used exclusively for the students of this college." 
Not, however, the "clinical advantages" of the "one hundred beds," for 52 of them 
are private. Its "clinical advantages" shrink on investigation to three weekly am- 
phitheater clinics of slight pedagogic value and four ward clinics in obstetrics, 
each of the latter attended by some 12 or 14 students in a ward containing 13 
beds. Supplementary connections give access to large surgical clinics. 
The dispensary service is in general adequate. 

Dates of visits: April, 1909; December, 1909. 

(4) CHICAGO COLLEGE OF MEDICINE AND SURGERY. Organized 1901, and since 1902 
the medical department of Valparaiso (Indiana) University ; up to 1905 an eclectic 
institution. 

Entrance requirement : A high school education or its equivalent, interpreted to in- 
clude anything that the state board will accept. 

Attendance :The school had an enrolment of 315 in 1907-8, and of 366 in 1908-9, 
the senior class of the former year numbering 95, the freshman 69. This dispro- 
portion is largely due to the fact that advanced standing has been indiscriminately 
granted to students who had previously attended low-grade institutions, some of 



210 MEDICAL EDUCATION 

them now defunct. Credit has been allowed to former students of even the worst 
of the Chicago night schools. 

Teaching staff: The school has a faculty of 71, of whom 87 are professors. There are 
no full-time teachers, though some of the scientific branches are taught by full- 
time teachers of Valparaiso University, who come to the Chicago department on 
certain days weekly. 

Resources available for maintenance : Fees, amounting to $43,430 (estimated). 

Laboratory facilities : The equipment throughout is ordinary, the usual laboratories 
being provided. There are few teaching accessories. 

Clinical facilities : Clinical facilities are inadequate, being limited in the main to an 
adjoining hospital of 75 beds, of which one-fourth can be used for teaching, and 
to the Cook County Hospital, on the staff of which the school has two represen- 
tatives. 

The dispensary has a fair attendance and is in some respects well organized. 

DaU ofviiit: April, 1909. 

(5) BENNETT MEDICAL COLLEGE. Organized 1868, and up to 1909 an eclectic school. 
A stock company, practically owned by the dean of the school : " there are enough 
others to legalize the thing." 

Entrance requirement : Nominal compliance with the Illinois law on the subject. A 
pre-medical department, Jefferson Park Academy, recruited by solicitors, has 
been organized by way of feeding the medical school. A vigorous advertising and 
soliciting system is operated. 

Attendance : 181 ; about one-half from Illinois. 
Teaching- staff': 42, of whom 21 are professors. 
Resources available for maintenance : Fees, amounting to $19,380 (estimated). 

Laboratory facilities : The school building is in wretched condition. One badly kept 
room is devoted to anatomy ; it contained a few cadavers as dry as leather; another, 
in similar condition, is given to chemistry. There is slight provision for pathology 
and bacteriology; equipment for physiology is sufficient only for simple demon- 
strations. There are no teaching accessories worthy of mention. 

Clinical faculties : These comprise a pay hospital of 45 beds, in which it is claimed 
that 20 are made available for teaching use by means of free medical (not hospi- 
tal) services ; and two places on the Cook County Hospital staff. The clinical facili- 
ties are utterly inadequate. 
There is a small dispensary. 



ILLINOIS 211 

The institution is frankly commercial. Its change of name (dropping "eclectic") is 
a business move. 

Date of visit: April, 1909. 

(6) AMERICAN MEDICAL MISSIONARY COLLEGE. Organized 1895. This school gives the 
bulk of its instruction at Battle Creek, Michigan, which see for complete account. 

(7) JENNER MEDICAL COLLEGE. Organized 1892. A night school, occupying three 
upper floors of a business house. An independent institution. 

Entrance requirement: Nominal compliance with state law. A one-year pre-medical 
class is operated by way of satisfying the law. 

Attendance: 112. 

Teaching staff: 37, of whom 28 are professors. 

Resources available for maintenance: Fees, amounting to $12,880 (estimated). 

Laboratory facilities : The equipment consists of a meager outfit for chemistry, a 
somewhat better equipment for physiology, though no animals were to be seen, 
and a slight outfit for pathology and bacteriology. Anatomy is taught by lectures 
"with the cadaver" from the beginning of the year until May 15, after which 
there is "dissecting until the close of the year." 

Clinical facilities : Clinical facilities are practically nil, one or two night clinics 
being all that the school claims to offer. The school once had access to Grace 
Hospital, a private institution of 30 beds; but it has recently been turned out for 
failure to pay for the privilege. 

The dispensary attendance varies from two to ten, four nights weekly. No par- 
ticular rooms for dispensary purposes are provided: "patients are taken right into 
the rooms where the classes are." 

An out-and-out commercial enterprise. The instruction is plainly a quiz-compend 
drill aimed at the written examinations set by the state board of Illinois and of 
other states. The possibility of teaching medicine acceptably in a night school is 
discussed below (p. 216, note). 
Date of visit: April, 1909. 

(8) ILLINOIS MEDICAL COLLEGE. Organized 1894. ) 

(9) RELIANCE MEDICAL COLLEGE. Organized 1907.J 

These two schools are bracketed because they are only different aspects of one en- 
terprise worked in two shifts, one body of students attending by day, the other by 
night. The plant is thus in "continuous performance." It is owned by its president, 
who is in the main assisted in the scientific branches by recent college graduates, 
to whom small sums are paid ; in the clinical branches by young physicians who 



212 MEDICAL EDUCATION 

tender their services gratis in order to "work up their business." The day school is 
affiliated with Loyola University. 

Entrance requirement: Of the kind usual in Illinois commercial medical schools. A 
pre-medical class, running three hours each night, covers in one year the work of 
two high school years. A boy who is engaged all day in trade can thus "finish" 
two years' English, Latin, and mathematics at night in a single session. It is prob- 
able that the pre-medical course will be lengthened to two such years, "equiva- 
lent" to an entire high school course according to the "Illinois idea." 

Attendance: Reliance Medical College, 83; Illinois Medical College, 69. 

Teaching staff: The night medical school (Reliance) has a faculty of 44, 23 being pro- 
fessors ; the day branch (Illinois Medical) has a faculty of 73, 38 being professors. 

Resources available for maintenance: Fees, amounting to $9945 (Reliance, estimated); 
$9175 (Illinois, estimated). 

Laboratory facilities: The equipment conforms to legal stipulations: there is a library, 
the beginnings of a museum, an ordinary dissecting-room, a small amount of ap- 
paratus for physiology, and fair laboratories, as things go, for chemistry, histology, 
pathology, and bacteriology. The laboratories are in good condition and are really 
used. 

Clinical facilities. Day students: Some eight or ten hours weekly for junior and senior 
classes in scattered hospitals; work almost wholly surgical; one to two hours daily 
in the dispensary in the college building. Students see no contagious diseases; 
obstetrical work is all out-patient. Night students: About six hours weekly at the 
Cook County Hospital between 6.30 and 9.30 p.m., opportunities being limited 
to looking on at surgical work; dispensary, nightly. The night students see no 
children's diseases, no acute medical diseases at the bedside, no contagious diseases. 

Datet of visit*. April, 1909; December, 1909. 

(10) NATIONAL MEDICAL UNIVERSITY. A night school, organized in 1891 as "homeo- 
pathic," which word was subsequently dropped. Ostensibly the medical depart- 
ment of the "Chicago Night University," which claims departments of arts, law, 
dentistry, pharmacy, etc. The school appears to be owned by the "dean." 

Entrance requirement: Entrance is on the same basis as in other night schools; a 
"preparatory department" is also in operation. 

Attendance: 150. "Free transportation from Chicago to Vienna by way of New York, 
London, Paris," etc., is offered to any graduate who has for "three years or more 
paid regular fees in cash." 

Teaching staff: 36. 

Resources available for maintenance: Fees, amounting to $22,500 (estimated). 



ILLINOIS 213 

Laboratory facilities; The school occupies a badly lighted building, containing no- 
thing that can be dignified by the name of equipment. There had been no dissecting 
thus far (October to the middle of April), anatomy being didactically taught. 
Persistent inquiry for the "dissecting-room" was, however, finally rewarded by 
the sight of a dirty, unused, and almost inaccessible room containing a putrid 
corpse, several of the members of which had been hacked off. There is a large 
room called the chemical laboratory, its equipment "locked up,"" the tables spot- 
less. "About ten" oil-immersion microscopes are claimed also "locked up in the 
storeroom." There is not even a pretense of anything else. Classes in session 
were all taking dictation. 

Clinical facilities: The top floor is the "hospital:" it contained two lonely patients. 
Access to a private hospital two miles distant is also claimed. 

Recently this school has been declared by the Illinois State Board of Health as "not 
in good standing." The same action was taken once before, but was afterwards re- 
voked; just why, it is impossible to find out; for the school was after the revoca- 
tion just exactly what it was at the time of its suspension; and it is the same 
to-day. 
Date of visit: April, 1909. 

(11) COLLEGE OF MEDICINE AND SURGERY: PHYSIO- MEDICAL. Organized 1885. An 
independent school. 

Entrance requirement: Such as satisfies the present interpretation of the law. A dili- 
gent search in the office desk and safe failed to discover any credentials of students 
now in the school. 

Attendance: 33. 

Teaching staff': 42, of whom 33 are professors. 

Resources available for maintenance: The school has no resources but fees, amounting 
to $2935 (estimated). 

Laboratory facilities : The equipment is very meager. 

Clinical facilities: Clinical facilities amount to little: there were in the hospital last 
year 167 patients, over one-half surgical; there is an annual attendance of 250 in 
the dispensary. 

Date of visit: April, 1909. 

(12) HERING MEDICAL COLLEGE. Homeopathic. Organized 1892. This school teaches 
homeopathic doctrine in its original purity. 

Entrance requirement: "High school or equivalent." 
Attendance: 32. 



214 MEDICAL EDUCATION 

Teaching staff: 44, of whom 30 are professors. 

Resources available for maintenance : Fees, amounting to $3360 (estimated). 

Laboratory facilities : The equipment is very meager. 

Clinical facilities : These are very limited. Students are not admitted to the adjoining 

hospital. There is a small dispensary. 
Daitofvirit: April* 1909. 

(13) HAHNEMANN MEDICAL COLLEGE. Homeopathic. Organized 1859. An indepen- 
dent institution. 

Entrance requirement : " High school or equivalent." 

Attendance :130. 

Teaching staff: 84, of whom 38 are professors. 

Resources available for maintenance : Fees, amounting to $14,300 (estimated). 

Laboratory facilities : The school occupies a building wretchedly dirty, excepting only 
the single laboratory, fairly equipped, devoted to pathology and bacteriology. The 
equipment covers in a meager way also anatomy, physiology, histology, chemistry. 

Clinicalfacilities : In the adjoining hospital there are accommodations in the wards for 
60 beds, but there are no ward clinics. The superintendent is a layman who " does 
not believe in admitting students to the wards. There is no regular way for them 
to see common acute diseases," as only amphitheater clinics are held. Hospital in- 
ternes do all the obstetrical work ; students " look on." The school also holds two 
appointments on the surgical side in the Cook County Hospital. 
There is a fair dispensary. 

Date ofvitit : April, 1909. 

(14) LITTLEJOHN COLLEGE OF OSTEOPATHY. An undisguised commercial enterprise. 
Entrance requirement: Nominal. 

Attendance: 75. 

Teaching staff: 43. 

Resources available for maintenance : Fees, and income from patients. 

Laboratory facilities : Practically none. At the time of the visit, some rebuilding was 
in progress, in consequence of which even such laboratories as are claimed were, 
except that of elementary chemistry, entirely out of commission and likely to re- 
main so for months : but " teaching goes on all the same." Class-rooms were prac- 
tically bare, except for chairs and a table. 

Clinical facilities .-The Littlejohn Hospital, a pay institution of 20 beds, mostly sur- 



ILLINOIS 215 

gical, which can be of little use. It was claimed, too, that " medicine and surgery 
are taught in the school," and color is lent to the statement by the presence on 
the faculty of physicians teaching materia medica, etc. 
Date of visit: December, 1909. 

(15) THE POSTGRADUATE MEDICAL SCHOOL AND HOSPITAL. A stock company. 
Teaching staff: 98. 

Resources available for maintenance : Fees. 

Laboratory facilities : A good working clinical laboratory. 

Clinical facilities : The school offers clinical instruction in its own hospital, containing 
a small number of beds, and in other Chicago institutions. The instruction is at- 
tended by physicians for periods varying from a few weeks to a year. 

Date of visit: April, 1909. 

(16) CHICAGO POLYCLINIC. A postgraduate institution organized as a stock company. 
Offers special courses to graduated physicians. 

Attendance: Perhaps 30 at any given time; a total of 350 in the course of a year. 
Teaching staff: 92, 30 being professors, 62 of other grade. 
Resources available for maintenance : Fees. 

Laboratory facilities : A small clinical laboratory, the instruction in technique being 
given by a first-year student in one of the night schools ; in the absence of the 
instructor, he also conducts classes. 

Clinical facilities : The main reliance is the Polyclinic Hospital of 80 beds, two-thirds 

of them surgical. 
Date of visit: December, 1909. 

(17) CHICAGO EAR, EYE, NOSE, AND THROAT COLLEGE. A stock company offering 
courses in certain specialties. 

Attendance: 20 on average; average period of residence, two months; a few remain 
six to twelve months. 

Teaching staff: 22. 

Resources available for maintenance: Fees. 

Facilities: A fairly equipped dispensary with a daily attendance of 15 to 20 new 
patients; a hospital with 10 ward beds, empty at time of visit, "but full a week 
ago. 1 " The work is all immediately practical; there are no facilities for fundamen- 
tal or intensive instruction or effort. 

Date of visit : December, 1909. 



216 MEDICAL EDUCATION 

(18) ILLINOIS POSTGRADUATE SCHOOL. A stock company. 

Entrance requirement: The M.D. degree. 

Attendance: 6 to 8 at any given time. 

Teaching staff': 86, of whom 26 are professors, 10 of other grade. 

Resources available for maintenance: Fees. 

Laboratory facilities: Practically none. 

Clinical facilities: The school offers courses at the West Side Hospital, a private in- 
stitution of 86 beds occupied mostly by surgical cases. There is a large dispensary. 
Date ofvitit: December, 1909. 

General Considerations 

THE city of Chicago is in respect to medical education the plague spot of the country. 
The state law is fairly adequate, for it empowers the board of health to establish a 
standard of preliminary education, laboratory equipment, and clinical facilities, thus 
fixing the conditions which shall entitle a school to be considered reputable. In pur- 
suance of these powers, the board has made the four-year high school or its equivalent 
the basis, and has enumerated the essentials of the medical course, including, among 
other things, clinical instruction through two annual terms. 

With the indubitable connivance of the state board, these provisions are, and have 
long been, flagrantly violated. Of the fourteen undergraduate medical schools above 
described, the majority exist and prepare candidates for the Illinois state board ex- 
aminations in unmistakable contravention of the law and the state board rules. 
These schools are as follows : (1) Chicago College of Medicine and Surgery (Valpa- 
raiso University), (2) Hahnemann Medical College, (3) Hering Medical College, (4) 
Illinois Medical College, (5) Bennett Medical College, (6) Physio-Medical College of 
Medicine and Surgery, (7) Jenner Medical College, (8) National Medical University, 
(9) Reliance Medical College, (10) Littlejohn College of Osteopathy. Of these, only 
one, the National Medical University, has been deprived of "good standing " by 
the state board. Without exception, a large proportion of their attendance offers for 
admission an " equivalent," which is not an equivalent in any sense whatsoever ; it 
is nevertheless accepted without question by the state board, though the statute ex- 
plicitly states that it can exact an equivalent by " satisfactory " examination. In the 
case of the night schools, 1 for instance, one or two years' requirements are satisfied 

1 Even supposing the night schools enforced an entrance standard and actually provided laboratories 
and hospitals of the right kind, the teaching of anything but didactic medicine at night is practically 
impossible, because : (1) The time is too limited. The day school is in operation all day long and the 
student has his evenings for study ; the night school can at most secure three or four hours when the stu- 
dent is already physically fatigued. (2) Laboratory work by artificial light is bound to be unsatisfac- 
tory, even if the lighting is good, which is not usually the case. (3) Hospital clinics, operations, etc., 
must be very limited at night, when the interest of the patient requires that he be allowed to rest. 
Children's diseases cannot be studied at night at all. (4) The situation is rendered even more absurd 
by the fact that, in addition to all these handicaps, the night school student frequently has to make 
up some conditions in preliminary studies. 



ILLINOIS 217 

by " coaching " one night a week in each of the several subjects : one evening is de- 
voted to Latin, the next to English, the next to mathematics. There is absolutely 
no guarantee that the candidate accepted on the equivalent basis has had an educa- 
tion even remotely resembling the high school training which the Illinois law intends 
as the minimum upon which it will recognize a candidate for the physician's license. 
If the state board should as in duty bound publicly brand these schools as "not 
in good standing" by reason of their failure to require a suitable preliminary educa- 
tion of their students, their graduates would be immediately excluded from practice 
in Illinois ; adjoining states would rapidly follow suit, with the result that the schools 
would shortly be exterminated. Fortunately, the case against them does not rest alone 
on the question of entrance requirements : for not a single one of the schools men- 
tioned furnishes clinical opportunities in proper abundance, and some of them even 
fail to provide the stipulated training in other branches, e. g., anatomy. An efficient 
and intelligent administration of the law would thus reduce in short order the medi- 
cal schools of Chicago to three, Rush, Northwestern, and the College of Physicians 
and Surgeons. 1 In the matter of entrance requirements, Rush alone is secure. The 
College of Physicians and Surgeons rests on the high school or equivalent basis; 
if a scholastic equivalent, such as would be acceptable to the academic department 
of the state university, is insisted on, the registration will be seriously diminished. 
Northwestern is in a similar plight: it requires now a high school education or 
equivalent, followed by a year of college which it does not get. If its standard were 
enforced, its present attendance would be considerably reduced. At both Northwest- 
ern and the College of Physicians and Surgeons the inequality and incapacity of the 
present student body are frankly conceded. "The facilities are better than the stu- 
dents," said a professor at the former; "the admission machinery doesn't stop the 
unfit," said a professor at the latter. That both these schools will be driven by in- 
ternal and external forces to a higher level, actually enforced, is inevitable. When 
that happens, their attendance will materially shrink; and as higher standards will 
check the invasion of medical schools by drifting waverers, and will tend to keep the 
number of doctors in more nearly normal relation to the needs of the population, it 
is not likely that either school will again attain its former size. This consideration is 
rendered additionally important because it portends a marked reduction in income 
through fees, upon which both schools still depend. 

In the matter of teaching facilities, the three schools under discussion satisfy the 
law ; but they satisfy the aspirations of their faculties only in varying degrees. The 
scientific work of the University of Chicago, relied on by Rush, is excellent; the pro- 
vision made by Northwestern and the College of Physicians and Surgeons is distinctly 
inferior to it. Assuming that Northwestern will rise to an actual one or two year 
college basis, it must provide correspondingly increased facilities both for the higher 
grade students and for the more productive teaching body which these students will 
a For the American Medical Missionary College, see "Michigan." 



218 MEDICAL EDUCATION 

demand. There are, for instance, several full-time instructors, but they are without 
an adequate force of assistants. The needs of the College of Physicians and Surgeons 
are much greater. Its laboratory facilities and equipment are inadequate even for the 
present student body ; and it has barely begun the development of a full-time teach- 
ing staff in the scientific branches. Both these schools face an era of increased in- 
vestment in plant and of considerably augmented running expenses, coinciding with 
a period of reduced income from tuition fees. 

On the clinical side, Rush and Northwestern do not differ substantially ; the College 
of Physicians and Surgeons is somewhat inferior. Both Rush and Northwestern have 
an exclusive staff connection with certain hospitals. Their hospital situation is there- 
fore, as things go in this country, tolerable. They command a sufficient number of 
cases, subject, however, to two defects that will be more acutely felt as clearer ideals 
become dominant in medical education : (1) they are not in position freely to import 
clinical teachers, nor (2) can they in general discontinue a professorial appointment 
without to the same extent abridging their clinical resources; none of them completely 
controls, even in a single hospital, the conditions under which clinical instruction is 
given. 1 

The Cook County Hospital is common to all three. Its relations to the medical 
schools have been subject to variation and disturbance. The institution is con- 
ducted by a lay warden, who, though a politician, is now friendly to the schools. 
At present, the staff is selected by civil service examination every six years. Rush 
now holds twice as many appointments as either of the other two schools, a discre- 
pancy that may be either emphasized, obliterated, or reversed at the next examina- 
tion. The main clinical facilities of the several schools are thus precarious. They are 
also limited: a recent unpleasantness due, according to one version, to a quarrel 
between certain doctors and some nurses who objected to the careless way in which 
the doctors replaced the bed sheets has resulted in the exclusion of students from 
the wards. Patients are exhibited in rooms. The incident involves serious limitations 
upon teaching methods, and illustrates the uncertainty which attaches to mere privi- 
leges and courtesies. Cases cannot be assigned for intensive study to particular stu- 
dents; hospital residents make the records and do the clinical laboratory work. The 
undergraduate student can see conditions in abundance; he cannot at close range 
observe processes in development. The Cook County Hospital is therefore, from a 
strictly educational point of view, not a laboratory in which beginners can be trained 
in a thorough technique. It is, however, immensely valuable as a storehouse of 
illustrative material for students who have elsewhere received a satisfactory prelimi- 
nary discipline. 

None of the supplementary hospitals used by the schools cures these defects. They 

1 Rush comes nearest to desirable conditions at Presbyterian Hospital, for staff appointments there 
are by contract completely controlled by its faculty. But it is provided that "no patient shall be made 
the subject of clinical instruction without his or her consent. 



ILLINOIS 219 

are too small; their purpose is only secondarily educational; friction is liable to arise 
over efforts to retain patients for teaching purposes; the students remain more or 
less outsiders. 

The modernization of medical education in Chicago requires, then, that two of 
the three schools in question should greatly strengthen their laboratory instruction, 
and that all three should strengthen their clinical instruction. The number of stu- 
dents to be provided for is a factor in determining a definite line of procedure. Rush 
has on its two-year college basis 488 students; Northwestern had in its first-year 
class, on a very loosely enforced one-year college basis, 66; the inevitable two-year 
standard will greatly reduce this number. Should the College of Physicians and Sur- 
geons go to the two-year college standard, an inevitable development if it lives, 
it would suffer similarly. It seems fair to estimate, then, that the actual number of 
medical students in Chicago on a two-year college basis will not be too large to be 
cared for in a single school adequately equipped with laboratories and hospital. 
As medical education on the proper basis cannot be attempted outside a university, 
and as none of the three universities now teaching medicine in Chicago is likely to 
abandon the field to the others, it is suggested in the interest of efficiency and eco- 
nomy that (1) each of the three universities continue to provide like the University 
of Chicago the instruction of the first two years; (2) all three universities combine 
to form a clinical department under joint management, the first step towards which 
would be a concerted effort to procure a proper hospital for the use of third and 
fourth year men. The sum necessary to procure three such hospitals is so large that 
it is highly improbable that as separate institutions the schools can acquire sepa- 
rate and adequate clinical departments. Inasmuch as there is no demand for gradu- 
ates exceeding the capacity of one clinical school, it would be sheer extravagance to 
equip three on the basis proposed. The Cook County and other hospitals would, on 
the suggested arrangement, play the part for which they are exactly suited in fur- 
nishing illustrative material for advanced students whose discipline had been else- 
where looked to, and in making possible the development of instruction for gradu- 
ates in all the specialties, a form of opportunity for which, just for lack of differ- 
entiation and organization, our physicians are still forced to go abroad. A great 
opportunity is thus fairly within the grasp of Chicago : the conditions to its realiza- 
tion are honesty and intelligence on the part of the state authorities, and cooperation 
between the three great universities of the state. The execution of this plan might 
set the country at large to thinking on the wisdom and necessity of coordinating our 
educational enterprises. Everywhere, thus far, our higher education has worn a com- 
petitive aspect. Some good has been thus accomplished; but now that local or nu- 
merical competition can be replaced by scientific and scholarly competition, to which 
the entire country and indeed the civilized world are parties, we begin to realize the 
waste and demoralization due to institutional competition. It is difficult to see how 
the state of Illinois, which in the interest of public health ought to be a factor in 



220 MEDICAL EDUCATION 

medical education, can make an effective contribution thereto except by cooperation 
with the Chicago schools. Should the state seek to develop its own school in Chicago 
with the inevitable low tuition fees, great friction must result. Much preferable to 
conflict would be the withdrawal of the state from participation in clinical instruc- 
tion altogether, content in that event with a half-school at Urbana, strengthened, 
be it hoped, by state laboratories of public health. The entire situation presents 
a rare opportunity for educational statesmanship. 

INDIANA 

Population, 2,808,115. Number of physicians, 5,036. Ratio, 1 : 558. 
Number of medical schools, 2. 

BLOOMINGTON-INDIANAPOLIS: (Population: Bloomington, 8,902; Indian- 
apolis, 249,426). 

(1) INDIANA UNIVERSITY SCHOOL OF MEDICINE. Started at Bloomington, 1908, it first 
gave two years' work at Bloomington, 1905, and the entire course at Indianapolis, 
1909, through absorption of the local school. The double department is an organic 
part of the state university. 

Entrance requirement; One year of college work. 
Attendance: 266, 94 per cent from Indiana. 

Teaching staff: 175, of whom 99 are professors. The laboratory branches at Bloom- 
ington are taught by full-time teachers, some of whom will for a while divide 
their time between Indianapolis and Bloomington. The Indianapolis teachers are 
otherwise all practitioners. 

Resources available for maintenance: Both departments will be hereafter supported 
out of the general funds of the university, as the Bloomington department has 
hitherto been, at a heavy loss, of course. Fees (amounting at Indianapolis and 
Bloomington together to $31,240) are paid into the university treasury. 

Laboratory facilities : At Bloomington separate laboratories with good equipment 
are provided for pathology and bacteriology, physiology and pharmacology, and 
anatomy, the last-named strong in histology and neurology. Embryology is 
taught in the department of biology, physiological chemistry in the department 
of chemistry. Books and periodicals are accessible. 

At Indianapolis the laboratories of the absorbed school were limited, but the 
university has already taken some steps to bring them up to the level of the Bloom- 
ington department. 

Clinical facilities : Clinical instruction will be given at Indianapolis alone. The city 
dispensary is under control of the school faculty and has just been placed in charge 



INDIANA 221 

of a man of modern training. The attendance has been good. The City Hospital 
staff is appointed by the board of health on nomination of the university. The 
facilities are fair, but they have been used to little advantage in the past. There 
is no pavilion for contagious diseases. 
Date of visit: December, 1909. 

VALPARAISO: Population, 6280. 

(2) VALPARAISO UNIVERSITY. This institution offers first two years at Valparaiso and 
all four in Chicago. (See Chicago College of Medicine and Surgery.) The two-year 
department was organized in 1901. 

Entrance requirement: A high school course or its equivalent. 
Attendance: 25. 

Teaching staff: Two instructors conduct the classes in physiology, pathology, bac- 
teriology, and anatomy, in the medical building. Chemistry, materia medica, and 
pharmacy are taught by men who give courses in these same branches to other 
students. The pathologist spends one-third of his time in the Chicago depart- 
ment. 

Resources available for maintenance: Fees only. 

Laboratory facilities : There is a simple but good equipment for teaching the neces- 
sary branches in an elementary form, pathology being perhaps the weakest by 
reason of the small amount of gross material available. The time of the teachers 
is consumed in routine work. 

Date of visit : December, 1909. 

General Considerations 

THE situation in the state is, thanks to the intelligent attitude of the university, 
distinctly hopeful, though it will take time to work it out fully. The university 
has just secured complete control of the Indianapolis school. The state board has 
already come to its help by making the two-year college standard, in force at the 
university in 1910, the legal minimum for practice within the state. This places medi- 
cal education in Indiana, as it already is in Minnesota, in the hands of the state uni- 
versity. The Bloomington department has been of such a character that it was easily 
possible to make it worthy of college-bred students, but the detachment of its teachers 
for regular service at Indianapolis should not long continue. While it is highly im- 
portant that close relations be encouraged, it is necessary to accomplish this by pro- 
gressively strengthening the Indianapolis end. 

The Indianapolis school has been of the ordinary local type of the better sort. 
In order to make the school attractive to highly qualified students, it will be neces- 
sary (1) to employ full-time men in the work of the first two years, (2) to strengthen 



222 MEDICAL EDUCATION 

the laboratory equipment, (3) greatly to improve the organization and conduct of 
the clinical courses. The trustees have formally committed themselves to this policy. 
It would appear necessary for some years to regard the needs of the Indianapolis 
department as a first lien on the increasing income of the university, if the univer- 
sity is to make good the ideals indicated by its entrance requirement. It can do Indi- 
ana no greater service in any direction. That done, Indiana will be one of the few 
states that have successfully solved the problem of medical education. 



IOWA 

Population, 2,192,608. Number of physicians, 3,624. Ratio, 1 : 605. 
Number of medical schools, 4. 

DES MOINES: Population, 89,113. 

(1) DRAKE UNIVERSITY COLLEGE OF MEDICINE. Organized in 1882 as an independent 
school, it became a university department in 1900. 1 

Entrance requirement: A four-year high school education. 
Attendance: 106. 

Teaching staff: 16 professors and 29 of other grade; total, 45. There are no whole- 
time teachers. Student assistants are employed in the laboratories. 

Resources available for maintenance: The school is practically dependent on its fees, 
the volume of which is not large, for the funds of the university are too slender 
to permit any considerable allotment to the medical department. The total budget 
of the department was $12,417, of which $9505 came from student fees, $1239 
from interest. 

Laboratory facilities : Modest laboratories, whose condition speaks well for the con- 
scientiousness of those in charge, are provided for chemistry, anatomy, pathology, 
and bacteriology. The provision for physiology is somewhat more slender. 

Clinical facilities : The school conducts clinics by courtesy at two hospitals, where 
instruction is given in a demonstrative way for some twelve to fifteen hours weekly. 
The opportunities are in every respect inadequate: the time is too short, the 
amount of material available too little, and the opportunities open to students too 
limited. A fair amount of obstetrical work is obtained. 

The school owns and controls a small dispensary, fairly well equipped and 
painstakingly conducted. 

Date of vint: April, 1909. 

1 As this report goes to press, it is announced that a fund of $100,000 has been subscribed with which 
to improve this school. 



IOWA 223 

(2) STILL COLLEGE OF OSTEOPATHY. Organized 1898. An independent school. 
Entrance requirement: Less than a common school education. 
Attendance: 115. 

Teaching staff: 15, of whom 13 are professors. 

Resources available for maintenance: Fees, amounting to $17,250 (estimated). 

Laboratory facilities : These are mainly limited to signs. " Anatomy " is painted pro- 
minently on a door which, on being opened, reveals an amphitheater ; "Physiology** 
on a door which, on being opened, reveals a class-room with an almost empty 
bookcase, but no laboratory equipment; the key to "Histology" could not be found; 
"Chemistry" proved to be a disorderly elementary laboratory with some slight out- 
fit for bacteriology besides. The dissecting-room was inadequate and disorderly. 

Clinical facilities : The school makes no pretense of having hospital facilities. The 
catalogue states: "Cases" pay cases of course "needing hospital service are 
placed in the hospitals of the city," where the students cannot see them. The 
catalogue says of the infirmary: "The patient in no way comes in contact with the 
college clinic." 

Everything about the school indicates that it is a business. One is therefore not sur- 
prised to find the following advertisement in the local newspaper: "Have your 
case diagnosed at Still College of Osteopathy, 1442 Locust Street." (Des Moines 
Register and Leader, Nov. 3, 1909.) 
Date of visit: April, 1909. 

IOWA CITY: Population, 9007. 

(3) STATE UNIVERSITY OF IOWA COLLEGE OF MEDICINE. Organized 1869. An organic 
department of the state university. 

Entrance requirement: One year of college work. 
Attendance: 267, 87 per cent from Iowa. 

Teaching staff: 32, of whom 12 are professors. The laboratory instructors devote 
full time to their work ; the clinical teachers are practitioners, some of them non- 
resident : the professor of surgery resides at Sioux City, the professor of gyneco- 
logy, who is likewise dean of the department, at Dubuque. 

Resources available for maintenance: The department is supported by state appro- 
priations. Its income from fees is $13,707 ; its budget, $35,216; the university hos- 
pital budget is $33,745. Chemistry, general expense (light, heat, etc.), and a share 
of expense of general administration are not included in these figures. 

Laboratory facilities : The equipment and instruction in the scientific branches are, 



224 MEDICAL EDUCATION 

in general, good. This is particularly true of anatomy, which is admirably cared 
for. The departments of pathology and physiology lack a sufficient number of 
skilled assistants. An excellent museum and books are at hand. 

Clinical facilities: The university hospital is, as it now stands, too small; the amount 
of material available in medicine, obstetrics, and contagious diseases has been very 
limited. An appropriation of $75,000 has, however, been made for the purpose of 
increasing the hospital capacity. The methods of clinical teaching hitherto pur- 
sued have not been entirely modern, mainly for lack of proper organization and 
material. Supplementary clinical material is obtainable at the Sisters' Hospital 
and the Tuberculosis Sanitarium. 

The dispensary is just in process of development. The dispensary clinic is so far 
largely limited to the eye, ear, nose, and throat. 

Latt of visit: November, 1909. 

(4) STATE UNIVERSITY OF IOWA COLLEGE OF HOMEOPATHIC MEDICINE. Organized 1877. 
An organic department of the state university. 

Entrance requirement: A four-year high school education. 
Attendance: 42, 83 per cent from Iowa. 

Teaching staff: 10 professors and 15 of other grade. The professor of materia medica 
and therapeutics, who is likewise dean of the department, resides at Des Moines, 
the professor of theory and practice at Davenport. 

Resources available for maintenance: The department is supported by state appropri- 
ations. Its income from fees is $1864, its budget is $5453, its hospital budget is 
$7847. The school budget does not include expense incurred for laboratory in- 
struction for a reason that the next paragraph will explain. 

Laboratory facilities : Homeopathic students receive their laboratory instruction to- 
gether with regular students of medicine, though there is now a difference of one 
year of college work and there will be next year a difference of two such years in their 
preparation, unless a resolution adopted by the board of education establishing the 
same basis of admission in the two departments becomes effective before that time. 

Clinical facilities: The department possesses a hospital of 35 beds, quite inadequate 
to its purpose. The dispensary is correspondingly slender. Operating during part 
of last year, it received only 134 cases, of which 101 were diseases of the eye, ear, 
nose, and throat. 

Date ofvitit: April, 1909. 

General Considerations 

IOWA is a state in which there are now between two and three times as many doctors 
as are really needed. The population of the state is increasing slowly, if at all. There 



KANSAS 225 

is, then, from the standpoint of the public interest no reason why a great number 
of physicians should be produced ; there is no reason why any physician should be 
graduated unless his entrance into the profession will actually improve it. Further 
dilution would be unpardonable. 

Of the four medical schools in the state none is at this time satisfactory. The 
osteopathic school at Des Moines is a disgrace to the state and should be summarily 
suppressed. In the absence of police power to terminate its career in this way, its 
graduates, undertaking as they do to treat all sorts of diseases, should be compelled 
to meet whatever standards are applied to other practitioners. The medical depart- 
ment of Drake University and the homeopathic department of the state university 
are well intentioned but feeble institutions that only a large outlay could convert 
into acceptable and efficient schools. Elevation of standards will probably embarrass 
rather than aid; for the urgent necessity of additional outlay will coincide with a de- 
crease in the revenues on which Drake, at least, wholly depends. It would be the part 
of wisdom to retire from a contest to which the institution is clearly unequal; at any 
rate, it ought to be content to limit its endeavor to the work of the first two years. 

The homeopathic department of the state university has now a small attendance 
on a relatively low entrance basis. As its students receive their scientific instruction 
with the classes now on a one-year, and hereafter to be on a two-year, college basis, 
it is clear that the entrance standard of the homeopathic department must be cor- 
respondingly elevated. The already slender enrolment is therefore destined still further 
to shrink. For so small a body of students the state is not likely to provide increased 
clinical facilities and a resident faculty of its own. Wisdom would therefore counsel 
the adoption in Iowa of the Minnesota plan : the two medical departments of the 
state university should be consolidated, with a provision for special teaching in ma- 
teria medica and therapeutics for students who desire the homeopathic diploma. 

The two university hospitals could thus be added together; the smaller would 
perhaps be devoted to obstetrics; the larger, with the additional wing now to be 
added, would provide comfortably for general medical and surgical clinics. The cre- 
ation of a strong resident faculty, and the adoption of a liberal and enlightened 
policy in dealing with the sick poor of the state, would place Iowa City in position 
to duplicate the honorable record which the University of Michigan has, under sim- 
ilar circumstances, made at Ann Arbor. 



KANSAS 

Population, 1,663,438. Number of physicians, 2650. Ratio, 1: 628. 
Number of medical schools, 3. 

LAWRENCE-ROSED ALE: (Population: Lawrence, 13,678; Rosedale, 3270 
suburb of the two Kansas Cities, population, 286,074). 



226 MEDICAL EDUCATION 

(1) UNIVERSITY OF KANSAS SCHOOL OF MEDICINE. The Scientific Department, at Law- 
rence, was organized in 1899; the Clinical Department, at Rosedale, was organized 
by merger with a local school in 1905. 

Entrance requirement: Two years of college work. 
Attendance: 89, 79 from Kansas, 8 from Missouri. 

Teaching staff: At Lawrence, anatomy, physiology, and bacteriology are taught by 
teachers whose instruction is confined to medical students; but the professor of 
anatomy is also professor of gynecology at Rosedale and practises his specialty. 
The pathologist is expected to eke out his income by outside work. Physiology, 
chemistry, and pharmacy are taught in general laboratories devoted to those sub- 
jects. The medical classes are not always separate. 

At Rosedale there is a teaching staff of 63, of whom 24 are professors. Two of 
them devote their whole time to teaching pathology, bacteriology, and clinical 
pathology. A third, the dean of this end, likewise gives his entire time to the 
school and hospital. 

Resources available for maintenance: The medical school shares in the general funds 
of the university. The budget for the current year is about $17,000 for the Sci- 
entific Department, and $23,000 for the Clinical Department. Income in fees, 
$5030. 

Laboratory faculties : The laboratories for anatomy, chemistry, and physiology are 
good and in active operation. Pathology and bacteriology are, so far, less highly 
developed. Books and current scientific periodicals are accessible. 

Clinical facilities: The Clinical Department has a small hospital of 35 beds, not 
used, however, to the best advantage, partly because the faculty is not composed 
of men whose training has been modern, partly because, being practitioners, they 
cannot devote time enough to teaching. The school enjoys additional privileges 
of the usual kind at a Catholic hospital in Kansas City, Kansas, and at the City 
Hospital in Kansas City, Missouri. The obstetrical work is mainly out-patient; 
contagious diseases are rarely seen. On the whole, far too little clinical material 
under proper control is offered. An excellent building, well equipped, devoted to 
pathology, clinical pathology, and bacteriology, adjoins the university hospital. It 
contains a few books and some current periodicals. 

Two dispensaries are available, one at the Rosedale building, not used for teach- 
ing until this year; the other, the so-called North End Dispensary, where a fair 
amount of material has hitherto been handled in an incredibly slipshod manner. 

Each of the two parts of the university school of medicine has its own dean ; for all 
practical purposes, the university conducts two half-schools. 
Dot* ofvitit: November, 1909. 



KANSAS 227 

(2) WESTERN ECLECTIC COLLEGE OF MEDICINE AND SURGERY. Organized 1898. A 
stock company. 

Entrance requirement: Nominal. 

Attendance: 21. 

Teaching staff": 32, of whom 30 are professors, 2 of other grade. 

Resources available for maintenance: Fees, amounting to perhaps $1600 this year. 

Laboratory facilities : These comprise a few small, indescribably dirty and disorderly 
rooms, containing three microscopes, a small amount of physiological apparatus, 
some bacteriological stains, a few filthy specimens, and meager equipment for ele- 
mentary chemistry, but no running water. All laboratory work is conducted by one 
teacher, who serves in the same capacity in the local osteopathic and homeopathic 
schools and does commercial work besides. No anatomy was going on at the time 
of the visit, as dissection runs only from January 3 to March 12. 

Clinical facilities : Practically none. A wretched room is called the "Dispensary," 
and an attendance of "about three a day" is claimed; it is hoped that this "can 
be worked up to six a day." The catalogue states that "clinics are held weekly at 
the Kansas City, Missouri, General Hospital," but the statement is denied by the 
superintendent of the hospital. 

Date of visit: November, 1909. 

TOPEKA: Population, 45,143. 

(3) KANSAS MEDICAL COLLEGE. Established 1890. Since 1902 the medical depart- 
ment of Washburn College, which teaches chemistry to the medical students, but 
is without control of appointments in the medical faculty. 

Entrance requirement: A four-year high school course or its equivalent. 
Attendance: 65, 92 per cent from Kansas. 

Teaching staff: 47, 31 being professors. There are no instructors giving their whole 
time to the school, except in so far as chemistry, above mentioned, is concerned. 

Resources available for maintenance: Practically only fe"es, amounting to $4876 a year. 

Laboratory facilities: The school occupies a three-story building, on the upper floors 
of which there have been improvised laboratories for pathology and bacteriology. 
They contain the necessary equipment for routine teaching, but are poorly kept. 
There is a small amount of apparatus for physiological demonstrations. The dis- 
secting-room is indescribably filthy ; it contained, in addition to necessary tables, 
a single, badly hacked cadaver, and was simultaneously used as a chicken yard. 1 
There is no museum, only a few old books, some charts, a few models, etc. 

1 This is explained as follows : " It had not been in use for eight months or so and would not be in use 



228 MEDICAL EDUCATION 

Clinical facilities: A total of eleven hours a week of clinical instruction, only nine of 
which can be attended by any one student, is offered at four different hospitals. 
The opportunities, limited as they are, are largely surgical. The feeling towards 
the school is unusually cordial, but the hospitals lack the necessary equipment 
and organization for effective teaching. 

At the time the school was visited a small room was used for a dispensary; the 
attendance was slight; there was no equipment at all. Recently larger quarters 
have been provided. 

Date of vitit : November, 1909. 

General Considerations 

RECENT action making a year of college work the minimum preliminary to prac- 
tise in Kansas will wipe out the eclectic school at Kansas City and the Topeka 
school, both of which would, however, die out even on the present standard. The 
future of medical education in the state, therefore, very properly lies with the state 
university. This institution has shown the desire to provide instruction of high grade 
by raising its entrance requirements until they now call for two years of college work; 
but it did not realize that it was incumbent upon it to improve facilities and in- 
struction at the same time. Great efforts must therefore be made to hasten their de- 
velopment, for the higher entrance requirement is already in force. The school is 
now a divided school. It would be a simple matter to develop the laboratory end at 
Lawrence; it will be difficult and expensive to develop the clinical end at Rosedale 
correspondingly ; and still more difficult, to establish effective cooperation between 
the severed halves of the department. The needs of a university medical department 
are so great that the university will find it necessary to refrain from many other 
projects, pending the upbuilding of a creditable school of medicine. It is therefore 
unfortunate that the educational funds of the state have been already to some extent 
needlessly consumed in the duplication of engineering and normal departments 
within the several state institutions. No comprehensive and well coordinated scheme 
of state educational development has been worked out. It would seem essential in 
the first place to demarcate the respective provinces of the several state institutions, 
so that each would care for certain interests without trespassing on the ground re- 
served to the others. That done, medicine would fall to the state university and would 
include a public health laboratory. Certain fundamental questions respecting the lo- 
cation, organization, and general scope of the entire department would next require 
to be settled. Thereafter, the plan adopted could be realized unit by unit, year by year. 



until cold weather. [It was then the middle of November. 1 The cadaver happened to be there be- 
cause of the private studies of one of the professors, who put it there for his own convenience. In the 
same way, because the room was not in public use and would not be for some time, another member 
of the faculty stored there, for use in embryology, the coop of live chickens." 



KENTUCKY 229 

KENTUCKY 

Population, 2,406,859. Number of physicians, 3708. Ratio, 1 : 649. 
Number of medical schools, 3. 

LOUISVILLE: Population, 240,160. 

(1) UNIVERSITY OF LOUISVILLE MEDICAL DEPARTMENT. Organized 1837, it has recently 
absorbed four other schools. Until lately the university was limited to loosely 
aggregated schools of law and medicine ; latterly an academic department without 
endowment has been started. 

Entrance requirement : Less than a high school education. Examples were found of 
students admitted from two-year high schools or less. 

Attendance : 600. 

Teaching" staff: 90, of whom 40 are professors. The distribution of the chairs is sig- 
nificant : the major medical staff contains twelve names, six of them professors ; sur- 
gery, twelve names, all professors. The laboratory branches are in marked contrast : 
two names make the major staff in physiology, one in chemistry, one in pathology 
and bacteriology. There are four whole-time professors of modern training in the 
scientific departments. Assistants, some of them also giving entire time to the 
school, are provided. 

Resources available for maintenance : Fees, amounting to $75,125. 

Laboratory facilities : Teaching laboratories are provided for chemistry, pathology, 
bacteriology, physiology, and pharmacy. They are inadequate in appointments and 
teaching force for the thorough teaching of the fundamental sciences to so large 
a student body. A separate building has just been set apart for anatomy, opera- 
tive surgery, and the city morgue. 

Clinical facilities : The school has a hospital of 50 beds, with an average of 30 pa- 
tients, two-thirds of the cases being surgical, and not all available for teaching. 
Obstetrical cases are rare, but there is an out-patient obstetrical service. At the 
City Hospital eight amphitheater clinics are held weekly for classes containing 
from 100 to 300 students. There are no regular ward classes. The obstetrical ward 
is not open to students ; there is no pavilion for contagious diseases. The hospital 
facilities are therefore poor in respect to both quality and extent : unequal to the 
fair teaching of an even smaller body of students, they are made to suffice for the 
largest school in the country. 

The school dispensary has an average daily attendance of over one hundred. 
It is regularly used for teaching on the section method. 

Date of visit : December, 1909. 



230 MEDICAL EDUCATION 

(2) SOUTHWESTERN HOMEOPATHIC MEDICAL COLLEGE. Organized 1892. An independent 
school. 

Entrance requirement: The same as that of the University of Louisville Medical 
Department. 

Attendance: 13. 

Teaching staff: 27, 12 being professors. 

Resources available for maintenance: Fees, amounting to $1100. 

Laboratory facilities : There is no outfit worth speaking of in any department ; the 
building is wretchedly dirty, especially the room said to be used for anatomy. 
There is nothing to indicate recent dissecting. 

Clinical facilities : The school gets one-fifth of the patients admitted to the City 
Hospital and can use them for demonstrative purposes. 

There is no organized dispensary. 
Date of visit : January, 1909. 

(3) LOUISVILLE NATIONAL MEDICAL COLLEGE (Colored). An independent school, organ- 
ized 1888, now affiliated with the colored State University. 

Entrance requirement: Less than high school education. 

Attendance : 40. 

Teaching" staff": 23, of whom 17 are professors. 

Resources available for maintenance: Fees, amounting to $2560. 

Laboratory facilities : Nominal. 

Clinical facilities: A small and scrupulously clean hospital of 8 beds is connected with 

the school. 
Datt of vifit : January, 1909. 

General Considerations 

THE situation in Kentucky is a simple one. The homeopathic school is without merit. 
Its graduates deserve no recognition whatsoever, for it lacks the most elementary 
teaching facilities. The University of Louisville has a large, scattered plant, unequal 
to the strain which numbers put upon it. In the old days, Louisville, with a half- 
dozen " regular "" schools, was a popular medical center, to which crude boys thronged 
from the plantations. The schools offered little beyond didactic teaching. Now, they 
have been arithmetically added together; the resulting school is indeed superior on 
the laboratory side to any of its component parts ; but there are radical defects for 
which there is no cure in sight. The classes are unmanageably huge ; the laboratories 
overcrowded and undermanned; clinical facilities, meager at best, broken into bits 
in order to be distributed among the aggregated faculty. To carry the school at all, 



LOUISIANA 231 

a large attendance is necessary ; but a large attendance implies a low standard. The 
situation is thus practically deadlocked. 

The outlook is not promising; for there is no indication of such support, financial 
or academic, as would be required in order to reconstruct the institution on accept- 
able lines. Elsewhere a strong college or university has been in reach : as, for example, 
across the Ohio, Indiana University has just now put its hand to the plow and 
will not turn back. But in Kentucky the state university is totally unequal to the 
task. It labors under the initial disadvantage of being situated in another town, 
not the less a disadvantage because capable of being overcome; more serious, how- 
ever, is its educational ineptitude. It has never been an active educational factor, 
and having now chosen a politician, without educational qualification or experience, 
as its president, its immediate future promises little. From the existing so-called aca- 
demic department of the University of Louisville neither aid nor ideals can come. 
It is quite without resources. We have indeed progressed too far in our social and 
educational development to use the word "university ""for an enterprise of this kind. 
Classes in literature, languages, and elementary science may indeed be organized by 
volunteer teachers, in hours left open by their regular engagements, or by instruc- 
tors supported from year to year by subscription ; they may discharge a highly use- 
ful office in any community, but they ought to be called by their right name. An 
academic department of a university they are not : why should they not be described as 
a people's institute, or by some other designation calculated to indicate their actual 
character? 1 The loose use of the words "college* 1 and "university" prolongs educa- 
tional chaos; it hinders the apprehension of genuine and fundamental educational 
distinctions. Assuredly, an institute of the type described cannot dominate or trans- 
form a hitherto independent group of medical schools. 



LOUISIANA 

Population, 1,618,358. Number of physicians, 1798. Ratio, 1 : 900. 
Number of medical schools, 2. 

NEW ORLEANS: Population, 332,169. 

(1) MEDICAL DEPARTMENT OF THE TULANE UNIVERSITY OF LOUISIANA. Organized in 
1834, the school affiliated with the University of Louisiana in 1845, and with Tulane 
in 1884, at which date the University of Louisiana became Tulane University. In 
1902 it assumed its present status as an organic part of the university. 

Entrance requirement: A four-year high school education or its equivalent, admin- 
istered by the academic authorities. The actual standard is somewhat below the 
nominal standard, though gradually rising towards it. 

1 These comments apply with equal force to Toledo. 



S MEDICAL EDUCATION 

Attendance: 439. 

Teaching staff: 75, of whom 17 are professors. The laboratory branches are in charge 
of five men, who give their entire time to teaching and investigation. 

Resources available for maintenance: Endowment funds, aggregating about $900,000, 
yield an income of $26,000 annually ; fees amount to $67,500. The budget of the 
department amounts to $101,781. 

Laboratory facilities: New and excellent laboratories are provided for the work of 
the first and second years. The professors in charge represent modern ideals, and 
are enthusiastically engaged in reconstructing the entire school on progressive 
lines. The anatomical museum is one of the best in the country. The library is small. 

Clinical facilities: The school enjoys unusual privileges and opportunities in the 
Charity Hospital, an institution of 1050 beds. Recently an additional ward for 
surgery and gynecology has been added, full control of the services being vested 
in the Tulane faculty by the terms of the gift. The abundant material is freely 
used by the medical faculty, though certain defects of organization, equipment, 
and relationship must be corrected in order to render the situation ideal. The 
main point, however, is secure, for the position of the medical school in the hos- 
pital is ensured through legislative enactment. The professorship in medicine has 
recently been filled by importation without any friction whatsoever. 
The dispensary service is adequate. 

Postgraduate instruction in specialties is offered by the New Orleans Polyclinic, 
affiliated with the Tulane University. 

(2) FLINT MEDICAL COLLEGE (Colored). Organized in 1889, it is a department of New 
Orleans University, which is managed by the Freedman's Aid Society of the 
Methodist Episcopal Church, North. 

Attendance: 24. 

Teaching staff: 15, of whom 6 are professors. All are practitioners. 

Resources available for maintenance: Tuition fees, $1300 (estimated), and small ap- 
propriations voted by the Freedman's Aid Society constitute the income. The entire 
budget, including that of the hospital adjoining, is less than $10,000 annually. 

Laboratory facilities : There is scant equipment in anatomy, chemistry, pathology, 
and bacteriology. The rooms are in poor condition. 

Clinical facilities: The school controls a hospital of 20 beds, with an average of 17 
patients monthly, and a dispensary with an average daily attendance of one or two. 
Date ofvitit: January, 1909. 



MAINE 233 

General Considerations 

THE medical department of Tulane University is one of a very few existing southern 
schools that deserve development. The south is in general overcrowded with schools 
with which nothing can be done; for they are conducted by old-time practitioners, 
who could not use improved teaching facilities if they were provided. The case is 
different at Tulane. Its recent reorganization has put imported men of modern train- 
ing and ideals in charge of the most important departments, laboratory and clinical. 
There is no question that if properly supported, they will quickly bring the institu- 
tion to a position of commanding influence. To achieve this result, the school must 
be freed of the necessity of so largely relying upon fees for its support. For once 
rendered by endowment comparatively independent, it can use its superior opportu- 
nities as a lever to brace up the general educational situation of the southern states. 
It could compel those seeking these opportunities to improve their preparation at 
least to the full limit of local possibilities. The urgent need of the south is an object 
lesson in medical education, such as will prominently embody what is sound and de- 
sirable; and such an object lesson the medical department of Tulane could readily 
be made: it possesses already the laboratories and the hospital; it requires only the 
means that will enable it to utilize them fully. 

Flint Medical College is a hopeless affair, on which money and energy alike are 
wasted. The urgent need in respect to the medical education of the negro is con- 
centration of resources slender at best on a single southern institution. Much the 
most favorably situated for this purpose is Meharry Medical College at Nashville. 

MAINE 

Population, 724,508. Number of physicians, 1198. Ratio, 1 : 600. 
Number of medical schools, 1. 

BRUNSWICK-PORTLAND: (Population: 1 Brunswick, 2321; Portland, 58,512). 

MEDICAL SCHOOL OF MAINE. Organized 1820. A divided school, being the medical 
department of Bowdoin College. 

Entrance requirement: Four-year high school diploma or equivalent, ascertained by 
examination, conducted, however, under the auspices of the medical school, not 
by Bowdoin College, and below the college standard. Certificates are accepted far 
below standard in value. 

Attendance: 81, 86 per cent from Maine. 

Teaching staff: 35, 14 being professors, 21 of other grade. 

1 Census Bureau without data. 



234 MEDICAL EDUCATION 

Resources available for maintenance: From endowment, $7600; from fees, $8100; 
total, $15,700. 

Laboratory facilities :The laboratory branches are taught in the medical school building 
at Brunswick with the exception of chemistry, which is well provided for in the col- 
lege laboratories ; the equipment covering physiology, bacteriology, and pathology 
is slender. There is nothing in pharmacology at all. There are no whole-time teachers 
in the scientific branches. The professor of anatomy is non-resident; his main duty 
is lecturing, the dissecting-room being supervised by recent graduates, engaged in 
practice. "The professor looks in occasionally." The professor of pathology is phy- 
sical director of Bowdoin College. The professor of physiology is non-resident. 

Clinical facilities: Clinical instruction is given at Portland by teachers who have little 
commerce with the laboratories at Brunswick. The chief clinical reliance of the 
school is the Maine General Hospital, where instruction is given principally in 
the amphitheater, as a majority of the cases are surgical. Obstetrical work is not 
to be counted on. Internes do the clinical laboratory work and make up case his- 
tories. The records are indexed only by name of the patient. Additional clinical 
material is obtained at the Eye and Ear Infirmary, Children's Hospital, etc. 

Students spend also a small amount of time at a thoroughly wretched city dis- 
pensary, where the cases are few, where no records are kept, and where not even 
copies of prescriptions are filed. The dispensary does not own a microscope. 

A course in clinical microscopy is given at the college building in Portland. 
"Urine and sputum are gathered, and students are told about the cases from 
which they come." Neither end of this school meets the requirements for the teach- 
ing of modern medicine. 

Date of visit: October, 1909. 

[For general discussion see " New England," p. 261.] 

MARYLAND 

Population, 1,319,132. Number of physicians, 2012. Ratio, 1 : 658. 
Number of medical schools, 7. 

BALTIMORE: Population, 583,475. 

(1) MEDICAL DEPARTMENT OF THE JOHNS HOPKINS UNIVERSITY. Established 1893. An 
organic university department. 

Entrance requirement: The bachelors degree, representing specific attainments in 
chemistry, physics, biology, German, and French. 

Attendance: 297. 

Teaching staff: 112, of whom 23 are professors. All the laboratory teaching is con- 
ducted by instructors who give their entire time to teaching and research ; the heads 



MARYLAND 235 

of the clinical departments are salaried teachers attached to the Johns Hopkins 
Hospital. 

Resources available for maintenance: The income from tuition fees is $60,542, that 
from endowments $19,687,making a total of $80,229. The budget calls for$102,429, 
not including salaries of the clinical faculty and other items carried by the Johns 
Hopkins Hospital, which is thus actually an integral part of the medical school. 
The productive hospital endowments now aggregate $3,632,289, not including the 
bequests for the Phipps Psychiatric Clinic and the Harriet Lane Johnson Home 
for Children. 

Laboratory facilities: These facilities are in every respect unexcelled. As the institu- 
tion has been from the beginning on a graduate basis, teaching and research have 
been always equally prominent in its activities. 

Clinical facilities: The Johns Hopkins Hospital and Dispensary provide practically 
ideal opportunities. The medical staff of the hospital and the clinical faculty of 
the medical school are identical; the scientific laboratories ranged around the hos- 
pital are in close touch with clinical problems, immediate and investigative. The 
medical school plant is thus an organic whole, in which laboratories and clinics 
are inextricably interwoven. Recent foundations have greatly augmented the ori- 
ginal hospital plant in the direction of psychiatry, pediatrics, and tuberculosis. 
Three hundred and eighty-five beds under complete control are now available. 

The dispensary is largely attended, and is admirably conducted from the stand- 
point of both public service and pedagogic efficiency. 

Date ofvitit: December, 1909, 

(2) COLLEGE OF PHYSICIANS AND SURGEONS. Established 1872. An independent insti- 
tution. 

Entrance requirement: Less than a high school education. 
Attendance: 252. 

Teaching staff": 59, of whom 21 are professors, 38 of other grade. One teacher devotes 
his entire time to medical instruction. 

Resources available for maintenance: Fees, amounting to $39,000. 

Laboratory facilities : Ordinary working laboratories are provided for bacteriology, 
histology, and pathology, including surgical pathology ; the chemical laboratory 
provides satisfactorily for general chemistry. The dissecting-room is fair, as far as 
it goes. There is no experimental pharmacology and no student work in experi- 
mental physiology. The museum consists of several hundred specimens; the library, 
of which there is a librarian in charge, of perhaps 1500 volumes and a few current 
periodicals. The undeveloped character of the laboratories is due, (1) to the pay- 



286 MEDICAL EDUCATION 

ment of faculty dividends; (2) to the application of current fee income to the dis- 
charge of building debts. 

Clinical facilities: The school completely controls the adjoining hospital, of which 
some 210 beds, including a maternity ward, are available for teaching. Ward- 
teaching on the section plan is in use. The clinical laboratory is open to the 
students. 

The dispensary occupies an excellent suite of rooms ; the attendance is ample. 

Dat ofvint: March, 1909. 

(8) UNIVERSITY or MARYLAND SCHOOL OF MEDICINE. Organized 1807. Essentially an 
independent institution with a university charter, though nominally the medical 
department of St. John's College (Annapolis) . 

Entrance requirement: Less than a high school education. 

Attendance: 316. 

Teaching staff': 61, of whom 24 are professors, 37 of other grade. 

Resources available for maintenance: Fees, amounting to $44,530 (estimated), out of 
which dividends are paid to the faculty and a large mortgage debt carried. 

Laboratory facilities : Good undergraduate laboratories adequate to routine teaching 
are provided in two poorly kept buildings for the following subjects: chemistry, 
physiology, including physiological chemistry and histology, pathology and bac- 
teriology. Anatomy is poor. There is a small museum. In a separate building is a 
large and interesting library, but it is open only two hours each day. 

Clinical facilities: The school controls its own hospital, opposite the laboratory build- 
ings, about 140 beds being available for teaching. The hospital records are well 
kept, senior students who pay for the privilege serving as clinical assistants. A 
separate maternity ward furnishes obstetrical work in abundance. 
The dispensary is large, properly equipped, and well kept. 

Date of vitit : March, 1909. 

(4) BALTIMORE MEDICAL COLLEGE. Organized 1881. An independent institution. 

Entrance requirement: Much less than a four-year high school education. Advanced 
standing is freely granted to failed students dropped from other schools. 

Attendance: 392. 

Teaching staff: 63, of whom 20 are professors, 43 of other grade. There are no 
teachers giving entire time to medical instruction. 

Resources available for maintenance: Fees, amounting to 833,424. 

Laboratory facilities : The school possesses a new and very attractive laboratory 



MARYLAND 237 

building. It is well equipped for undergraduate instruction in chemistry and 
pathology; inadequately for physiology and bacteriology. A large room with 
ample material provides for dissecting. 

Clinical facilities: The school has the use of about 122 beds in a hospital which it 
built and has leased to the Sisters of Charity ; it has access to several other institu- 
tions besides. 

A suite of poorly kept rooms is set aside for a dispensary. The attendance is ample. 

Date of visit: March, 1909. 

(5) WOMAN'S MEDICAL COLLEGE OF BALTIMORE. Organized 1882. An independent 
institution. 

Entrance requirement: Less than a high school education. 
Attendance: 22. 

Teaching staff': 31, of whom 18 are professors, 13 of other grade. 
Resources available for maintenance: Fees, amounting to $2000. 

Laboratory facilities: Small laboratories, scrupulously well kept, show a desire to 
do the best possible with meager resources : pathology, bacteriology, embryology, 
chemistry, and anatomy are thus taught. 

Clinical facilities: These are quite insufficient: across the street from the school is a 
hospital with 17 beds; supplementary material is obtained at several institutions 
through staff connections. 

A suite of rooms in the college building is devoted to dispensary purposes. 
There is a fair attendance. 

Date of visit : March, 1909. 

(6) MARYLAND MEDICAL COLLEGE. Organized 1898. An independent institution. 
Entrance requirement: Nominal. 

Attendance: 95. Almost one-half the school is in the senior class. 
Teaching staff: 39, of whom 21 are professors, 18 of other grade. 
Resources available for maintenance: Fees, amounting to $7460 (estimated). 

Laboratory facilities : The school building is wretchedly dirty. Its so-called labora- 
tories are of the worst existing type : one neglected and filthy room is set aside 
for bacteriology, pathology, and histology: a few dirty test-tubes stand around 
in pans and old cigar-boxes. The chemical laboratory is perhaps equal to the 
teaching of elementary chemistry. The dissecting-room is foul. This description 
completely exhausts its teaching facilities. There is no museum or library and 
no teaching accessories of any sort whatsoever. 



2 38 MEDICAL EDUCATION 

Clinical facilities: The college faculty own and conduct a hospital within a few blocks. 
It is essentially a private institution, of no great value to students. Less than 50 
beds are free. 

The dispensary claims a fair attendance. 

Dot* of visit: March, 1909. 

(7) ATLANTIC MEDICAL COLLEGE. Organized 1891 as an independent homeopathic 
institution. Having "passed through many vicissitudes," it is now non-sectarian. 

Entrance requirement: Nominal. 

Attendance: 43, of whom 31 are in the senior class, 1 in the freshman class. Of 21 
graduates, class of 1908, almost all had failed at other schools or before the regu- 
lar state board before entering the Atlantic Medical College, on graduation from 
which they could appear before the Homeopathic State Board of Maryland, "re- 
puted to be a much easier board to pass." 

Teaching staff": 47, of whom 12 are professors, 35 of other grade. Two members of 
the teaching staff were graduated in the class of 1908, above mentioned, after 
having failed before the regular state board; a third instructor, also a graduate 
of 1908, entered this school after failure at the local College of Physicians and 
Surgeons. 

Resources available for maintenance: Fees, amounting to $3905 (estimated). 

Laboratory facilities: The school occupies a filthy building, in which are to be found 
an elementary chemical laboratory, a small room assigned to pathology, bacte- 
riology, and histology, equipment being scant and dirty, an ordinary dissecting- 
room, a lecture-room with half a skeleton, a small amount of imperfect physiolo- 
gical apparatus with a few frogs, and a few cases of books, mostly old and use- 
less. 

Clinical facilities: These are claimed at a small private hospital several miles off. 
They can at best be hardly more than nominal. 

The basement of the college building is used for a dispensary. 
DaU ofvitit: March, 1909. 

General Considerations 

THERE are seven medical schools in Maryland, a state whose population increases 
slowly and in which there are between two and three times as many physicians as it 
now requires. Of these seven schools, two belong to the worst type of American 
medical school, viz., the Atlantic Medical College and the Maryland Medical College. 
That such unconscionable concerns should at this day continue to flourish is a blot 
upon the state of Maryland and the city of Baltimore. 

Two more of the seven schools, the Baltimore Medical College and the Woman's 



MASSACHUSETTS 239 

Medical College, are weak ; two others, the College of Physicians and Surgeons and 
the University of Maryland, are large commercial enterprises, whose financial respon- 
sibilities are far too extensive for their capital or fee income; the sums annually ap- 
plicable to debts in order to simplify their position, or to maintenance in order to 
improve their teaching, are reduced by the payment of substantial dividends to 
practitioner teachers. Education is thus overshadowed by business. Entrance stand- 
ards are low, the full-time teacher is practically unknown, the laboratories are slov- 
enly, the atmosphere depressing. 

Like Pennsylvania, Maryland has granted lump sums to private corporations en- 
gaged in charitable work. The larger ones of the six medical schools mentioned have 
thus combined to obtain from the state money enough to build and partly to sup- 
port their hospitals. Should the state ever conduct its philanthropic business intel- 
ligently, these irresponsible methods would stop; and with them, the medical schools 
which they have helped to float. The Johns Hopkins Medical School, for which 
neither the state of Maryland nor the' city of Baltimore has ever done anything, is 
thus the only medical school in Maryland that either ought to or can live, and to its 
development greatly increased means should be freely devoted. 

If, meanwhile, a combination of the better independent schools of Baltimore were 
effected, much of their property could be disposed of, the equity being used to equip 
the resulting institution. A single independent school might thus have a brief and 
not discreditable career. In the end, however, the independent schools will pass away, 
in Maryland as elsewhere. To their present hospitals the Johns Hopkins would be- 
come the heir, thus greatly strengthening its clinical resources. At this date the 
Johns Hopkins University is the only academic institution in the state capable of 
conducting a modern medical school. It would be safe, interesting, and instructive 
to leave medical education in Maryland for a decade or two wholly in its hands. The 
state will not meanwhile lack for doctors; it is already overcrowded. 

The prerequisite to any reconstruction of the Baltimore situation is the revision 
of the state law. The country affords no more conclusive proof of the viciousness of 
the two-board system. Not only is neither state board empowered to enforce a pre- 
liminary educational requirement, but candidates refused by the "regular" board 
subsequently succeed before the homeopathic board. This underground traffic is re- 
sponsible for the existence of the Atlantic Medical College, a homeopathic school 
that has rendered itself an attractive haven of refuge to rejected "regular'" students 
by dropping the significant word from its title. 



MASSACHUSETTS 

Population, 3,162,347. Number of physicians, 5,577. Ratio, 1 : 567. 
Number of medical schools, 5. 



240 MEDICAL EDUCATION 

BOSTON : Population, 629,868. 

(1) MEDICAL SCHOOL OF HARVARD UNIVERSITY. Organized 1782. An integral depart- 
ment of Harvard University. 

Entrance requirement : The student has a choice between the bachelor's degree or cer- 
tain definite requirements in science and modern languages representing two years 
of undergraduate work, provided that in the latter case a higher passing mark is 
required for graduation. In the present year, out of a first-year class of 62, 60 en- 
tered with the bachelor's degree. 

Attendance : The total enrolment is 285 ; about 69 per cent from New England, 53 
per cent from Massachusetts. 

Teaching staff: 173, of whom 23 are professors ; laboratory instructors as a rule de- 
vote their entire time to the department. 

Resources available for maintenance: The department has an endowment of $3,326,- 
961 ; the fees are merged in the general income of the school. The annual budget 
is $251,389, of which $72,037 are derived from tuition fees. 

Laboratory facilities : The laboratories are unexcelled in equipment and organiza- 
tion, in respect to both teaching and research. 

Clinical facilities : Abundant clinical material is available at the Massachusetts Gen- 
eral Hospital, the City Hospital, and elsewhere. But serious restrictions are felt 
in two directions : (1) While the university is free to secure laboratory men wher- 
ever it chooses, it is practically bound to make clinical appointments by seniority, 
in accordance with the custom prevailing in the hospital which it uses, or to leave 
its professor without a hospital clinic. In general it follows that the heir to the 
hospital service is heir to the university chair. In consequence there is a noticeable 
lack of sympathy between the laboratory and the clinical men. They do not repre- 
sent the same ideals. There is no question but that an institution of this rank ought 
to work in the most intimate cooperation with a hospital ; and that, if such were 
the case, the same principles would obtain in selecting clinical teachers as prevail 
elsewhere in the university. (2) The extent to which hospital material can be util- 
ized is also limited, though less in surgery than in medicine. The teaching is in 
the main of the demonstrative character. Something more intimate is possible in 
a limited way with fourth-year students. The hospital services with one exception 
rotate at the end of periods of four months. 

The school is now installing its own dispensary, likely to be of great value in 
its clinical instruction. 

DaU of vifit : October, 1909. 

(2) TOFTS COLLEGE MEDICAL SCHOOL. Organized 1893. Administratively an integral 
department of Tufts College, though actual scientific intercourse is not intimate. 



MASSACHUSETTS 241 

Entrance requirement: Below an actual four-year high school course, since certificates 
of uncertain value have been accepted and examinations used cover less than half 
a high school course. This is the less defensible as 97 percent of the total enrol- 
ment come from New England. 

Attendance: The attendance is 384; 97 per cent from New England, 80 per cent from 
Massachusetts. 

Teaching staff: 103, of whom 33 are professors. There are five full-time professors 
and five full-time assistants in pathology, histology, physiology, and chemistry. 

Resources available for maintenance: The school relies on its fees, amounting to 
$59,093, repaying out of them large advances for buildings made out of the general 
income of the college. 

Laboratory facilities: The laboratories are entirely adequate to the teaching work of 
the school. 

Clinical facilities: For medical clinics the school is confined to the Boston City Hos- 
pital and the Boston Dispensary, which furnish abundant material under the usual 
more or less imperfect control. The Carney Hospital provides considerable addi- 
tional work in surgery; the specialties are cared for in other institutions. The 
school is thus clinically handicapped in exactly the same way as Harvard, but 
to a greater degree by reason of its being restricted in its medical clinics to a 
single municipal hospital and dispensary. Its range of choice in the matter of 
clinical professors is limited by the same considerations. 

Date of visit: October, 1909. 

(3) BOSTON UNIVERSITY SCHOOL OF MEDICINE. Homeopathic. Organized 1873. The 
University connection is nominal. 

Entrance requirement: A certificate of graduation from an approved four-year high 
school, or examination ; the examination is not set by the university, but by the 
medical school, and is markedly below the four-year high school standard. 

Attendance: Total enrolment, 90; 83 per cent from New England, about 60 per cent 
from Massachusetts. 

Teaching staff: 64, 29 being professors. 

Resources available for maintenance: The institution is mainly dependent on fees 
($12,762, estimated), but these have been consistently used to develop its facilities. 

Laboratory facilities : In striking contrast with schools in which, whatever the claim, 
fees have not been so used, this school has an excellent building, admirably kept 
and well equipped, and attractive laboratories for pathology, bacteriology, physi- 
ology, chemistry, and anatomy. There is no experimental pharmacology. It pos- 
sesses a library in charge of a permanent librarian, a beautifully mounted collection 



MEDICAL EDUCATION 

of pathological material, an excellent refrigerator plant, and other features in- 
dicative of intelligent and conscientious effort. 

Clinked facilities: The school adjoins a hospital of some 230 beds, of which 125 are 
available for amphitheater and ward clinics. The material is fairly abundant and 
varied; but students do not make laboratory examinations for the patients whom 
they see in the wards. A pavilion for contagious diseases is also accessible. Con- 
nected with the hospital is a large, thoroughly modern, and systematically con- 
ducted dispensary, in which laboratory work and physical examination are more 
closely connected. 

Dat ofvltU: October, 1909. 

(4) COLLEGE OF PHYSICIANS AND SURGEONS. Organized 1882. An independent insti- 
tution. 

Entrance requirement : Vague. 

Attendance: 172, called in the catalogue "matriculates and applicants." 

Teaching staff: 30 professors and 15 lecturers. 

Resources available for maintenance : Fees, amounting to $10,000 (estimated). A re- 
duction of 20 per cent is made to students who pay in advance for the entire four 
years. 

Laboratory facilities : These facilities are wretched : ill-lighted, dirty, and poorly 
equipped so-called laboratories are provided for anatomy, pathology, etc. 

Clinkal facilities : The clinical resources are dubious. The catalogue attempts to con- 
vey the idea (p. 21) that the school has the same opportunities as Harvard and 
Tufts ; as a matter of fact, no member of the faculty of the College of Physicians 
and Surgeons has a staff appointment in the City Hospital, and teaching there is 
utterly impossible otherwise. The same is true of the wards of the Massachusetts 
General Hospital. At both institutions anyone, whether a student or not, may 
attend the public amphitheater clinics once weekly. But as these are freely open 
to the public and are of little or no value, they are hardly to be counted as teaching 
facilities. A limited attendance is required at a miserable dispensary, more than 
an hour's journey from the college building. 

Dot* ofvint: October, 1909. 

CAMBRIDGE : Population, 102,982. 

(5) MASSACHUSETTS COLLEGE OF OSTEOPATHY. Established 1897. An independent in- 
stitution. 

Entrance requirement : Vague. 
Attendance: 90. 



MICHIGAN 243 

Teaching staff: 34, of whom 19 are professors. 

Resources available for maintenance: Fees, amounting to 811,400 (estimated). 

Laboratory facilities : The school occupies a neatly kept building, in which are pro- 
vided one poorly equipped laboratory in common for pathology and bacteriology, 
and another, similar in character, for chemistry and urinalysis, and an anatomical 
room. It possesses neither museum nor library. Instruction at the school building 
is limited to lectures, recitations, and " laboratory " work. 

Clinical facilities : No " treatment" is administered in the school building. For that 
the students resort in their last year to the Chelsea Hospital, a pay institution 
of 10 to 15 beds, more than one hour's journey from the college building. Patho- 
logy is taught in the same year. 

Date of visit : October, 1909. 

{For general discussion see " New England" p. 261.} 

MICHIGAN 

Population, 2,666,308. Number of physicians, 4109. Ratio, 1 : 649. 
Number of medical colleges, 5. 

ANN ARBOR: Population, 14,734. 

(1) UNIVERSITY OF MICHIGAN DEPARTMENT OF MEDICINE AND SURGERY. Organized in 
1850. An integral part of the university. 

Entrance requirement: Two years of college work, including sciences strictly enforced. 
Attendance: 389, 45 per cent from Michigan. 

Teaching staff: 63, of whom 22 are professors. The laboratory work is wholly in 
charge of full-time instructors ; but assisi^ints in adequate number are lacking. The 
clinical teachers are salaried and owe their first duty to the school. 

Resources available for maintenance: The school and the university hospital are sup- 
ported mainly by state appropriation. The budget of the school is $83,000, that of 
the hospital, $70,000. Endowments to the extent of $175,000 carry a part of this 
charge. The income in fees is $34,093.* 

Laboratory facilities: Excellently equipped laboratories are provided for all the fun- 
damental branches; the men in charge are productive scientists as well as com- 
petent teachers. There is a large library, a good museum, and other necessary 
teaching aids. 

Clinical facilities: The school is fortunate in the possession of its own hospital, every 
1 Including laboratory fees paid by students registered in the homeopathic department; see (2). 



244 MEDICAL EDUCATION 

case in which can be used for purposes of instruction. A liberal policy has largely 
overcome the disadvantages of location in a small town ; for the clinical material is in 
the departments of surgery, psychiatry, and various specialties, of sufficient amount; 
it is fair in medicine, increasing in obstetrics. The thoroughness and continuity 
with which the cases can be used to train the student in the technique of modem 
methods go far to offset defects due to limitations in their number and variety. 

Date of visit: March, 1909. 

(2) UNIVERSITY OF MICHIGAN HOMEOPATHIC COLLEGE. Organized 1875. An organic 
department of the university. 

Entrance requirement: A four-year high school education. 
Attendance: 80, 38 per cent from Michigan. 
Teaching staff: 26, of whom 15 are professors. 

Resources available for maintenance: The school and its hospital are supported by 
state appropriations. Its budget is $16,400; that of its hospital, $31,000. The in- 
come in fees is $4515. 

Laboratory facilities : The students receive their laboratory instruction in common 
with the students of the Department of Medicine and Surgery, despite the fact 
that there is a difference of two years of college work in their preparation. 

Clinical facilities : The college has its own hospital of about 100 beds, where clinical 
instruction is given according to homeopathic principles. 

Date of visit: March, 1909. 

BATTLE CREEK: Population, 25,862. 

(3) AMERICAN MEDICAL MISSIONARY COLLEGE. Organized 1895. An independent in- 
stitution. A divided school, part of the work being given in Chicago, part at 
Battle Creek. No year is given entire at either place. 

Entrance requirement: A four-year high school course or its equivalent. Christians only 
are admitted. The Chicago teachers are all practitioners ; the Battle Creek teachers 
are connected with the Battle Creek Sanitarium as laboratory workers or physicians. 

Attendance: 75. 

Teaching- staff: 31, of whom 22 are professors, 9 of other grade. 

Resources available for maintenance : Income from endowment of $200,000 and fees. 

Laboratory facilities : Anatomy is given in Chicago, where the student spends six 
weeks during each of the first three years and 30 weeks of the fourth year. The 
other laboratory courses are given at Battle Creek by the laboratory men and 
physicians connected with the Battle Creek Sanitarium. Indeed, the school and the 



MICHIGAN 245 

sanitarium are inextricably interwoven. Students assist in the laboratories and 
treatment-rooms. Their laboratory training thus takes on a decidedly practical 
character. But this has its disadvantages; for the sanitarium is devoted to the ap- 
plication of certain ideas rather than to untrammeled scientific investigation. 
Disciples rather than scientists are thus trained. The outfit is adequate for routine 
work, with abundant practical illustration in chemistry, pathology, bacteriology, 
and histology. In physiology and pharmacology the provision is slighter. 

Clinked facilities: Of the last year, 30 weeks are spent in Chicago, where the students 
attend St. Luke's Hospital, one or two other institutions, and a dispensary in the 
school building. For additional clinical teaching they depend on Battle Creek : in 
the sanitarium they see an abundance of chronic and surgical cases; acute cases 
are rare, and are accessible chiefly when physicians can ask students to accompany 
them on their rounds. The clinical laboratory is closely correlated with bedside 
work. By assisting in the sanitarium and out, the student gets an unusually close 
experience as far as it goes, but, once more, under the limitations of the therapeutic 
theories approved by the sanitarium authorities; a critical and investigative spirit 
is not cultivated. 

The instructors of the divided parts of the school form practically separate faculties. 
Date of visit: February, 1910. 

DETROIT: Population, 393,536. 

(4) DETROIT COLLEGE OF MEDICINE. Organized by merger 1885. An independent 
institution. 

Entrance requirement: A four-year high school diploma or its equivalent, actually 
enforced. 

Attendance: 161, 70 per cent from Michigan (16 per cent from Canada). 

Teaching staff: 104, of whom 25 are professors and 79 of other grade. There are 
no full-time teachers. 

Resources available for maintenance: Fees only, amounting to $22,000 (estimated). 

Laboratory facilities : The school is provided with separate laboratories, each with 
ordinary routine equipment, for the following subjects : chemistry, anatomy, phys- 
iology, pathology, clinical microscopy, histology, and bacteriology. There is a slight 
additional equipment in the way of museum, charts, books, and other teaching ad- 
juncts. 

Clinical facilities : The school has access on the usual terms to several hospitals, staff 
members of which hold positions on the school faculty. The hospital service ro- 
tates every three months. At one hospital 100 available beds are perhaps equally 



246 MEDICAL EDUCATION 

divided between medicine and surgery; elsewhere surgery greatly predominates. 
Obstetrical work is mainly furnished by the Woman's Hospital and by an out- 
patient department just started. Post-mortems are hard to get. 

The dispensary service is fair. 
Date of visit .-December, 1909. 

(5) DETROIT HOMEOPATHIC COLLEGE. Organized 1899. An independent school. 
Entrance requirement: A four-year high school course or its equivalent. 
Attendance: 34. 

Teaching- staff': 35, of whom 17 are professors, 18 of other grade. 
Resources available for maintenance: Fees, amounting to $3010 (estimated). 

Laboratory facilities : These are wretched. There is an ordinary laboratory for chem- 
istry; another, much less than ordinary, for bacteriology. The pathological room 
contained a few dozen specimens in utter disorder; the anatomical room contained 
a single cadaver. The teaching-rooms are bare, except for chairs and tables; the 
building is poorly kept. The dean and the secretary have their offices "downtown." 

Clinical facilities : The school has access to Grace Hospital, the wards of which con- 
tain 56 beds, mostly surgical. Clinics are held two days weekly. The hospital 
authorities are well disposed towards the school, but the "boys don't take ad- 
vantage of their opportunities." 

There is a dispensary at the school building. It is incredibly bad. Prescriptions 
are found written on scraps of paper, unnumbered. There are no systematic records. 
Date of visit : December, 1909. 

General Considerations 

MICHIGAN is fortunate in the possession of an alert state board, which enforces with 
vigor the high school requirement, and may perhaps be counted on to advocate an 
advance of the state practice standard to meet the educational standard of the state 
university. As the state furnishes a thoroughly admirable education at relatively 
slight expense, there is no reason why it should keep the practice of medicine open 
to low-grade physicians, whether trained within or without its borders. Sound policy 
would quickly close the two homeopathic schools and, in all probability, the Detroit 
College of Medicine. To the credit of the latter institution, however, be it said that 
its officers have heartily cooperated with the state board in the enforcement of a 
genuine high school standard. 

The real problem now agitating the state concerns the medical department of the 
state university at Ann Arbor. The defects of Ann Arbor as the seat of a medical 
school have been touched on in these pages. There is no question that, if the entire 
state university were at Detroit, the medical department would be better off. But 



MINNESOTA 247 

this is by no means equivalent to urging that it be detached or split. The entire 
detached school is now on trial at Galveston, Indianapolis, New York. It would be 
well to watch the outcome of those experiments before trying any others. It is already 
clear that if a university department of medicine is to be genuinely productive, the 
remote department requires most generous support ; for much that is provided at 
the seat of the university for other departments will have to be duplicated. To cre- 
ate the university spirit in a distant institution is almost like developing a second 
though much less expensive university. 

An alternative suggestion looks to the removal to Detroit of part or all of the 
clinical instruction. If part is removed, clinical teachers must oscillate backward and 
forward between Detroit and Ann Arbor. Where would the productive clinical teacher 
have his workshop ? Nowhere, in all likelihood. If the entire clinical department is 
removed, the split school faces the conditions we encounter in Nebraska, California, 
and Kansas. Once more, let us wait for the successful operation of one of these divided 
schools before multiplying unpromising experiments. Meanwhile, the state can by 
increased liberality almost at will develop the medical clinic of the university hos- 
pital. Agitation in favor of splitting or removing it may proceed from several con- 
siderations, it is not inspired by sound scientific or educational ideas. 

For, Ann Arbor has itself proved what the experience of Germany had previously 
demonstrated, that a school of medicine can be developed in a small university 
town. The ideals are there; the contiguous departments are there; there is an ab- 
sence of the distractions which have thus far proved so damaging to city clinicians. 
A faculty of distinction, with a hospital well equipped for the care of the sick, 
and for teaching and research, can successfully overcome the most serious diffi- 
culties of the situation. The problem can be solved by intelligent organization and 
liberal support. Gaps may indeed remain in the student's experience. But if he has 
been well drilled in technique and method, his defects will be readily cured by a hos- 
pital year. The solution for Michigan may therefore come, as has been proposed, 
through an effective affiliation of the hospitals of the state with the school of medicine 
of the state university. The hospitals would profit bya connection of this kind, and they 
would assist by becoming factors in the education of the future physicians of the state. 

MINNESOTA 

Population, 2,162,726. Number of physicians, 2204. Ratio, 1 : 981. 
Number of medical schools, 1. 

MINNEAPOLIS-ST. PAUL : Population, 552,211. 

(1) UNIVERSITY OF MINNESOTA COLLEGE OF MEDICINE AND SURGERY. Organized in 1883, 
it has step by step absorbed all other medical schools in the state, including (1909) 
the homeopathic department of the university. Elective courses in homeopathic 



248 MEDICAL EDUCATION 

materia medica and therapeutics are offered on condition that students follow- 
ing them shall receive the degree of Doctor of Medicine in Homeopathy. 

Entrance requirement: Two years of college work, specifically including the funda- 
mental sciences and a modern language. 

Attendance : 174 , 83 per cent from Minnesota. 

Teaching staff: 49 professors and 71 of other grade, total, 120. 

Resources available for maintenance: State appropriations. The budget calls for 
$71,336. The income from fees is $16,546. 

Laboratory facilities : Excellent, exceedingly attractive, and well organized labora- 
tories are provided for all the scientific branches. The State Laboratory of Pub- 
lic Health is practically part of the school plant. The instruction is in charge of 
full-time teachers, generously supplied with books, apparatus, and material. 

Clinical facilities : The school has hitherto relied on the municipal hospitals and un- 
paid clinical teachers, with the usual results. Teaching opportunities were both lim- 
ited in extent and precarious in character. These institutions are in fact not organ- 
ized, equipped, or conducted with educational requirements in mind. An appropria- 
tion has now been made to build a teaching hospital ; and a small temporary hos- 
pital has been started. Simultaneously, the clinical teaching has been reorganized 
by placing the chiefs in medicine and surgery respectively on salaries that com- 
mand the interest and effort of active teachers. The same policy must be applied 
generally throughout the clinical department. 

The dispensary, well attended and long loosely conducted, has recently been re- 
constructed along the same lines. 

Date ofvifit : May, 1909. 

General Considerations 

MINNESOTA is perhaps the first state in the Union that may fairly be considered to 
have solved the most perplexing problems connected with medical education and prac- 
tice except as to osteopathy. It has indeed still to realize its plans for an adequate 
clinical establishment of modern character; but there is little doubt that this is only 
a question of time, and of a short time, at that. Meanwhile medical education has, 
with the active cooperation of the state board, been concentrated in the hands of the 
university, fortunately situated in the heart of the largest community of the state ; 
the state has got rid of rival schools, regular and sectarian, the latter by a perfectly 
fair provision for separate instruction in sectarian dogmas for any student who is will- 
ing to accept a diploma qualified so as to mark that fact. Since all else anatomy, 
physiology, surgery are common to and the same for all " schools " of medicine, there 
is one standard of admission to the department, one quality of instruction, one exami- 
nation for the degree for all alike. Finally, the educational preliminary qualification of 



MISSISSIPPI 249 

the state medical school has become the practice preliminary of the state. In future, 
any person desiring to practise medicine in Minnesota must get as good an education 
preliminary and professional as the state furnishes and requires of its own sons : 
a regulation both fair and wise, whether viewed from the standpoint of the student 
or from the broader standpoint of public interest, to which all else is properly 
subordinate. Henceforth, the success of the school will depend largely on the gener- 
osity of the state in developing the clinical teaching, and on the character of the 
hospital and dispensary which it organizes with that in view. 



MISSISSIPPI 

Population, 1,786,773. Number of physicians, 2054. Ratio, 1 : 887. 
Number of medical schools, 2. 

MERIDIAN : Population, 22,415. 

(1) MISSISSIPPI MEDICAL COLLEGE. Organized 1906. A stock company. 
Entrance requirement : Nominal. 

Attendance: 100, 94 per cent from Mississippi. 

Teaching staff: 19, of whom 12 are professors, 7 of other grade. 

Resources available for maintenance : Fees, amounting to 87500 (estimated). 

Laboratory facilities : At the date of visit, there was no outfit at all. Subsequent 
reliable report credits the school with a vat containing four cadavers in a room 
without other contents, a simple outfit for elementary chemistry, and twenty brand- 
new microscopes, but no material to use with them. 

Clinical facilities : Practically none. Some of the faculty have places on the staff of a 
small hospital over a mile distant. 

There is no dispensary. 
Date of visit : January, 1909. 

OXFORD-VICKSBURG: (Population: Oxford, 2104; Vicksburg, 16,800). 

(2) UNIVEBSITY OF MISSISSIPPI, MEDICAL DEPARTMENT. 1 A divided school. First half 
organized 1903; second half organized 1909. An organic part of the university. 

Entrance requirement: A four-year high school education or its equivalent. Over 
one-half of this year's entering class had had two or more years of college work. 

Attendance : 39. 

1 As this report goes to press, it is announced that the clinical end of this school (at Vicksburg) is 
discontinued. The first two years will continue to be given at Oxford. 



250 MEDICAL EDUCATION 

Teaching staff: At Oxford, 8 professors, 3 of whom give entire time to this depart- 
ment, and 3 assistants ; at Vicksburg, 6 professors and 10 of other grade. 

Resources available for maintenance : The department shares the general funds of the 
university. Its budget calls for $15,000. Fees amount to $3500. 

Laboratory facilities : (Oxford.) Laboratories, adequate to the needs of the instruc- 
tion offered, are provided for physiology, pharmacology, histology, and anatomy ; 
pathology and bacteriology are less satisfactory. Chemistry is well cared for in 
the university laboratory. The teachers need a larger number of competent as- 
sistants and helpers; a beginning has been made towards a departmental library. 

Clinical facilities : (Vicksburg.) The clinical end has been so recently started that no 
attempt will be made here to deal with it. It will probably be discontinued. 

Date ofvitit: November, 1909. 

General Considerations 

OF the two schools, that at Meridian is without merit. At a time when the state has 
already more doctors than it needs, the starting of a didactic school, conducted by 
the local practitioners of a small town, is absolutely unjustifiable. The state laws 
ought to be promptly amended so as to make such ventures impossible. 

The state is indeed not favorably situated for the entire training of its own doctors. 
The state university, the only institution to which the task could fall, is unfortunately 
located. Its present experiment with a divided school is even more problematical than 
similar ventures elsewhere; for to the inherent disadvantage of division is to be added 
the fact that Vicksburg itself is a small town. Moreover, the first half of the school, at 
Oxford, though distinctly creditable, is far from satisfying its faculty. It is a ques- 
tion whether the university would not do more wisely to concentrate its outlay on 
the Oxford branch. 

Up to this time, the medical profession of Mississippi has been educated mainly 
in the proprietary schools of the southern states. It would be fortunate indeed if 
henceforth its members should get at least their first two years at Oxford. To make 
itself the main factor in the education of the physicians of the state, the university 
should keep its entrance requirement in touch with the secondary school system. Its 
present and prospective facilities do not really warrant a higher requirement. Besides, 
it can perform a more useful service by training a relatively large body of students 
at the high school level than by training a few on a higher standard. McGill and 
Toronto do not prove that a high school standard is as good as a college standard ; 
but they do prove that where a high school standard, or even less, is enforced, well 
chosen teachers, well equipped and liberally sustained laboratories, are capable of 
producing a very useful type of physician. The present duty of the southern state 
universities is not to press prematurely to a standard that either cannot be enforced 
or that, if enforced, will relegate the main army of students to medical schools with- 



MISSOURI 251 

out either facilities or ideals, but to endeavor themselves to get hold of a sufficient 
body of students to meet the demand on an enforceable basis, to improve their facilities 
so that this number can be well trained, and to urge the legislature to make their 
standard the practice standard of their respective states. Under more favorable cir- 
cumstances, a decade hence, the state can and should ask more. But just now it is 
more important to develop the medical department of the state university at the 
high school level than to push it higher, leaving the training of southern physicians 
to schools without ideals or resources. 



MISSOURI 

Population, 3,491,397. Number of physicians, 6323. Ratio 1 : 552. 
Number of medical schools, 12 {plus 1 postgraduate school). 

COLUMBIA: Population, 7302. 

(1) UNIVERSITY OF MISSOURI SCHOOL OF MEDICINE. A two-year school. Organized 1872. 
An organic department of the university. 

Entrance requirement: One year of college work. 

Attendance: 47, all from Missouri. 

Teaching staff': 14, 8 being professors, 6 of other grade. 

Resources available for maintenance: The department shares the general income of 
the university. Its budget calls for $31,000; fees amount to $2820. 

Laboratory facilities: The medical department occupies a new and well equipped 
building, excellently adapted to its purposes. The teaching is in charge of full- 
time instructors of modern training and ideals. A university hospital of 45 beds 
gives the department the advantage of clinical material and connection, even though 
the actual instruction is limited to the work of the first two years, a feature of 
great importance. There is a library, supplied with important current periodicals, 
domestic and foreign. 

Date of visit: April, 1909. 

KANSAS CITY: Population, 205,022 (plus Kansas City, Kan., 81,052). 

(2) UNIVERSITY MEDICAL COLLEGE. Organized 1881. An independent institution. 
Entrance requirement: Less than a high school education. 

Attendance: 174, 82 per cent from Missouri and Kansas. 

Teaching staff: 65, 30 being professors, 35 of other grade. There is one full-time 
teacher. 



252 MEDICAL EDUCATION 

Resources available for maintenance: Fees, amounting to $17,600 (estimated). 

Laboratory facilities: A single large laboratory is set aside for chemistry of all kinds, 
and urinalysis: huge bottles are furnished instead of separate reagent sets; his- 
tology, pathology, and bacteriology occupy a second room, equipped for routine 
work in each of these branches. Physiology is similarly provided for. There is the 
usual dissecting-room, large, clean, and well lighted. There are no books. There 
is a small museum and a large supply of pathological material. 

Clinical facilities: Adjoining the school is the University Hospital, most of the work 
of which is surgery ; but as there are no free beds, it is of no real use to students. 
The main reliance for clinical instruction is the City Hospital, a beautiful modern 
structure, in which clinics are held, mainly in the amphitheater, one day weekly 
from 8 to 12. The school has no access to the clinical laboratory, to autopsies, 
obstetrics, or infectious diseases, but an out-patient department and a Rescue 
Home furnish obstetrical opportunity in abundance. Other institutions furnish 
additional material. The school dispensary fairly clean has a large attendance; 
but it is poorly equipped and loosely conducted. The clinical facilities are, there- 
fore, unsatisfactory in both quality and extent. 

Date of virit : November, 1909. 

(3) KANSAS CITY HAHKEMANN MEDICAL COLLEGE. Homeopathic. Organized 1888, an 
independent institution. 

Entrance requirement: Less than a high school education. 

Attendance: 59. 

Teaching staff: 41, of whom 33 are professors, 8 of other grade. 

Resources available for maintenance: Fees only, amounting to $5900 (estimated). 

Laboratory facilities: All laboratory work is conducted by one teacher, who serves 
in the same capacity in the local eclectic and osteopathic schools. The chemical 
laboratory is small and poor; that for pathology, histology, bacteriology, and em- 
bryology, urinalysis and blood work combined, is worse meagerly equipped and in 
utter disorder. Anatomy had not as yet started (November). There are a few books. 

Clinical facilities: Amphitheater instruction is given one morning a week at the 

City Hospital. 

In the school building is a small dispensary, with an estimated attendance of 

6 or 7 a day. A neatly kept card index is employed. 
Dot* ofvitti: November, 1909. 

(4) CENTEAL COLLEGE OF OSTEOPATHY. Established 1902. An independent institution. 
Entrance requirement: Nominal. 



MISSOURI 253 

Attendance: 40. 

Teaching staff*: 20. 

Resources available for maintenance: Fees only, amounting to $4500 (estimated). 

Laboratory facilities: Practically none at all: hopelessly meager appointments in two 
rooms are denominated respectively chemical and pathological laboratories. Dissec- 
tion was not in progress at the time of the visit. It is held that "students ought 
to know anatomy before they dissect, they get more out of it." A single cadaver 
was dissected in September and October; another was expected in February. 

Clinical facilities: A pay-dispensary is operated, senior students giving "treatments" 
to patients who pay three dollars a month. Students may on payment of fee attend 
public clinics at the City Hospital, but the school has no hospital facilities or 
connections of its own at all. 

Date of visit: November, 1909. 

KIRKSVILLE: Population, 8422. 

(5) AMERICAN SCHOOL OF OSTEOPATHY. Established 1892 and owned by two individ- 
uals. 

Entrance requirement: Less than a common school education. 

Attendance: 560 (ranging in age from 18 to 54 years). 

Teaching staff": 12, with 11 student assistants. 

Resources available for maintenance: Fees, amounting to $89,600 (estimated). 

Laboratory facilities: These are absurdly inadequate for the number of students, as 
is likewise the teaching staff. A single room, with a corresponding preparation 
room, is used as bacteriological and physiological laboratory, a six weeks' course 
being given by one teacher to successive squads of 32. In the same way separate 
additional laboratories are provided for chemistry, anatomy, and pathology. Ma- 
terial for pathological demonstration is bought; there is no museum, and no effort 
is made to save gross material. The dissecting-room is foul. The "professors" in 
charge of histology, pathology, and bacteriology are senior students. 

Clinical facilities: A hospital of 54 beds adjoins, but its work is practically all 
"surgery;" the ward cases are "occasionally used for clinics. Students witness 
operations." Obstetrical work is comparatively scanty. There is no other hospital 
in the town. 

A large dispensary is operated. An instructor is at hand the first time the stu- 
dent administers a "treatment;' 1 after that, "only if summoned." A course of 
twenty lectures on the fallacies of medicine is given, so that the graduate will 
know why he does not use "drugs." 



254 MEDICAL EDUCATION 

The school is a business in which a large margin of profit is secured by its owners. 

The teaching furnished is of the cheapest kind. Its huge income is therefore largely 

profit. 

Date of visit: November, 1909. 

ST. JOSEPH: Population, 132,954. 

(6) ENSWORTH MEDICAL COLLEGE. Organized in 1876, it has twice merged with other 
schools. An independent institution. 

Entrance requirement: Less than a four-year high school education. 

Attendance: 72, 68 per cent from Missouri. 

Teaching staff: Numbers 40, 32 being professors, 8 of other grade. 

Resources available for maintenance: Fees only, amounting to $7060 (estimated). 

Laboratory facilities : These are very weak. The chemical laboratory is of elementary 
character; there is a small outfit for physiological demonstration; a single room 
with little material is provided for pathology, bacteriology, and histology. There 
is the usual ill kept dissecting-room. There is no museum, books, or teaching ac- 
cessories. The building is very dirty. 

Clinical facilities: These are wholly inadequate. The adjoining hospital, containing 
six free beds, is of little use. Fifty beds, of which 14 were occupied at the time of 
visit, are accessible at a Catholic institution, but four-fifths of its work is surgical. 
Obstetrical work is entirely inadequate; post-mortems are very rare. The available 
material, scant as it is, is poorly used, as far as teaching is concerned. 

There is a small dispensary, without records, organization, or equipment. 

Date of visit: November, 1909. 

ST. LOUIS: Population, 698,706. 

(7) WASHINGTON UNIVERSITY MEDICAL DEPARTMENT. Organized 1842. United in 
1891 with Washington University, of which it has been since 1907 an organic 
department. Completely reorganized on modern lines 1910. 

Entrance requirement: Four-year high school education. Credentials are passed on 
and examinations conducted by the university. 

Attendance: 178, 60 per cent from Missouri. 

Teaching staff: 99, 48 being professors, 51 of other grade. There had been four full- 
time professors and a few full-time assistants, but as this report goes to press, the 
entire faculty is undergoing reconstitution. All the laboratory branches, as well as 
the departments of medicine, surgery, and pediatrics, have been already reorganized 
on a strict university basis. 



MISSOURI 255 

Resources available for maintenance: The school shares the general funds of Wash- 
ington University. Its fee income is $21,000; its budget (1909-10) $51,265, (not 
including $30,000 spent on the University Hospital). Productive endowments to 
the extent of $1,500,000 will become available in 1910-11. 

Laboratory facilities: These have hitherto sufficed for only routine work in the fun- 
damental branches, but the reorganization on productive modern lines, already 
under way, will shortly be completely effected. The museum, though small, is good ; 
a start towards a modern medical library has been made. 

Clinical facilities: The school has its own hospital of 98 beds, one-fourth of them free; 
and has access to other hospitals on the usual footing. The amount of material thus 
available was fair; but the close affiliation which has been made with the trustees 
of the Barnes and the Children's Hospitals revolutionizes the clinical situation of 
the school. 

The school controls two dispensaries, one connected with the University Hos- 
pital, the other situated in the medical school building. Their combined atten- 
dance is very large. 

Date ofvitit: April, 1909. 

(8) ST. Louis UNIVERSITY. The school, organized 1901 by merger, was in 1903 pur- 
chased for cash by the university, of which it is now an organic part. 

Entrance requirement: Less than a high school education. 
Attendance: 243, 42 per cent from Missouri. 

Teaching staff: 121, 39 being professors, 82 of other grade. There are six full-time 
instructors with competent helpers; but the assistants are as a rule students. 

Resources available for maintenance: Fees, amounting to $26,630 (estimated), supple- 
mented by small allotment from the university treasury. During a period of seven 
years (1903-10), the university devoted $40,817 to its medical school. $20,000 
have been recently subscribed towards an endowment fund for the department. 

Laboratory facilities : Excellent teaching laboratories are provided for all the funda- 
mental branches, in addition to which provision has been made for research in 
several directions. 

Clinical facilities : The school has a small hospital of its own (12-16 free beds), and 
has access on the usual terms to several other institutions. The material, while fair 
in amount, is scattered and under imperfect control. The hospitals used are not or- 
ganized, equipped, or conducted with a view to the requirements of modern medi- 
cal teaching. 

The dispensary is fair. 

Date of visit: April, 1909. 



256 MEDICAL EDUCATION 

(9) ST. Louis COLLEGE OF PHYSICIANS AND SURGEONS. Organized 1869. An independent 
institution. 

Entrance requirement: Nominal. 

Attendance: 224. 

Teaching staff: 49, of whom 25 are professors, 24 of other grade. 

Resources available for maintenance : Fees only, amounting to $16,035 (estimated). 

Laboratory facilities: The school occupies a badly kept building, the inner walls cov- 
ered with huge advertisements. A single ordinary laboratory is provided for chem- 
istry ; there is a make-believe laboratory for experimental physiology ; for the school 
owns the equipment stipulated by the state board, though the dust-covered tables 
do not indicate use. Rows of empty reagent bottles are also to be seen. The " mu- 
seum" consists of some cheap photographs and drawings and a few badly preserved 
wet specimens, all carefully arranged so as to occupy as much space as possi- 
ble. Microscopes appear to indicate a laboratory of pathology or bacteriology; 
but the "individual lockers" were empty. It was explained that "students have 
to bring slides, holders, and cover-glasses with them, for they furnish their own 
and keep them at home." Anatomy was "over" only empty tables were found in 
the dissecting-room, the sole access to which is by way of a fire-escape. 

Clinical facilities : A small, poorly lighted, badly ventilated, and overcrowded hospi- 
tal is part of the school building. Its operating amphitheater is good. Clinics of 
slight value are also held at the City Hospital. A few other opportunities of infe- 
rior importance are obtained in the usual way. 

A dark and dingy suite of rooms serves for a dispensary. The room devoted to 
gynecology, for instance, is without a window, and contains no equipment except 
a deal table covered with a sheet. 

The school is one of the worst in the country. 
Date of visit: April, 1909. 

(10) BARNES MEDICAL COLLEGE. Organized 1892. An independent institution. 
Entrance requirement: Less than a high school education. 

Attendance: 124. 

Teaching staff: 64, of whom 39 are professors, 25 of other grade. 

Resources available for maintenance: Fees only, amounting to $12,400 (estimated). 

Laboratory facilities : A huge "chemical laboratory, the largest in the world devoted 
to medical education," is the most striking feature; its equipment suffices for ele- 
mentary work only; another large room with ordinary equipment is devoted to 
bacteriology, histology, and pathology. A physiological laboratory is equipped 



MISSOURI 257 

in literal compliance with the state board stipulations. The dissecting-room is 
spacious and well lighted. There is no museum; few books and few teaching 
accessories. 

Clinical facilities : These are wholly inadequate. The Centenary Hospital, adjoin- 
ing the school, is without educational importance. Its work is mainly private and 
almost altogether surgical. The school has access to the City Hospital, too, but its 
clinics, held one afternoon a week, are of little value. 

The college buildings contain a suite of rooms used as a dispensary. A consid- 
erable attendance is claimed, but the arrangements are shockingly bad. The rooms 
are in poor condition and almost devoid of proper equipment. 

Date of visit : April, 1909. 

(11) AMERICAN MEDICAL COLLEGE. Eclectic. Organized 1873. An independent school. 
Entrance requirement: Nominal. 

Attendance .-28. 

Teaching staff: 28, of whom 25 are professors. 

Resources available for maintenance: Fees, amounting to $3801 (estimated). 

Laboratory facilities : Meager equipment is provided for anatomy, chemistry, pa- 
thology, and bacteriology. A small amount of apparatus for physiology demonstra- 
tion, as required by the state board, is displayed in a case. There is no suggestion 
of use. 

Clinical facilities are equally scanty. A weekly clinic can be held at the City Hos- 
pital; the rest depends on the professor's connections. 

A dispensary room is also provided, and "almost every day some one comes." 

Date of visit: April, 1909. 

(12) HIPPOCRATEAN COLLEGE OF MEDICINE. A night school. An independent institu- 
tion, in its third year. 

Entrance requirement: Nominal. 

Attendance: 31. 

Teaching staff: 30 professors, 8 of other grade. 

Resources available for maintenance: Fees, amounting to $3315 (estimated). 

Laboratory facilities: A brand-new outfit is visible in the shape of a few microscopes, 
physiological apparatus, chemical reagents, etc. But though two classes were in 
session, none of the equipment was in use, nor did its appearance indicate previ- 
ous use. One of the classes mentioned was receiving eloquent didactic instruction 
in osteology, the other in anesthesia. 



258 MEDICAL EDUCATION 

Clinical facilities: Being not yet needed, these are not yet arranged for. 
Lat of vint: April, 1909. 

KANSAS CITY: 

(13) POSTGRADUATE HOSPITAL SCHOOL. This institution has a hospital of 25 ward 
beds, containing 15 patients, 2 medical, 13 surgical. There were no students in 
attendance at the date of the visit. The institution is really a private hospital, but 
incorporation as a school gives its faculty privileges at the City Hospital. 

Date ofvitit: April, 1909. 

General Considerations 

MEDICAL education in Missouri is at a low ebb. The state board lacks authority to 
enforce even a high school preliminary, the more regrettable as, under the stimu- 
lating influence of the state university, an excellent high school system has been 
developed. Missouri is therefore in the attitude of requiring every boy and girl who 
wishes to attend the state university to spend four years in good secondary schools 
supported by the people, but men and women who are charged to safeguard public 
health may attend medical schools chartered by the state without the assurance of 
any definite training whatever. 1 In consequence, the state is badly overcrowded 
with practitioners trained in poor schools, and still maintains some of the poorest 
schools in the country. Utterly wretched are (1) Kansas City Hahnemann Medi- 
cal College, (2) Central College of Osteopathy, (3) American School of Osteopathy 
(Kirksville), (4) St. Louis College of Physicians and Surgeons, (5) American Medical 
College, (6) Hippocratean College of Medicine; feeble and without promise are 
(7) Barnes Medical College, (8) Ensworth Medical College, and (9) University Medical 
College, though the last named is distinctly superior to the other eight. There re- 
main the two-year school conducted by the state university, the medical department 
of Washington University, and the St. Louis University School of Medicine. 

There are in the state of Missouri fifty-odd academic institutions, of which only 
two have resources adequate to support medical schools, viz., the state university and 
Washington University. Of the several towns in the state capable of supplying clin- 
ical material, only one St. Louis contains a strong resident university. Wash- 
ington University, St. Louis, is therefore at this writing marked out as the natural 
patron of medical education in Missouri. 

Its importance is bound to be more than local. Aside from its obvious possibili- 
ties as a productive scientific center, Washington University must be the main fac- 
tor in the training of physicians for the southwest country; the city of St. Louis 
has in this section an even clearer opportunity than has Chicago in the middle west, 
New York in the east, or Boston in New England. For there is no other large city 

1 That is what a certificate from a county school commissioner amounts to, no matter what it pre- 
tends to certify. 



NEBRASKA 259 

south of Minneapolis or as far west as the Pacific which as completely meets all the 
requirements of the case. 

There is abundant evidence to indicate that those interested in Washington Uni- 
versity appreciate its "manifest destiny ;" it bids fair shortly to possess faculty, 
laboratories, and hospital conforming in every respect to ideal standards. It is, how- 
ever, worth asking whether it may not supplement its own resources by some form 
of cooperation. The state university formerly conducted a four-year school at Colum- 
bia; realizing that its clinical instruction could not without immense expenditure 
be brought to the present level of the scientific years, it has had the wisdom and 
courage to confine its efforts to the first two years. The easy expedient of a clinical 
end at Kansas City or elsewhere, it has with equal wisdom and firmness rejected. Its 
resources and influence, however, may not impossibly be enlisted in behalf of the 
medical work of Washington University, for the latter institution is in position to 
use effectively whatever can be placed at its disposal. Should St. Louis University 
receive financial support enabling it to enforce the same entrance standard as the 
other two institutions mentioned, it also would be wise to forego clinical instruction, 
turning over its students in their last two years to Washington University. A sec- 
ond clinical establishment on the same scale is neither desirable nor likely. Nor will 
St. Louis University or its students be permanently satisfied with an old-fashioned 
clinical department superposed on its modern laboratory foundation. 



NEBRASKA 

Population, 1,069,579. Number of physicians, 1776. Ratio, 1: 602. 
Number of medical schools, 3. 

LINCOLN-OMAHA: (Population: Lincoln, 53,667; Omaha, including South 
Omaha, 164,519). 

(1) COLLEGE OF MEDICINE, UNIVERSITY OF NEBRASKA. Organized 1881. Affiliated in 
1902 with the state university, of which it is now an organic part. A divided school, 
the first two years being given at the university (Lincoln), the last two at Omaha. 

Entrance requirement: Two years of college work. 
Attendance: 122. 

Teaching staff': 84, of whom 38 are professors, 46 of other grade. The laboratory 
branches are taught by full-time teachers, using in the main student or practitioner 
assistants. 

Resources available for maintenance: The department is supported by state appro- 
priations. Its income in fees for the year ending June, 1909, was $4905; its budget 
amounts to $20,612, reckoning only items due directly to the medical department. 



260 MEDICAL EDUCATION 

Laboratory facilities : (Lincoln.) The department has the necessary laboratories, on 
the whole fairly equipped. The instructors are active men of modern training, 
eager to do research work. They are, however, in position to accomplish little in 
this direction for lack of space, proper assistance, and funds. The opportunities 
are nevertheless adequate for good routine undergraduate teaching. Animals are 
provided in abundance; there is a good library and a fair collection of necessary 
teaching adjuncts. 

Clinical facilities: (Omaha.) The school has the privilege of the County Hospital for 
half the year, and staff privileges at the Methodist Hospital and several other in- 
stitutions. These institutions are, of course, not equipped or conducted with regard 
to teaching. For example, the clinical pathologist of the school is not now a mem- 
ber of the staff of either institution; in consequence of which fact, the teaching of 
this important branch is isolated. Section visits are, however, arranged. There is 
little scientific intercourse or pedagogical interplay between the severed laboratory 
and clinical ends at Lincoln and Omaha respectively. 

The dispensary has a fair attendance, but is not well organized. 

Date ofviiit: April, 1909. 

(2) LINCOLN MEDICAL COLLEGE. Eclectic. Organized 1890. Nominally the medical de- 
partment of Cotner University. 

Entrance requirement: Nominal. 

Attendance: 42, 77 per cent from Nebraska. 

Teaching staff: 34, all of whom are professors. 

Resources available for maintenance: Fees, amounting to $3794 (estimated). 

Laboratory facilities : There are practically no laboratory facilities beyond a separate 
room set aside for dissecting and the meager chemical laboratory of Cotner Univer- 
sity. Some little microscopical work may also be carried on at the latter institution. 

Clinical facilities: There are no definite clinical opportunities, not even a dispensary. 
Date ofvirit: April, 1909. 

OMAHA 

(3) JOHN A. CREIGHTON MEDICAL COLLEGE. Organized 1892. Integral part of 
Creighton University. 

Entrance requirement: Less than a four-year high school education. 
Attendance: 175. 

Teaching staff": 49, 28 of whom are professors, 21 of other grade. One teacher de- 
votes his entire time to medical instruction. 



NEW ENGLAND 261 

Resources available for maintenance: Mainly fees, amounting to $17,850 (estimated). 

Laboratory facilities : Student laboratories, with individual equipment adequate to 
routine instruction, are provided for chemistry, pathology, histology, and bacteri- 
ology; the professors of the last three subjects have private laboratories besides. 
The provision for anatomy is poor; it comprises an ordinary dissecting-room and 
a lecture-room, equipped with a papier-mache model, charts, a defective skeleton, 
and some odds and ends of bones. The outfit for experimental physiology and phar- 
macology is small. Animals are obtained as needed. There is a small museum and a 
small library. Quiz-compends are sold on the premises. 

Clinical facilities: The school has access to several hospitals where clinical material 
is obtained. Its use is subject to the customary limitations. The main hospital is 
two miles from the school. Though 90-100 beds are there available for ward teach- 
ing, students cannot work in the clinical laboratory of the hospital. Opportunities 
at the other hospitals are not considerable. 

Several large and well arranged rooms in the college building are used for dis- 
pensary work, one hour daily. The attendance is fair. 
Date of visit: April, 1909. 

General Considerations 

IN Nebraska, as in most of the western states, the hope of sound instruction in 
medicine lies with the state university. There is apparently no other institution in the 
state which can confidently count on spending much more on a medical department 
than fees bring in, though Creighton has succeeded in obtaining gifts for building 
purposes. The problem confronting the state university, however, is not simple. It 
has undertaken to require two years of college work for entrance, while the state law 
does not contemplate the enforcement of even a high school standard. The strength- 
ening of the law, by way of backing the state university, ought not, however, to be 
difficult, for the eclectic school is surely without influence and Creighton has prom- 
ised to come to the higher standard in 1910. 

A more perplexing problem arises from the division of the state university depart- 
ment between Omaha and Lincoln. The edges of the two halves do not now touch. 
If our position in respect to divided schools is correct, the state must choose between 
wholly dropping clinical instruction and organizing a complete school on one of the 
two sites now partially occupied. An entire department at Omaha seems at this mo- 
ment the more feasible. 

NEW ENGLAND 

THE medical schools of Massachusetts, Maine, Vermont, New Hampshire, Connecticut 
(nine in all), may profitably be considered together, for the reputable ones among 
them are largely engaged in training local students, 85 per cent of their enrolment 



MEDICAL EDUCATION 



coming from this section. At present, the ratio of physicians to population in this 
section is 1 : 592, not reckoning osteopaths. The section is thus badly overcrowded 
with physicians; and as population is increasing slowly, there is no possibility that 
its increase will within a generation bring about a satisfactory adjustment. In the 
matter of distribution, the usual conditions prevail : cities and small towns are alike 
oversupplied. 1 

It is clear, then, that New England will need no more physicians for years to come; 
it can of course begin none too soon the process of substituting a higher grade of 
physician for what it now has. To bring about a gradual reconstruction of the pro- 
fession, it is important that certain legal changes be promptly made. Massachusetts, 
for example, remains one of three states which obstructs the improvement of medical 
education by permitting non-graduates to be examined for license. The law should 
not only require graduation from a reputable medical school, but should, in the in- 
terest of the public, fix with due warning a minimum basis for admission thereto, as 
Connecticut has wisely done, and should empower and require the state boards to 
refuse examination to graduates of schools whose facilities are inadequate. Of course, 
a thorough practical examination would still further increase the effectiveness of the 
boards in protecting the public against ill trained practitioners. 

If, now, the law prescribed a thorough knowledge of physics, chemistry, and biology 
surely feasible in New England if feasible in Minnesota and Indiana as the 
minimum basis of medical education, attendance in medical schools would promptly 
shrink in number and improve in quality. A more critical attitude on the part of the 
state boards and the student body in reference to the educational advantages offered 
by the several schools would probably result in a reconstruction of the situation 
somewhat along these lines : 

A thoroughly wretched institution, like the College of Physicians and Surgeons 
of Boston, would be at once wiped out. The clinical departments of Dartmouth, 
Bowdoin, and the University of Vermont would certainly be lopped off; there is no 
good reason why these institutions colleges all of them should be concerned with 
medicine at all. The mere fact that they are all old schools is a poor reason for con- 
tinuing them if they fail to do justice to the student, and thereby fail to subserve 



1 By way of example, the 
Massachusetts: 



State ratio, 1 


svr 


Maine : 
State ratio, 1 


000 


New Hampshire 
State ratio, I 


051 


Vermont: 
State ratio, I 


534 


Connecticut: 
State ratio, 1 


740 


Rhode Island : 
State ratio, I 


724 



following are cited at random ; 

Onset 

Westport 

Sacp 

Springfield 

Lisbon Falls 

Centerville 

Lisbon 

Orford 

Plainfleld 

Newhaven 

Randolph 

Stefhey Depot 

Suffield 

Centerdale 

Thornton 

Wickford 



population til number of phytriciang 4 
u 900 " * 3 



C270 

582 

300 

88 

2100 
704 
040 
040 

3000 
420 

3400 
270 
413 

1913 



NEW HAMPSHIRE 263 

the public interest. They originated as didactic schools, and as such were quite as well 
off in small communities as anywhere else. They find themselves now compelled to 
teach clinical medicine by practical methods. They cannot command the necessary 
material nor the financial resources required to procure it. Why should either the 
students or the public make a sacrifice merely to enable them to continue, when it 
is easily possible for both to do better? The argument that these small schools 
train all-round doctors who go out into the country, prepared to do everything, is 
refuted by the obvious fact that schools, unable to command obstetrical cases, con- 
tagious diseases, and the ailments that throng dispensaries, are not really sending 
out the type of practitioner which, by their own admission, the rural districts need. 
Whether even Boston will or should continue to support two regular schools 
Harvard and Tufts is decidedly doubtful. The enrolment of Tufts, even on the high 
school basis, is much swollen. The strict enforcement of that standard and why 
should it not be enforced? will greatly reduce the attendance. The inevitable ele- 
vation of requirements will still further cut it down. The school has no resources but 
fees; out of them it cannot possibly provide for the legitimate demands of the near 
future. It is difficult to see how the department in question can avoid being seriously 
crippled; for its remarkable prosperity has depended to no slight extent on the in- 
ducement held out by low entrance standards. Its only hope of escape is through 
endowment, first, so that it may develop its laboratories independently of fee income, 
next, that it may secure its own hospital. Why should such an expensive step be 
recommended? If New England is in future to be supplied with high-grade doctors, 
the quickest and cheapest road to that end is to complete Harvard and to develop 
Yale, rather than to maintain several more or less imperfect institutions. Whatever 
may once have been the case, local competition needs no longer be relied on to ex- 
pose defects and to stimulate improvement. Keen scientific and educational emulation 
over a wide area provides a sharper incentive and involves no waste. It is, therefore, 
of supreme importance that higher standards be legalized in New England and that 
the clinical independence of the Harvard Medical School be established. The medi- 
cal department of Yale is modestly working in the same spirit and to the same end. 
To these two institutions the future of medical education in New England may for 
many years to come be safely left. 

NEW HAMPSHIRE 

Population, 443,140. Number of physicians, 680. Ratio, 1 : 651. 
Number of medical schools, 1. 

HANOVER : Population, 1951. 

DARTMOUTH MEDICAL SCHOOL. Organized 1798. The medical department of Dart- 
mouth College. 



264 MEDICAL EDUCATION 

Entrance requirement : A four-year high school education. 
Attendance: 58, 91 per cent from New England. 

Teaching- staff ': 24, of whom 17 are professors, 7 of other grade. There are two pro- 
fessors giving entire time to medical subjects, viz., pathology, bacteriology, and 
physiology. Chemistry, botany, embryology, and comparative anatomy are taught 
in the regular college laboratories. Ten clinical professors and one lecturer are non- 
resident. 

Resources available for maintenance: The department is carried by the general re- 
sources of Dartmouth College. The income in fees is $5583 (estimated). 

Laboratory facilities : Excellent working laboratories are provided for pathology, 
bacteriology, histology, physiology, and for the medical subjects cared for in the 
academic department. Every student serves four weeks during his second year as 
assistant in the pathological laboratory and thus gets an admirable practical expe- 
rience. Anatomy, taught by a practitioner, has not as yet been developed on mod- 
ern lines. There are good departmental libraries, supplied with books and current 
periodicals, foreign and domestic. 

Clinical facilities: These are very limited. The college controls a hospital of 40 beds, 
of which 24 are in wards at reduced rates. These are available for teaching ; to some 
extent private cases may also be demonstratively used. Still further to weaken the 
teaching value of the hospital, surgery predominates to the extent of 80 per cent 
of all cases. Students are employed to assist in surgical operations, but the back- 
bone of clinical instruction an adequate clinic in internal medicine is lacking. 
An isolation pavilion of fourteen beds for college use is employed for teaching 
as occasion presents. For obstetrical work, students sojourn for a period in Boston 
or New York. There are 1214 post-mortems a year. 

There is no dispensary. 
Date ofvuit : March, 1910. 

General Considerations 

DARTMOUTH is already providing excellent modern instruction in most of the work 
of the first two years. The development of its clinical work presents a serious diffi- 
culty. The village is rather inaccessible; the surrounding country is thinly populated, 
containing perhaps 50,000 people in a zone 100 miles north and south. Surgical 
cases are attracted easily enough. Can medical cases be attracted too? Certainly not 
without a very large outlay in the form of professional salaries and hospital expense. 
To what extent a compulsory fifth year spent as interne in a large hospital would 
answer in compensation of defective facilities is a question: much depends on the 
hospitals available for the purpose. That the school cannot much longer continue 
in its present stage is clear: for with the requirement of two years of college work 



NEW YORK 265 

for entrance in 1910, it asks a student to spend six years to get a degree in medicine, 
in attaining which he can enjoy only a very limited opportunity to learn internal 
medicine. It is safe to predict that on that basis the present facilities will not hold 
the student body together during the third and fourth years. 
[See "New England," p. 261.] 

NEW YORK 

Population, 8,706,039. Number of physicians, 14,117. Ratio, 1: 617. 
Number of medical schools, 11, plus 4 postgraduate schools. 

ALBANY: Population, 101,461. 

(1) ALBANY MEDICAL COLLEGE. Organized 1838. Nominally the medical department 
of Union University; actually an independent institution in all but form. 

Entrance requirement: The Regents' Medical Student Certificate. 
Attendance: 180, 91 per cent from New York state. 

Teaching staff: 94, of whom 16 are professors, 78 of other grade. The professor of 
chemistry, the associate professor of physiology, and the director of the Bender 
Laboratory are non-practitioners. 

Resources available for maintenance: Practically fees only, amounting to $20,276. 
$10,000 have been bequeathed to the school as the nucleus of a building fund. 

Laboratory facilities : The Bender Laboratory, at a considerable distance from the 
school, with endowment sufficient to keep up insurance and repairs, provides 
instruction in pathology, bacteriology, histology (not including embryology), clini- 
cal microscopy, and a small amount of demonstrative work in physiology. There 
is no course in pharmacology. The head of the laboratory is pathologist to the 
Albany Hospital and other institutions; autopsies are thus procured. The labora- 
tory has made itself practically self-supporting through board of health and simi- 
lar work. The college, after equipping it, now contributes to its support no more 
than it absolutely must in order to keep it going. In consequence, there is now 
little active research in progress. 

At the medical school building good laboratories are provided for chemistry 
and physiological chemistry, and the usual dissecting-room with a few charts, 
models, etc. Otherwise equipment is scant. The laboratory branches have been 
slighted in pursuance of the policy of paying annual dividends to the faculty. 

Clinical facilities: The main clinical reliance is the Albany Hospital, in which per- 
haps 200 beds are available. But three-fourths of the work of the hospital is sur- 
gery. The service in medicine and surgery rotates every three months. On the 
medical side, students work up assigned cases. In general surgery, students can only 



266 MEDICAL EDUCATION 

"look on." They have no access to the obstetrical ward, though students serving 
as externes are allowed to observe free cases. Other institutions furnish supple- 
mentary material in obstetrics, pediatrics, mental diseases, etc. 

The school uses two dispensaries: that at the hospital is unimportant; the South 
End Dispensary has a fair attendance and is conducted in an orderly manner. 
Date of vitit : January, 1910. 

BROOKLYN: Population, 1,543,630. 

(2) LONG ISLAND COLLEGE HOSPITAL. Organized 1858. An independent institution. 

Entrance requirement : The Regents'* Medical Student Certificate. 

Attendance: 360, 89 per cent from New York state. 

Teaching- staff': 94, 9 being professors, 85 of other grade. There is no full-time 
instructor belonging to the school. 

Resources available for maintenance: Fees, amounting to $61,398. Practically this 
amount is supplemented by advantageous arrangements to be described below in 
connection with laboratory and clinical facilities. 

Laboratory facilities: The Hoagland Laboratory (endowment $131,000), independent 
of but affiliated with this school, sets aside a suite of rooms, in which pathology, 
bacteriology, and histology are taught to medical students. The college is thus 
partly relieved of the expense involved in the equipment and teaching of these 
branches. The opportunities provided are of routine character. The research work 
of the laboratory and its teaching are entirely distinct. 

The college itself contains a good and well kept dissecting-room, in which draw- 
ing and modeling are employed, and two good, though ordinary, chemical lab- 
oratories. 

There is no library, no museum, no physiological or pharmacological labora- 
tory, though a demonstration course in physiology is offered. Freed from the ne- 
cessity of providing certain laboratories, fees might have been used to provide 
others; instead of that, the surplus is annually divided among the faculty. What 
gifts have not provided, the college goes on lacking. 

Clinical facilities: The school adjoins, and is legally one with, the Long Island Col- 
lege Hospital, with 200 beds usable in teaching. The hospital, though new, is not 
designed to serve modern ideas in medical teaching. It lacks adequate laboratories; 
specimens must be carried by students to the college building for examination. 

For dispensary purposes, the college gets the use of the Polhemus Clinic, built 
at a cost of $500,000, having a productive endowment of $400,000. 

The entire plant school and clinic is admirably kept. 

Dot* of vitit : March, 1909. 



NEW YORK 267 

BUFFALO : Population, 401,441. 

(3) UNIVERSITY OF BUFFALO MEDICAL DEPARTMENT. Organized 1846. Despite the uni- 
versity charter, the University of Buffalo is a fiction. Schools of medicine, law, 
dentistry, and pharmacy are aggregated under the designation ; but they are to all 
intents and purposes independent schools, each living on its own fees. 

Entrance requirement: Admission is on the basis of the Regents' Medical Student 
Certificate, being the equivalent of a high school education. 

Attendance: 193. 

Teaching staff: 97, of whom 38 are professors. 

Resources available for maintenance: Fees amounting to $31,984. 

Laboratory facilities : The school has a conventionally adequate equipment for an- 
atomy, ordinary laboratories for chemistry, bacteriology, and pathology, a meager 
outfit in physiology, it having been found that the students cannot profitably do 
much experimental work themselves, nothing for pharmacology. The "whole- 
time" teachers have in the main other duties besides teaching in medicine: the 
professor of pathology and bacteriology is registrar, the chemist officiates in the 
pharmacy department, the anatomist in the dental department. There is a small 
museum, but a good library of 8000 volumes, current German and English periodi- 
cals, with a librarian in charge. 

Clinical facilities : For clinical teaching, the school relies mainly on the Buffalo Gen- 
eral Hospital close by. It has access to some 200 beds, used for demonstrative 
teaching in the wards. Records are made by internes. Students do no clinical labo- 
ratory work in connection with special patients, the teaching in clinical micro- 
scopy being separately given at the college. Infectious diseases are didactically 
taught. Clinical obstetrics is imperfectly organized. Besides the Buffalo General 
Hospital, a weekly clinic is held at the County Hospital, four miles distant, four 
clinics at the Sisters' Hospital, one and a half miles away, etc. 

Despite the size of the city, the college dispensary is wretched. It has an at- 
tendance of perhaps 3000 during the college year, skin, eye, and ear cases mainly. 
A definite statement is impossible because there are no systematic records. The 
rooms are ill equipped. Records consist of brief pencil notes in separate books, 
usually without index. The work is hastily and superficially done, and its influ- 
ence on the students, so far as it goes, must be thoroughly bad. The catalogue 
states, however, that as attendance in the dispensary is obligatory, each student 
"will secure an unusually thorough training in the taking and recording of his- 
tories." 

Date of visit: October, 1909. 



268 MEDICAL EDUCATION 

NEW YORK: Population, 4,563,604. 

(4) COLLEGE OF PHYSICIANS AND SURGEONS. The Medical Department of Columbia 
University. Organized in 1807; affiliated with Columbia College 1860; an organic 
part of Columbia University since 1891. 

Entrance requirement: The Regents'* Medical Student Certificate, which must in- 
clude physics and chemistry. Of the present first-year class of 86, 48 have the 
bachelor's degree, 11 more have had at least two years of college work: the de- 
partment is therefore already close to the two-year college basis, which goes into 
effect 1910-11. 

Attendance: 312, 56 per cent from New York state. 

Teaching staff: 176, of whom 38 are professors, 138 of other grade. 

Resources available for maintenance: The department has special endowments amount- 
ing to $832,351. Fees amount to $75,500. The budget calls for $239,072, includ- 
ing maintenance of Sloane Maternity Hospital and the Vanderbilt Clinic. 

Laboratory facilities: The school laboratories are of modern equipment and organ- 
ization, conducted by full-time instructors, amply assisted. Teaching and research 
are thus actively prosecuted in all departments. Anatomy deserves to be especially 
mentioned, as perhaps the most elaborate plant of its kind in the country. The 
school lacks a general library, though books and periodicals are available in sev- 
eral departments and in the students' study. 

Clinical facilities : The school is admirably situated in i-espect to the Sloane Maternity 
Hospital (to which gynecology is now to be added) and the Vanderbilt Clinic (dis- 
pensary), which adjoin it and are under its control. Both philanthropically and 
pedagogically, they are effectively conducted on modern lines. 

In other respects, the clinical department labors under the disadvantages com- 
mon to the schools of New York. The situation will be more fully discussed be- 
low; suffice it here to say that various hospitals furnish an abundance of clinical 
material of all kinds under limitations that interfere with effective scientific or 
pedagogic use, and make exceedingly difficult anything like intimate interplay 
between laboratory and clinical teaching. Nowhere has the school rights; at 
Bellevue (municipal hospital), custom establishes a qualified security, liable, how- 
ever, to be disregarded; elsewhere the basis is purely personal. Permission has re- 
cently been obtained to institute clinical clerking in a few places. 

Date of rntit: October, 1909. 

(5) CORNELL UNIVERSITY MEDICAL COLLEGE. Organized 1898. An organic department 
of Cornell University. 

Entrance requirement: Three years of college work. 



NEW YORK 

Attendance: 207. 

Teaching staff: 132, 32 being professors, 100 of other grade. 

Resources available for maintenance: The department is liberally supported. Its 
budget (New York city) calls for $209,888; income from fees, $24,410; Ithaca: 
budget, $32,840; income from fees is negligible. 

Laboratory facilities : The school laboratories in New York are, in general, of modern 
equipment and organization, anatomy and chemistry being, however, less elabo- 
rately developed than physiology and pathology. The professor of anatomy is a 
practising surgeon. Otherwise the laboratories are in charge of full-time teachers, 
properly assisted, devoting themselves unreservedly to teaching and research. De- 
spite geographical separation from the university at Ithaca, the department is 
animated by university ideals: in part, this is ascribable to actual intercourse, in 
part, to the selection of teachers devoted to science, whom the university has so gen- 
erously supported that they have reproduced the university spirit. At Ithaca the 
seat of Cornell University the first year's instruction is also offered: the depart- 
ments of anatomy and physiology as there organized and conducted are thoroughly 
admirable, with their own additional teaching staff, supported by separate funds. 

Clinical facilities: The major part of the clinical instruction is given at the Bellevue 
Hospital, directly opposite the college, in which the school enjoys the same privi- 
leges as Columbia and New York Universities. The service is good in point of 
extent; limitations which render it unsatisfactory will be discussed below. Sup- 
plementary hospitals increase the amount of available material, but always under 
serious pedagogic restrictions. Intimate correlation of laboratories and clinic is 
thus not feasible. 

A thoroughly satisfactory dispensary, well conducted, occupies part of the school 
building. 

Date of visit: February, 1910. 

(6) UNIVERSITY AND BELLEVUE HOSPITAL MEDICAL COLLEGE. Formed in 1898 by 
merger of University Medical College (established 1841) and Bellevue Hospital 
Medical College (established 1861). An integral part of New York University. 

Entrance requirement: The Regents' Medical Student Certificate, representing a four- 
year high school education. 

Attendance: 408, 74 per cent from New York state. 
Teaching staff: 164, 37 being professors, 127 of other grade. 

Resources available for maintenance: The school is mainly dependent on fees, amount- 
ing to $76,115; these are supplemented by gifts and income from endowment 
amounting to about $11,000. 



270 MEDICAL EDUCATION 

Laboratory facilities: The laboratories are developed unevenly, as the resources of 
the school are not equal to uniform promotion of all the medical sciences. Patho- 
logy is excellently organized and equipped both for teaching and research; in other 
branches good teaching facilities rather than any considerable opportunity for in- 
vestigation have been aimed at. The departments of pathology, physiology, phar- 
macology, and chemistry are in charge of full-time teachers. Anatomy, including 
histology and embryology, has just been reorganized on the same basis. Available 
laboratory accommodations are being largely increased by an addition now in pro- 
cess of erection. 

Clinical facilities : The major part of the clinical instruction is given at Bellevue 
Hospital, opposite the college, in which the school enjoys the same privileges as 
Cornell and Columbia. The service is good in point of extent. Limitations which 
make it unsatisfactory will be discussed below. Supplementary hospitals increase 
the amount of available material, but always under serious pedagogic restric- 
tions. Intimate correlation of laboratories and clinic within the hospital is thus 
not feasible. 

A thoroughly satisfactory dispensary, well conducted, occupies part of the 
school building. 

Date of visit : November, 1909. 

(7) FORDHAM UNIVERSITY SCHOOL OF MEDICINE. Organized 1905. An organic part of 
Fordham University. 

Entrance requirement: Something over a four-year high school education. 
Attendance: 42, 83 per cent from New York state. 

Teaching staff": 72, of whom 32 are professors, 40 of other grade. Two instructors 
give their entire time to the medical school. Chemistry and physiology are taught 
in the university by full-time teachers. 

Resources available for maintenance: Fees, amounting to $7330 (estimated 1908-9), 
supplemented by appropriations amounting to several thousand dollars annually 
from the general funds of the university. 

Laboratory facilities : Chemistry and physiology are explained above. The equipment 
in pathology, bacteriology, and histology is adequate for the routine instruction 
of the small student body. Anatomy is limited to dissection. There is a library 
with current scientific journals. 

Clinical facilities : Much of the clinical work of the school is carried on at Fordham 
Hospital, a municipal institution close by; the school has no voice in making its 
staff appointments. Supplementary opportunities are obtained at other institu- 
tions, scattered, as is generally the case, with the medical schools of the city. The 
amount of material available is adequate, but it cannot be organized or controlled. 



NEW YORK 271 

There is a good and growing dispensary service connected with Fordham Hospital. 
Date of visit: October, 1909. 

(8) NEW YORK MEDICAL COLLEGE AND HOSPITAL FOE WOMEN. Homeopathic. Organ- 
ized 1863. An independent school. 

Entrance requirement: Regents' Medical Student Certificate, equivalent to a four- 
year high school course. 

Attendance: 24. 

Teaching staff: 45, 23 being professors, 22 of other grade. No teacher devotes entire 
time to the school. 

Resources available for maintenance: Fees, amounting to $2545. 

Laboratory facilities: Attractive and well kept laboratories are provided for patho- 
logy, bacteriology, and histology together, chemistry and physiology and anatomy. 
The equipment is simple, but recent. There are a small library, a number of ana- 
tomical charts, and some normal and pathological preparations. Autopsy material 
is reported as scarce. 

Clinical facilities : These consist of the hospital, occupying the same building and 
containing 35 available beds, most of the cases being surgical, and of the usual 
rotating services scattered among other hospitals, public and private. They do not 
include infectious diseases. 

Most of the first floor of the school building is given over to a dispensary. 

Date of visit: October, 1909. 

(9) ECLECTIC MEDICAL COLLEGE. Organized 1865. An independent school. 
Entrance requirement: Regents' Medical Student Certificate. 
Attendance: 96, 84 per cent from New York state. 

Teaching staff: 45, 16 being professors, 29 of other grade. No one devotes full time 
to teaching. 

Resources available for maintenance: Mainly fees, amounting to $8311. 

Laboratory facilities : The chemical laboratory, adequate for routine teaching, is ac- 
tive. Otherwise the facilities are weak : one room is used for bacteriology, histology, 
pathology, and clinical microscopy; this with the dissecting-room completes the 
laboratory outfit. There is no museum ; but the school possesses a small collection 
of models, a materia medica cabinet, a stereopticon, and a fair-sized library, of 
which the books are mostly not recent. 

Clinical facilities : There is no eclectic hospital. Twice weekly three students spend 
their entire afternoon at the Sydenham Hospital (80 free beds). There are some 



272 MEDICAL EDUCATION 

supplementary clinics of the usual kind. There is a small dispensary in the school 
building and an outside dispensary is also used. The clinical facilities are utterly 
inadequate in respect to both extent and control. 
Dato ofvitit: March, 1909. 

(10) NEW YORK HOMEOPATHIC MEDICAL COLLEGE AND FLOWER HOSPITAL. Organized 
1858. An independent institution. 

Entrance requirement: Regents' Medical Student Certificate. 
Attendance: 159, 88 per cent from New York. 

Teaching staff: 65, of whom 31 are professors, 34 of other grade. The professors of 
chemistry, physiology, pathology, and bacteriology are full-time teachers. 

Resources available for maintenance: The school and hospital budgets are combined. 
The institution has an endowment of $600,000, which carries a hospital of 125 
free beds, dispensary with ambulance service, etc. Income from student fees 
amounts to $18,658. 

Laboratory facilities : An attractive, well kept laboratory with models and bone- 
mounts is provided for anatomy; a single laboratory for chemistry; one, with a 
small museum, for pathology and histology ; and others, with ordinary equipment, 
for bacteriology and physiology. There is a library of several thousand volumes. 

Clinical facilities: Though the school possesses its own hospital, clinical teaching has 
not hitherto been so organized as to take the fullest advantage of it. The records 
are meager; the clinical laboratory inadequate. Improvements are, however, under 
way. 

The dispensary enjoys a very large attendance. 

Date ofvint: December, 1909. 

SYRACUSE: Population, 127,281. 

(11) COLLEGE OF MEDICINE, SYRACUSE UNIVERSITY. Organized 1872. An integral de- 
partment of the university. 

Entrance requirement: A year's work in science in addition to the Regents' Medical 
Student Certificate. Credentials are passed upon by the academic authorities. Of 
the present class of 40, the first on the new basis, 20 had had a year or more 
of college work ; the rest presented high school or preparatory school certificates 
in the required sciences. 

Attendance: 151, 90 per cent from New York state. 

Teaching- staff': 57, of whom 1 5 are professors and 42 of other grade. The sciences 
are taught by full-time teachers. 



NEW YORK 278 

Resources available for maintenance: Income, almost wholly from fees, amounting to 
$28,861. 

Laboratory facilities: Chemistry is well cared for in the university laboratories. The 
equipment in anatomy, physiology, pathology, including clinical microscopy and 
bacteriology, is adequate for instruction ; the income of the school has been con- 
sistently and intelligently used to develop these departments. They are all in 
charge of full-time teachers, each provided with a competent helper. There is a 
good library, in charge of a librarian, but no museum. 

Clinical facilities : Clinical facilities have not yet been put on the same modern basis 
as the laboratory branches. They are insufficient in respect to both extent and con- 
trol. The school relies mainly on two local hospitals of about 150 beds, providing 
ward and bedside work in general medicine, surgery, and pediatrics, surgery pre- 
dominating. The hospitals do not contain a working clinical laboratory for stu- 
dents. Supplementary opportunities are provided by several other institutions in 
the usual manner. The work in obstetrics is not sufficient. 

Students attend the city dispensary, which is, from an educational point of view, 
of doubtful value. It has an attendance of 10,000; but the records, though sys- 
tematic, are so brief that the experience would hardly conduce to thorough and 
careful habits. The head clinical professors have apparently been indifferent to it. 

Date of visit: October, 1909. 

POSTGRADUATE SCHOOLS 

(1) BROOKLYN POSTGRADUATE MEDICAL SCHOOL. Established 1907. 
Entrance requirement: The M.D. degree. 

Attendance: Students are scarce; four or five may be in attendance at any one time. 
Teaching staff": 52, of whom 19 are professors, 33 of other grade. 
Resources available for maintenance: Fees. 
Laboratory facilities : None. 

Clinical facilities: The school offers graduate courses mainly in the Williamsburg Hos- 
pital, most of the cases in which are surgical. The hospital itself is wretched and has 
no teaching facilities worth mentioning. It is even without a clinical laboratory. 

The existence of the school is a reproach to the state. It now operates on a limited 
charter from the state department of education, and is enabled to continue because 
it is aided by the city. It deserved no charter in the first place, and it deserves no 
recognition from the city now. 

Date of visit: January, 1910. 

(2) NEW YORK POSTGRADUATE SCHOOL. Established 1881. 



274 MEDICAL EDUCATION 

Entrance requirement: The M.D. degree. 

Attendance: There is an average attendance of 90 students in winter, 50 in summer. 
Short courses, usually six weeks in length and of a practical nature, are given. 
Formerly, the so-called "general" ticket was most popular; now, specialties are in 
demand and the medical courses are gaining on the surgical. 

Teaching staff: 156, of whom 38 are professors, 118 of other grade. 

Resources available for maintenance: The school, long without productive resources, 
has recently received a gift of $1,600,000, which, after paying debts and provid- 
ing needed extensions, will leave a productive endowment of perhaps $400,000. 

Laboratory facilities : These are very meager. A single room is devoted to laboratory 
work; little or no research or experimental work is carried on. 

Clinical facilities: The Postgraduate Hospital is of modern construction and is ex- 
cellently conducted. It contains 225 beds, 75 per cent of which are free. The new 
building will add 170 beds and space for clinical and laboratory teaching. Other 
hospitals are also used. 

There is a good dispensary, very largely attended. 

Date ofvitit: January, 1910. 

(3) NEW YORK POLYCLINIC MEDICAL SCHOOL AND HOSPITAL. Organized 1881. 
Entrance requirement: The M.D. degree. 

Attendance: 25 to 50 students are in attendance usually. 

Teaching staff: 149, of whom 24 are professors, 125 of other grade. 

Resources available for maintenance: Fees. 

Laboratory facilities: There is a pathological laboratory for practical work. 

Clinical facilities: Postgraduate instruction is offered in the Polyclinic Hospital (100 
beds), in the dispensary, which is largely attended, and in a considerable number 
of other hospitals, with which members of the faculty are connected as staff 
officers. The instruction is practical in character. 

Date ofviiit: December, 1909. 

(4) MANHATTAN EYE, EAR, AND THROAT HOSPITAL POSTGRADUATE' SCHOOL. Estab- 
lished 1869. An independent institution. 

Entrance requirement: The M.D. degree. 

Attendance: There is an average attendance of 12 students. Courses range from one 
to six months or more in length. Students who attend at least three months are 
eligible to appointment as clinical assistants. 

Teaching staff: 11. 



NEW YORK 275 

Resources available for maintenance: Fees and income from endowment of SI 70,000, 
the latter yielding income sufficient to carry mortgage. 

Laboratory facilities: These consist of two laboratories, one for pathological, the 
other for bacteriological, examinations. 

Clinical facilities : There is an excellent modern hospital, with 125 ward beds. The 
teaching is demonstrative and practical in character, though assistants enjoy 
larger opportunities. 

The dispensary has a very large daily attendance. 
Date of visit : April, 1910. 

General Considerations 

NEW YORK has a double duty and a double opportunity in medical education. It 
must in the first place produce most of its own physicians and a considerable share 
of those who practise in neighboring states, which, like New Jersey, are without 
medical schools. Its eleven medical schools have so energetically done their part in 
this matter that New York itself and all the adjoining states are suffering from 
plethora. 1 There is, therefore, no section of the Union which is at this moment readier 
for an upward step : population is comparatively well distributed, communication is 
easy, roads are good, educational facilities abundant, and doctors superabundant. 
In the city of New York the two-year college requirement can be met at Columbia, 
New York University, and without expense at the College of the City of New York. 
Students outside the metropolis are, up to a certain number, similarly cared for by 
Cornell University. 

But New York may be fairly asked to do more than produce doctors, however 
excellent the type. Its vast hospital and university resources should make it the Ber- 
lin or Vienna of the continent; a genuinely productive contributor to medical pro- 
gress ; the center to which, in the intervals of a busy life, physicians will repair to 
freshen their knowledge and to renew their professional youth; to which the young 
graduate from the interior from the schools of Pittsburgh, Ann Arbor, Madison, 
Iowa City will look for the extension of his scientific and clinical experience. 

Little has as yet been done to realize this opportunity. The postgraduate schools 
are of very limited scope; the great New York schools have been in the main clinically 
unproductive. Why? 

The reason is a matter of history. The schools that are now called university de- 
partments grew up as proprietary institutions. They have never been adequately 
financed. They obtained, and still obtain, their clinical facilities at each other's ex- 
pense: that is to say, what one gets, the other loses. In the Bellevue Hospital a 
modus vivendi was found by division, with an arrangement that enables two schools 
to watch and obstruct the third and a lay board to oversee all three; in the great 

!The ratios prove this : New York, 1:617; New Jersey, 1 : 950 ; Delaware, 1 : 906 ; Connecticut, 1 : 740 ; 
Rhode Island, 1 : 724; Vermont, 1 : 534. 



276 MEDICAL EDUCATION 

private hospitals personal considerations nominate the staff, and the school subse- 
quently negotiates with the appointees. Competition, professional and institutional, 
has molded the hospital situation, and in consequence clinical faculties are organ- 
ized on a personal rather than a scientific or educational basis. Doubtless if Colum- 
bia, New York University, and Cornell had at this moment a free hand, they would 
retain some of their clinical teachers in their present positions. But at bottom this is 
a fortunate accident rather than a natural result: it just happens that some compe- 
tent teachers find themselves in prominent hospital positions; but the system is not 
designed to pick them out. In the event of their withdrawal, their successors in the 
hospital would not be sought on the basis of scientific eminence, and if not in the 
hospital, then not in the school. Under these conditions, the schools can hardly be said 
to have ideals, policy, or genuinely organized departments, except by fortunate acci- 
dent. For the nonce, there may be a continuous medical service here, clinical clerks 
there, post-mortems elsewhere. But the favoring conditions are perishable. The schools 
skate on thin ice. An accident may shatter the arrangement and convert a "depart- 
ment" into a congeries of courses lacking unity in conduct and aim. Indeed, most of 
the clinical departments now conform to just this description: there are a half-dozen 
professors of medicine and surgery in place of one; and no possibility of team-work 
on their part. 

For many years nothing more than this was asked ; but meanwhile the school point 
of view has changed. Doubtless there are professors who are satisfied to go on pro- 
ducing doctors and to let other institutions produce knowledge; but the produc- 
tivity of the first and second years has suggested another ideal. The problems of 
clinical medicine have been the more sharply formulated as the pathologist and the 
bacteriologist have passed up to the clinician the results of their own scientific activity. 
The teachers of medicine must attack these problems. To attack them, they require 
quite another environment. The modus vivendi which enabled rival schools to lecture in 
the same hospitals does not provide the conditions in which a clinical scientist can work. 

We have now suggested two results that medical schools in New York must at- 
tain: (1) they must make doctors in sufficient number; (2) they must actively par- 
ticipate in the advance of medical science. If the standpoint previously expounded 
is correct, the same institutions must do both. Of the eleven medical schools now 
existing in the state, only the bona-fide university departments can then expect to 
survive: outside of New York city, Syracuse University alone has just now a chance. 
The schools of Buffalo, Albany, and Brooklyn belong to the past. None of the three 
has even yet entirely emerged from the fee-dividing stage. Syracuse, with a smaller 
total fee income than any of them, devotes every dollar to the development of the 
fundamental branches and has fairly earned support from outside. 

Of the New York city schools, Columbia and Cornell alone have at this moment 
any financial strength. Neither of them, indeed, is in actual possession of sufficient 
endowment; but there is little reason to doubt that what is additionally requisite 



NEW YORK 277 

will be forthcoming. New York University is much less secure. Its maintenance at 
its present level is conditioned on adherence to a lower admission standard than is 
scientifically justifiable or educationally necessary. It cannot much longer resist the 
upward trend ; for its scientific faculty and thence the initial stimulus comes is 
apt to chafe under the limitations which the lower standard imposes. Whether on 
the higher basis the school will be a permanent factor in the situation is thus largely 
a question of adequate support from the outside in the next few years. None of the 
other local schools have at this date a substantial foundation of any sort. 

The ground being thus cleared, the clinical difficulty still presses. Institutional 
competition is reduced; but personal and professional competition remain. Why 
should non-schoolmen freely retire for the sake of schoolmen? The situation is curi- 
ously deadlocked. The school faculties are not now made up on educational lines, 
they cannot be. If the number of schools were reduced to two or three, it 
would still be true that their clinical faculties would in the main be constituted of 
men very much like the more important men omitted from them. Such being the 
case, the hospitals and the doctors naturally refuse to yield to the universities; and 
until they do yield, the universities cannot freely reconstruct their clinical branches. 
The faculty men would themselves doubtless make common cause with the outsiders 
as against a university which asks a free hand in order to bring in a body of clinical 
teachers from the outside. The usual hospital staff will not vacate for the present 
type of clinical faculty, because the faculty lacks commanding scientific and peda- 
gogical preeminence; nor will the present faculties surrender to the universities for 
the purpose of enabling the latter to fill the places with men of another type. 

Under these circumstances, palliation may perhaps come through some cooperative 
effort. Tension and friction will at least decrease as the number of schools diminishes. 
Clinical teaching in the municipal hospitals, perhaps, could then be controlled under 
some form of federation. The vast resources of these great institutions might under 
combined management form a great postgraduate and special clinic; and the muni- 
cipal authorities might conceivably relax, for the common benefit of a single organ- 
ization and for the glory of a great enterprise, restrictions which they have found 
necessary in dealing with several institutions engaged simultaneously in training 
boys. Unquestionably such action would bring the present postgraduate schools into 
the university, where they ought to be. 

With this arrangement consummated, however, the schools still lack teaching 
hospitals in which the undergraduate student can be vigorously disciplined while his 
freely chosen teachers are themselves engaged in intensive clinical research. The 
teaching hospital must be in close geographical proximity to, and in the most in- 
timate intercommunication with, the scientific laboratories. In the case of Columbia, 
every physical and educational condition is already satisfied by Roosevelt Hospital: 
the scientific laboratories, the dispensary, the maternity hospital, are on one side of 
the street; the general hospital on the other. Together they would form an ideally 



278 MEDICAL EDUCATION 

compact and complete plant. That they are not so operated cannot but be deplored 
as a tragic mischance. It is to the world at large of no consequence how they hap- 
pened to drift apart. There are interests at stake that are entitled to outweigh all 
personal and historic considerations. 

That an effective affiliation is feasible between a department of medicine and an 
endowed hospital, Western Reserve and Lakeside Hospital assuredly prove, just as 
Toronto proves the same as between a medical school and a municipal hospital. There 
are in New York city a dozen hospitals, each of them capable of becoming a teach- 
ing hospital in the best sense of the term. Their usefulness from every point of view 
would increase in precisely the measure in which they lend themselves to this func- 
tion. They are already comfortable and indeed charming retreats for the sick and 
injured. Why should they be satisfied to be that, and nothing more? They are favor- 
ably known to the poor and to the philanthropic of New York city; and they are 
deservedly proud of their repute. Is it a defect of intelligence or of imagination that 
prevents them from reaching out for more substantial laurels ? Perhaps neither, so 
much as a disinclination to depersonalize the hospital staff management; for de- 
personalization, in hospital management as in faculty appointments, each involving 
the other, is the condition precedent to reconstitution of medical education in New 
York. Without sacrificing a jot of their local distinction, without limiting in the 
slightest degree their usefulness to the sick poor, the New York hospitals may any 
or all of them win a place as scientific laboratories beside Guy^s and St. Bartho- 
lomew's, the Royal Infirmary of Edinburgh, the Charite of Berlin, the Hotel-Dieu 
of Paris. Mount Sinai, the Presbyterian, St. Luke's, and Roosevelt Hospitals might 
under such conditions be familiar names in medical science; as well known to the pro- 
gressive clinicians of St. Petersburg, Vienna, Edinburgh, St. Louis, and San Francisco, 
as they are to the stricken widows of the East Side of New York city itself. What the 
Sloane Maternity Hospital wisely does for a single department, the general hospitals 
can do for general medicine and surgery. The great universities on the ground can 
be trusted with the opportunities and responsibilities which effective affiliation would 
give them. In the absence of such affiliation, separate endowment, procured for the pur- 
pose, must provide teaching hospitals in which the universities will be supreme. Would 
any contend that these hospitals are likely to be less admirably conducted than the un- 
attached hospitals we have named? or that the university faculty of medicine, freely 
recruited, is likely to prove a less competent staff than present methods procure? 

The issue is one that cannot be much longer fought off: Columbia and Cornell 
are already graduate schools in medicine. Their laboratories produce a high-grade 
student, to whom the university is bound to furnish a clinical opportunity of the 
same quality. Neither school can now do it. An effective affiliation, or endowment 
adequate to support a teaching hospital and a scientific medical faculty, is therefore 
their immediate need and desert. 



NORTH CAROLINA 279 

NORTH CAROLINA 

t> i r- o-iiOMui XT u f i. ( 1761 (Amer.Med. Direct.). Ratio, 1:121 6; 

Population, 2,142,084. Number of physicians j 1932 V (polk) u 1:ino ; 

Number of medical schools, 4. 

CHAPEL HILL: Population, 1181. 

(1) UNIVERSITY OF NORTH CAROLINA MEDICAL DEPARTMENT. A half-school. Established 
1890. An organic part of the university. 

Entrance requirement : A year of college work not, however, strictly enforced during 
this, the first session in which it has been required. 

Attendance: 74; 95 per cent from North Carolina. 

Teaching staff ': 15, of whom 10 are professors who take part in the work of the depart- 
ment. The instructors are trained, full-time teachers. 

Resources available for maintenance: The department is provided for in the univer- 
sity budget. Its budget calls for $12,000. Its income in fees is $6500. 

Laboratory facilities: The laboratories at Chapel Hill are in general adequate to 
good routine teaching of the small student body. The equipment covers patho- 
logy, bacteriology, histology, physiology, and pharmacology. Anatomy is inferior. 
Animals are provided for experimental work. The general scientific laboratories 
of the university are excellent; a small annual appropriation is available for books 
and periodicals. The work is intelligently planned and conducted on modern lines. 

Date of visit: February, 1909. 

CHARLOTTE : Population, 36,320. 

(2) NORTH CAROLINA MEDICAL COLLEGE. Organized 1887, it has given degrees since 
1893. A stock company; professorships are represented by stock and can be sold 
subject to the concurrence (never yet refused) of the faculty. 

Entrance requirement : Nominal. 

Attendance: 94, 87 per cent from North Carolina. 

Teaching staff: 32, of whom 19 are professors, 13 of other grade. 

Resources available for maintenance: Fees, amounting to $8345 (estimated), a large 
part being required to carry a building mortgage and to retire the debt. 

Laboratory facilities : These comprise a poor chemical laboratory, containing one set 
of reagents, a wretched dissecting room, and a meager outfit for pathology, bac- 
teriology, and histology. There is no museum, no library, and no teaching aids of 
any kind whatever. No post-mortems are even claimed. 



280 MEDICAL EDUCATION 

Clinical facilities: The school, in virtue of a subscription, holds four weekly clinics at 
a colored hospital of 35 beds; other hospital connections are unimportant. Ob- 
stetrical cases are rare. 

There is a poor dispensary, with a small attendance, in the school building. It 
occupies a fair suite of rooms. 

Late of visit: February, 1909. 

WAKE FOREST: Population, 900. 

(3) WAKE FOREST COLLEGE SCHOOL OF MEDICINE. A half-school. Organized 1902. An 
integral part of Wake Forest College. 

Entrance requirement: Two years of college work, actually enforced, but resting upon 
the irregular secondary school education characteristic of the section. 

Attendance: 53. 

Teaching staff": 6 whole-time instructors take part in the work of the department; 
two of them devote their entire time to medical instruction. 

Resources available for maintenance: The budget is part of the college budget. Fees 
amount to $2225. 

Laboratory facilities: The laboratories of this little school are, as far as they go, 
models in their way. Everything about them indicates intelligence and earnestness. 
The dissecting-room is clean and odorless, the bodies undergoing dissection being 
cared for in the most approved modern manner. Separate laboratories, properly 
equipped, are provided for ordinary undergraduate work in bacteriology, patho- 
logy, and histology, and the instructor has a private laboratory besides. Chemistry 
is taught in the well equipped college laboratory; physiology is slight; there is no 
pharmacology. There is a small museum ; animals, charts, and books are provided. 

Date of visit: February, 1909. 

RALEIGH : Population, 20,533. 

(4) LEONARD MEDICAL SCHOOL. Colored. Organized 1882. An integral part of Shaw 
University. 

Entrance requirement: Less than four-year high school education. 

Attendance: 125. 

Teaching staff': 9, of whom 8 are professors, one of other grade. 

Resources available for maintenance: Mainly fees and contributions, amounting to 
$4721, practically all of which is paid to the practitioner teachers. 

Laboratory facilities : These comprise a clean and exceedingly well kept dissecting- 
room, a slight chemical laboratory, and a still slighter equipment for pathology. 



NORTH CAROLINA 281 

There are no library, no museum, and no teaching accessories. It is evident that the 
policy of paying practitioners has absorbed the resources of a school that exists 
for purely philanthropic objects. 

Clinical facilities: These are hardly more than nominal. The school has access to a 
sixteen-bed hospital, containing at the time of the visit three patients. There is 
no dispensary at all. About thirty thousand dollars are, however, now available 
for building a hospital and improving laboratories. 

Date of visit; February, 1909. 

General Considerations 

THE state of North Carolina makes a comparatively satisfactory showing in the 
matter of ratio between population and physicians ; but this may, perhaps, in some 
measure be due to the fact that practitioners, unlicensed and unregistered, exist un- 
disturbed in the remote districts. It is futile to maintain a low standard in order to 
prepare doctors for those parts ; for the graduates, instead of scattering to them, hud- 
dle together in the small towns already amply supplied. It is admitted that all eligible 
locations are overcrowded. There is not the slightest danger that the necessary sup- 
ply of doctors would be threatened if, for instance, the practice of medicine in the 
state were pitched on the plane of entrance to the state university ; higher than that 
it probably ought not to be at this time. 

The standard suggested any real standard whatsoever, indeed would quickly 
dispose of the thoroughly wretched Charlotte establishment. No clinical school would 
remain in the state. The two half-schools at Wake Forest and at the state univer- 
sity are capable of doing acceptable work within the limits of their present re- 
sources. Both of these schools now require college work for entrance. Is this step to 
be generally recommended at this time to southern universities with medical depart- 
ments ? Without attempting to arrive at a decision, it may be pointed out that there 
are two sides to the question. On the one hand, the college requirement is essential 
to the symmetrical development of the medical curriculum ; on the other, a good 
medical course can be given at an actual high school level, provided that facilities 
and teaching are developed to a high point of efficiency. How will the university 
best serve the state, by training a small number at the higher level, or by getting 
actual control of the state situation on a high school basis before pushing ahead to 
a basis just generally feasible in more highly developed sections of the country? The 
University of Michigan is only now requiring college work for entrance ; it became 
a strong school of immense influence in its own community on a lower basis. Un- 
doubtedly it is right now to go to the higher standard ; perhaps it should have done 
so earlier. But its present efficiency and influence show as McGill and Toronto 
show that if a lower standard is felt to be a reason for better teaching and not 
an excuse for poor teaching, an institution unfavorably located for the initiation of 



282 MEDICAL EDUCATION 

the higher standard can do good work on the lower basis. In the south now is it 
more important to destroy commercial schools by collecting in good university 
institutions a sufficient body of students, or to provide high-grade teaching for a few, 
leaving utterly wretched teaching for the vast majority? The dilemma is worthy of 
very careful consideration. 

A word as to the colored school at Raleigh. This is a philanthropic enterprise that 
has been operating for well-nigh thirty years and has nothing in the way of plant 
to show for it. Its income ought to have been spent within ; it has gone outside, to 
reimburse practitioners who supposed themselves assisting in a philanthropic work. 
Real philanthropy would have taken a very different course. As a matter of fact, 
Raleigh cannot, except at great expense, maintain clinical teaching. The way to help 
the negro is to help the two medical schools that have a chance to become efficient, 
Howard at Washington, Meharry at Nashville. 



NORTH DAKOTA 

Population, 536,103. Number of physicians, 552. Ratio, 1:971. 
Number of medical schools, 1. 

GRAND FORKS : Population, 12,602. 

STATE UNIVERSITY OF NORTH DAKOTA, COLLEGE OF MEDICINE. Organized 1905. A half- 
school. An organic part of the state university. 

Entrance requirement: Two years of college work. 
Attendance: 9. 

Teaching staff: 9 professors and 7 instructors take part in the work of the depart- 
ment. The professor of bacteriology is State Bacteriologist. 

Resources available for maintenance: The department shares in the general funds of 
the university. Its budget amounts to $6300; income from fees, $450. 

Laboratory facilities : The laboratory of bacteriology, being at the same time the 
public health laboratory of the state, is well equipped and very active. Subjects 
given in the regular university laboratories are likewise well provided for. For the 
specifically medical subjects physiology, pathology, anatomy the provision is 
slighter. The students are, of course, few. A library and museum have been started. 

Dale of visit: May, 1909. 

[See South Dakota, " General Considerations," p. SOI.] 



OHIO 283 

OHIO 

Population, 4,594,240. Number of physicians, 7838. Ratio, 1 : 586. 
Number of medical schools, 8. 

CINCINNATI: Population, 353,108. 

(1) OHIO-MIAMI MEDICAL COLLEGE OF THE UNIVERSITY OF CINCINNATI. Organized by 
merger, 1909. An organic department of the university. 

Entrance requirement: A four-year high school education or its equivalent. 
Attendance: 197, 80 per cent from Ohio. 

Teaching staff': 126, of whom 50 are professors, 76 of other grade. There are nine 
professors of medicine and nine professors of surgery (not including gynecology). 
There are three whole-time teachers. 

Resources available for maintenance: Mainly fees, amounting to $26,345 (estimated). 

Laboratory facilities: The university has so recently obtained complete control that 
it is not fair to make an inventory of the situation at this moment in a critical 
spirit. A modern outfit adequate to routine teaching has been already installed 
in pathology, bacteriology, and physiology. The subjects are taught by whole- 
time modern teachers. Chemistry, including physiological chemistry, is given at the 
university by whole-time instructors. Anatomy is as yet unorganized. 

Clinical facilities : These are likewise in a state of transition, not only because of the 
recent formation of the department, but further, because the city has just begun 
the erection of a new hospital, whose exact relation to the university remains to 
be determined. There is an apparent disposition to make the relation close enough 
to be educationally effective. In that event, the university must on its side reor- 
ganize its clinical departments. The various schools may have disappeared, but 
their professorial titles remain. There must be a single professor of medicine, a 
single professor of surgery, etc., if the hospital facilities in prospect are to be de- 
served and properly utilized. 

The school dispensary awaits proper organization. 

Date of visit : December, 1909. 

(2) ECLECTIC MEDICAL INSTITUTE. Chartered 1845. An independent institution. 

Entrance requirement: For Ohio students, a four-year high school education or its 
equivalent. Students from outside states are not held to the same standard. 

A ttendance : 86. 

Teaching staff: 24, of whom one-half are professors. None of the instructors devotes 
his entire time to teaching. 



284 MEDICAL EDUCATION 

Resources available for maintenance: Fees, amounting to $7500. 

Laboratory facilities: A new building has just been provided; it contains an ordinary 
laboratory for elementary inorganic chemistry and a good dissecting-room. Sepa- 
rate laboratories, as yet meagerly equipped, are set aside for histology, pathology, 
and bacteriology. There is a small museum and a small collection of books, but 
practically no other teaching accessories. The course of instruction is not graded. 

Clinical facilities: The school adjoins the Seton Hospital, with which it is affiliated. 
This institution has 60 beds, of which not over 24 are usable, those mostly sur- 
gical. Little medical material is accessible. The teaching is carried on mainly in 
the amphitheater. 

Sophomores are required to attend public clinics at the city hospital (never given 
by eclectic teachers), but the school does not know whether they attend or not. 

A dispensary with a small attendance is connected with the hospital. 
Datet of vitit* : December, 1909; April, 1910. 

(3) PULTE MEDICAL COLLEGE. Homeopathic. Established 1872. An independent in- 
stitution. 

Entrance requirement: A four-year high school education or its equivalent. 
Attendance: 16. 

Teaching staff: 36, of whom 24 are professors, 12 of other grade. 
Resources available for maintenance: Fees, amounting to SI 325 (estimated). 

Laboratory facilities : Anything more woe-begone than the laboratories of this insti- 
tution would be difficult to imagine. The dissecting-room is a dark apartment in 
the basement, in which (December 14) the year's dissecting had not yet begun; 
but the teaching of anatomy was not therefore halted. A disorderly room with a 
small amount of morbid material and equipment is known as the pathological and 
bacteriological laboratory. The chemical laboratory contains a few desks, with re- 
agent bottles, mostly empty. There are a few old books in the faculty-room. No 
charts, museum, models, or other teaching accessories are to be seen. 

Clinical facilities : There was formerly a hospital in the same building, but it is now 
closed. The school claims to hold clinics at certain private institutions, in which, 
however, the work is mainly surgical and the cases not free. Except by attending 
amphitheater clinics at the city hospital, it is not clear that the Pulte students 
can regularly see any hospital medical cases at all. 

There is an inexpressibly bad dispensary in the school building. 

Date of visit: December, 1909. 



OHIO 285 

CLEVELAND: Population, 522,475. 

(4) CLEVELAND HOMEOPATHIC MEDICAL COLLEGE. Organized 1849. An independent 
institution. 

Entrance requirement: A four-year high school education or its equivalent. 
Attendance: 46. 

Teaching staff": 61, of whom 30 are professors, 31 of other grade. 
Resources available for maintenance: Fees, amounting to $5750. 

Laboratory facilities : These comprise a good laboratory for physiology, in which 
vigorous teaching was in progress. In other subjects chemistry, anatomy, patho- 
logy, and bacteriology the provision is only fair. There are several cases of old 
medical books in the office. 

Clinical facilities: These are limited to the City Hospital, a large institution three 
miles distant, in which one-fifth of the material is assigned to this school. Adjoin- 
ing the school building is a homeopathic hospital, with which the school was 
once intimately connected; they have now drifted apart. 

Several rooms in the basement and on the first floor of the college building are used 
for a dispensary. Their equipment is poor; no complete or lasting records are kept. 

Date of visit: December, 1909. 

(5) WESTERN RESERVE UNIVERSITY MEDICAL DEPARTMENT. Organized 1843; in 1881 
joined Western Reserve University, of which it is now an organic part. 

Entrance requirement : Three years of college work. 
Attendance: 98, of whom 70 per cent are from Ohio. 

Teaching staff: 100, of whom 18 are professors, 82 of other grade. The laboratories 
are, with the exception of anatomy, manned with teachers giving their entire time 
to the school. 

Resources available for maintenance: The department has endowments aggregating 
$784,865. Its income from fees is $11,000. Its budget calls for $63,000. 

Laboratory facilities : Excellent laboratories, in which teaching and research are both 
vigorously prosecuted, are provided for all the fundamental scientific branches. A 
special endowment carries the department of experimental medicine. Books, mu- 
seum, and other teaching accessories, all in abundance, are at hand. 

Clinical facilities : From the faculty of the school is appointed the staff of Lakeside 
Hospital, an endowed institution of 215 available beds, thoroughly modern in con- 
struction and equipment. The school has erected a clinical laboratory on the 
premises, so that close correlation of bedside and laboratory work is easily attain- 
able. The relation of the two institutions has progressively become more intimate, 



286 MEDICAL EDUCATION 

and in the same measure mutually more helpful. The situation is one that might 
be reproduced with infinite advantage in New York, Boston, Chicago, etc. 

In addition, the school holds clinics at the City Hospital, Charity Hospital, 
St. Ann's Maternity Hospital, etc. It commands, therefore, all the material that is 
necessary. It requires now only additional endowment in order that it may com- 
pletely command the time of clinical teachers. 

The Lakeside Dispensary, admirably conducted, is used by the school on the 
same terms as the Lakeside Hospital. The attendance is large and varied. There 
is also an excellent dispensary connected with the Charity Hospital. 
Date of visit: December, 1909. 

(6) COLLEGE OF PHYSICIAKS AND SURGEONS.* Organized 1863; since 1896 nominally 
the medical department of Ohio Wesleyan University. 

Entrance requirement: Four-year high school education or equivalent. 
Attendance: 89, 92 per cent from Ohio. 

Teaching staff: Numbers 59, of whom 18 are professors, 41 of other grade. There 
are no teachers devoting their entire time to the school. 

Resources available for maintenance: Fees only, amounting to $9520 (estimated). 

Laboratory facilities : These cover only routine needs in chemistry, anatomy, bacteri- 
ology, and pathology. There is a meager supply of apparatus for experimental physi- 
ology, no museum, few books, and little else in the way of teaching accessories. 

Clinical facilities: The school holds clinics at the City Hospital during four months, 
and at several private institutions, in which, however, the work is largely surgi- 
caL It has access to a fair amount of material, but under limitations that greatly 
impair its value. All the hospitals are at considerable distance from the school ; 
none of them is provided with clinical laboratories for student use. In conse- 
quence, the teaching is of the discontinuous demonstrative type. Close contact of 
student with patient or systematic following of cases is impossible. Obstetrical 
work is limited to an out-patient service. 

The dispensary is small and poorly organized. The attendance is slight 

Date ofvitit: December, 1909. 

COLUMBUS: Population, 158,649. 

(7) STARLING-OHIO MEDICAL COLLEGE. Formed by merger in 1907. An independent 
institution. 

Entrance requirement: A four-year high school education or its equivalent. 

1 As this report goes to press, it is announced that this school has been consolidated with the Medical 
Department of Western Reserve University. 



OHIO 287 

Attendance: 220. 

Teaching staff": 60, of whom 32 are professors, 28 of other grade. There are no 
teachers giving their whole time to medical instructions. Some of the laboratory 
instruction is given by men who also teach in Ohio State University. 

Resources available for maintenance: Fees only, amounting to $27,500. 

Laboratory facilities : The school has a large plant. Laboratories adequately equipped 
for routine instruction are provided for anatomy, chemistry, physiological chemistry, 
bacteriology, pathology, and histology. There is no experimental pharmacology. 
Student assistants are employed. There is no evidence anywhere of original activity 
or interest. The school has a library, museum, and a supply of teaching accessories. 

Clinical facilities: The school controls two hospitals, in one of which containing, 
however, only 40 usable beds it might introduce modern teaching methods. The 
other hospital, containing 150 beds, is a Catholic institution. Neither hospital is 
built, organized, or equipped with the necessities of teaching in view. No pavilion 
for contagious diseases is accessible. The city has thus far done nothing to provide 
proper hospital facilities for the sick poor. The state institutions are, however, 
available. 

The school dispensaries enjoy an abundance of material, but lack equipment, 
organization, and oversight. 

The conditions described are doubtless to some extent due to the difficulty of 
welding two schools into one. Vigorous measures might, however, produce here a 
good institution. 
Date of visit : December, 1909. 

TOLEDO: Population, 178,753. 

(8) TOLEDO MEDICAL COLLEGE. Organized 1883. The medical department of Toledo 
University, a municipal institution of uncertain status and without substantial 
resources. 

Entrance requirement: A four-year high school education or its equivalent. 
Attendance: 32. 

Teaching- staff": 48, of whom 16 are professors, 32 of other grade. No one gives entire 
time to medical classes. 

Resources available for maintenance: Fees only, amounting to $3240 (estimated). 

Laboratory facilities: The school has nothing that can be fairly dignified by the name 
of laboratory. Separate rooms, badly kept and with meager equipment, are pro- 
vided for chemistry, anatomy, pathology, and bacteriology. The class-rooms are 
bare: no charts, bones, skeleton, or museum are in evidence. There is a small 
library in the office. 



288 MEDICAL EDUCATION 

Clinical facilities : These are entirely inadequate. The school formerly held clinics at 
the County Hospital, but the connection has been severed in consequence of a 
political overturning. It still has access to two hospitals: in one of them it holds 
a small number of clinics, both medical and surgical ; in the other it conducts a 
surgical clinic twice a week. In neither of them can such material as exists be 
thoroughly used for teaching purposes. 

There is a wretched little dispensary in the college building. 

Date ofvitit: February, 1910. 

General Considerations 

OF the eight medical schools of Ohio one has already won a permanent place and 
two more have possibilities. The present administration of the state law is tighten- 
ing about the other five, and there is every reason to suppose that they will all shortly 
have to submit to the inevitable. Just why the law should be tenderly applied is not 
clear. The state is rich, prosperous, and well supplied with secondary schools, though 
the competition of state-supported institutions has hitherto interfered with their 
systematic organization ; and two or three doctors now contest every field capable of 
decently supporting one. It would appear feasible at once to enforce a genuine four- 
year high school preliminary and forthwith to move towards the higher standard just 
declared in Indiana. 

The most prosperous universities of the state are, from the standpoint of medical 
education, fortunately situated : Western Reserve, at Cleveland, the Ohio State Uni- 
versity, at Columbus, the University of Cincinnati, at Cincinnati. Of the future of 
Western Reserve there is no doubt. It is already one of the substantial schools of 
the country. Its clinical problem has been solved on lines that create a precedent 
worthy to be generally followed. Its financial resources are, however, decidedly in- 
ferior to its deserts and ideals. A keener appreciation of its worth must surely result 
in substantial improvement of its position in this respect. 

The state of Ohio has a duty in reference to medical education and public health, 
the performance of which is made comparatively simple by the appropriate location 
at Columbus of the most important of its three state universities. As for the rest, it 
is a question of money and ideals. The plant of the Starling-Ohio school can prob- 
ably be readily secured. Its educational value though not large may be readily 
increased; its laboratories could be easily consolidated, remodeled, and reorganized 
under trained teachers with paid assistants. On the clinical side, the difficulties are 
more serious, though not improbably the present Protestant Hospital could be de- 
veloped into a good teaching hospital if the state supplied the necessary funds. The 
problem of procuring clinical teachers of modern type would still remain. 

The city of Cincinnati seems definitely committed to the project of a municipal 
university. Coincidently, the building of the new municipal hospital furnishes an 
unusual opportunity to its medical department. A municipal university has two ob- 



OKLAHOMA 289 

vious sources of support: taxation may well be employed at least to maintain de- 
partments calculated to meet local needs, industrial, social, or cultural; the pride 
of its citizens ought to supplement its tax income by way of supporting departments 
like medicine, whose main function can hardly be circumscribed by local considera- 
tions. The future of the medical department is thus likely to depend on the intelli- 
gence and munificence of the private benefactors of the university. The city can con- 
tribute its hospital and part of the current maintenance. Thus far the university has 
surely deserved well for its success in bringing together the rival schools which long 
divided and demoralized the field; the schools themselves made generous sacrifice of 
property rights in order to consummate the merger. It should, however, be added 
that this impersonal attitude has yet to be applied to the organization of the faculty. 
Property rights were yielded; professorial titles remain. Now, if the professors of the 
medical department of the University of Cincinnati really desire as the coming to- 
gether of the schools signifies that there should be one strong medical school in 
the city, they must realize that a school in which there are nine professors of medi- 
cine and nine professors of surgery is as yet without organization. They ought there- 
fore to surrender their titles to the university with the request that each clinical 
department be reconstructed by placing at its head the single individual marked out 
for the position, in the best judgment of the trustees of the university, by his scien- 
tific eminence and pedagogic skill. 

OKLAHOMA 

Population, 1,592,401. Number of physicians, 2703. Ratio, 1: 589. 
Number of medical schools, 2. 

NORMAN: Population, 3389. 

(1) STATE UNIVERSITY OF OKLAHOMA, SCHOOL OF MEDICINE. Organized 1898. A half- 
school. An integral part of the university. 

Entrance requirement: One year of college work in sciences. 
Attendance: 22, all but 2 from Oklahoma. 

Teaching staff": The instruction is given mainly by whole-time university teachers, 
two of whom devote their entire time to the department ; the dean of the depart- 
ment is a practising physician. 

Resources available for maintenance: The department is supported out of the general 
revenues of the university; fees amount to $600. 

Laboratory facilities: Modest laboratories, adequate to routine work, are provided in 
anatomy, physiology, physiological chemistry, pharmacology, histology, pathology, 



290 MEDICAL EDUCATION 

and bacteriology. The laboratory of the state board of health is in the depart- 
ment. There are a small museum and a small departmental library. 
Date ofvitit: November, 1909. 

OKLAHOMA CITY: Population, 49,899. 

(2) EPWORTH COLLEGE OF MEDICINE.* Organized 1904. A stock company, nominally 
the medical department of Epworth University. 

Entrance requirement: Nominal. 

Attendance: 51. 

Teaching staff": 42, of whom 28 are professors, 14 of other grade. 

Resources available for maintenance: Fees, amounting to $4285. 

Laboratory facilities : These are hardly more than nominal: a little apparatus has 
been procured for each of the several subjects, but all is disorderly and neglected. 

Clinical facilities: Clinics are held in a private hospital, where perhaps 30 beds, mostly 
surgical, are available. 

There is no school dispensary. 

Data of vitit: November, 1909. 

General Considerations 

THE new commonwealth of Oklahoma may, if wise, avoid most of the evils which this 
report has described; for though they have already appeared, they have not taken deep 
root. Immigration of physicians, among others has been so rapid that the state 
has easily three times as many doctors as it needs. They pour in from the schools of 
St. Louis, Kansas City, and Chicago. If, however, the state wishes a high-grade sup- 
ply only, it must speedily define a standard such as will (1) suppress commercial 
schools, as, for example, that now nominally belonging to Epworth University, 
and (2) by the same action exclude inferior doctors trained elsewhere. Having done 
this, only an institution with considerable resources, derived either from taxes or from 
endowment, will even attempt to conduct a medical school in the state : which is as it 
should be. 

The state university is of course marked out for the work. Its present modest be- 
ginning must be developed. Perhaps it will have at once to occupy Oklahoma City 
with a clinical department so as to obtain control of the field ; though, if its sole 
right could be established without that, the project might well be delayed for a 
time. A good medical school is so costly that a new university does not want to an- 
ticipate the responsibility. Possible expenditures on such a department have in a way 
been crippled in advance by the absurd duplication of state institutions. There are 

1 As this report goes to press, it is stated that this school has been consolidated with the medical 
department of the state university, which thus becomes a complete school of the divided type. 



OREGON 291 

26 state-supported educational institutions in Oklahoma. In other respects the people 
of the state have been quick to profit by the experience of other sections. Oklahoma 
City has not in its building recapitulated the phases of growth elsewhere. Its streets 
are of asphalt, its large buildings are fire-proof, their plumbing modern ; they have 
begun with enamel, not with tin or zinc, bathtubs. Why do they not in the same way 
avoid the weary and costly errors in educational organization that the states about 
them have one after the other made ? Ordinary intelligence, surveying the states of the 
middle west to-day after their educational experience of the last thirty years, could 
reduce its lessons to a few simple propositions which would be universally accepted. 
No two judges would differ as to the principle that state institutions of higher 
learning should be concentrated in a town of assured future; that proprietary medical 
schools should be forbidden, etc. The older states are painfully correcting or paying 
for their blunders: should Oklahoma, to soothe the local pride of this little town or 
that, run up a bill of the same sort ? 

OREGON 

Population, 505,339. Number of physicians, 782. Ratio, 1: 646. 
Number of medical schools, 2. 

PORTLAND: Population, 131,508. 

(1) UNIVERSITY OF OREGON MEDICAL DEPARTMENT. Organized 1887. Nominally the 
medical department of the state university. 

Entrance requirement: Less than a high school education. 
Attendance: 72, 65 per cent from Oregon. 

Teaching staff: 41, of whom 14 are professors, 27 of other grade. No teachers de- 
vote full time to the school. 

Resources available for maintenance: An annual appropriation of $1000 from the 
funds of the state university, and fees amounting to $8000 (estimated). 

Laboratory facilities : The school occupies a frame building, wretchedly kept. It has 
one good laboratory, that of bacteriology, conducted by the city bacteriologist. 
Other branches, like chemistry, anatomy, pathology, and histology, are provided 
in the usual perfunctory manner. There is a scanty equipment in physiology; one 
thousand to fifteen hundred books, mostly old text-books, form the library. Other 
teaching accessories there are none. 

Clinical facilities : The school has access by courtesy to two hospitals, in which stu- 
dents may look on. They cannot work in the clinical laboratories of the hospital, 
and there is no clinical laboratory at the school. Obstetrical cases are entirely 
insufficient. 



292 MEDICAL EDUCATION 

The dispensary has an attendance varying from two to seven daily. 
Dot* of visit: May, 1909. 

SALEM: Population, 7287. 1 

(2) WILLAMETTE UNIVERSITY MEDICAL DEPARTMENT. Organized 1865. An inde- 
pendent institution in all but name. 

Entrance requirement: Less than a high school education. 

Attendance: 29, 86 per cent from Oregon. 

Teaching- staff": 16, of whom 15 are professors. 

Resources available for maintenance: Fees, amounting to $3580 (estimated). 

Laboratory facilities: The school has a fairly well equipped laboratory for bacteri- 
ology and histology; a small laboratory, with little material and no running water 
for chemistry; and a dissecting-room. There are no museum, no books, no other 
teaching accessories. Inquiry on the subject of physiology elicited the response 
that the "apparatus is in a physician's office downtown." 

Clinical facilities: These are hardly more than nominal. Students have some access 
to a private hospital of 30 beds in Salem and to the State Asylum and Peniten- 
tiary a few miles distant. "Medical clinics depend on cases." Obstetrical cases 
"depend on private practice." 

There is no dispensary at all. 
Datt ofvifit: May, 1909. 

General Considerations 

NEITHER of these schools has either resources or ideals; there is no justification for 
their existence. The entire coast is oversupplied with doctors by immigration ; unless 
something better can be made than can be thus readily obtained, the state will do 
well to let the field lie fallow. 

The Salem school is an utterly hopeless affair, for which no word can be said. Port- 
land may conceivably some day maintain a distant department of the state uni- 
versity. Until, however, the financial strength of the state university permits it to 
develop there a school equal, for instance, to that which the University of Texas sup- 
ports at Galveston, it has no right to allow a group of local doctors to exploit its 
name in the conduct of a low-grade proprietary institution. That out of its own 
slender revenues it should divert a thousand dollars annually into the coffers of this 
concern is well-nigh incredible. 



1 Not estimated by U. S. Census Bureau. 



PENNSYLVANIA 293 

PENNSYLVANIA 

Population, 7,032,915. Number of physicians, 11,056. Ratio, 1:636. 
Number of medical schools, 8, plus 1 postgraduate school. 

PHILADELPHIA: Population, 1,540,430. 

(1) UNIVERSITY OF PENNSYLVANIA DEPARTMENT OF MEDICINE. Organized 1765. An 
organic part of the university. 

Entrance requirement: One year of college work, in which, however, conditions have 
been very freely allowed. 

Attendance: 546, 63 per cent from Pennsylvania. 

Teaching staff: 157, of whom 26 are professors, 131 of other grade. The laboratory 
instructors, with a few of their assistants, devote their entire time to teaching and 
research. 

Resources available for maintenance: The department shares the general funds of the 
university. Its budget exclusive of the hospital and dispensary is $131,255; 
the income from fees is $104,612. 

Laboratory facilities: Five separate well equipped buildings are provided for the 
laboratories of the department: the first for histology, embryology, etc.; the sec- 
ond new and admirably adapted to its purposes for pathology, physiology, 
and pharmacology; the third for chemistry and anatomy, with a deservedly 
famous anatomical museum; the fourth for hygiene; the fifth is the clinical 
laboratory, never as yet adequately supported. Near by is the Wistar Insti- 
tute, open to graduate students for research in anatomy. The department pos- 
sesses an admirable library. Its scientific faculty has been recently strengthened 
by the creation of chairs of physiological chemistry and experimental medicine, 
specially endowed. The department has, therefore, an admirable material equip- 
ment. 

Clinical facilities : The University Hospital of 350 beds, of which 280 are available 
for instruction, is contiguous to the laboratories. There is a separate maternity 
pavilion of 50 beds. Considerable use is also made of several other hospitals, not- 
ably the Philadelphia General Hospital and the Pennsylvania Hospital, extra- 
mural instruction being given at the latter. The recently established Phipps In- 
stitute for tuberculosis is also now part of the clinical plant. The equipment of 
the department thus fully satisfies all essential conditions. 

Two dispensaries are used, one at, the other at a distance from, the university. 
Abundant material is thus obtained. 

Date of visit: March, 1909. 



294 MEDICAL EDUCATION 

(2) JEFFERSON MEDICAL COLLEGE. Organized 1825. An independent institution. 

Entrance requirement: A high school education or its equivalent. Of all independent 
schools outside New York state, this institution comes nearest to obtaining its 
published entrance requirements. It lacks, however, an organization adapted to the 
evaluation of secondary school credentials. A fair percentage of those admitted 
have had some college work. 

Attendance: 591, of whom 57 per cent are from Pennsylvania. 

Teaching staff: 122, of whom 22 are professors, 100 of other grade. Seven instructors 
devote their entire time to the school. 

Resources available for maintenance: Fees only, amounting to $102,995. Part of the 
school income is, however, diverted in order to pay off building mortgages. The 
hospital has independent sources of support. 

Laboratory facilities : An attractive building contains separate laboratories for ana- 
tomy, physiology, chemistry, pathology, histology, bacteriology, and pharmacy. 
The equipment is in general modern and adequate to the needs of undergraduate in- 
struction ; in certain departments, e. g., anatomy and bacteriology, additional activ- 
ity is in progress. Lack of space and means restricts the school to undergraduate 
teaching. There are an attractive library, museum, and other teaching accessories. 

Clinical facilities : The Jefferson Hospital a modern structure, with 223 teaching 
beds, belonging to the institution adjoins the laboratory building; it is con- 
nected with a dispensary which supplies an abundance of material. The maternity 
department, with 17 beds, occupies a separate building. Students are freely ad- 
mitted to the hospital wards and its clinical laboratory. 

The plant of the institution is therefore modern and compact. 

Dat of visit: March, 1909. 

(3) MEDICO-CHIRURGICAL COLLEGE OF PHILADELPHIA. Organized 1881. An indepen- 
dent school. 

Entrance requirement: Less than a four-year high school education. 
Attendance: 480, 82 per cent from Pennsylvania. ^ 

Teaching staff": 109, of whom 23 are professors, 86 of other grade. No teachers devote 
their entire time to medical instruction; three teachers, however, devote themselves 
entirely to the school, if the dental and pharmacy departments are counted in. 

Resources available for maintenance: Fees, amounting to $48,281. 

Laboratory facilities : Well equipped for ordinary undergraduate teaching are the 
laboratories of physiology, chemistry, pathology, and bacteriology. Anatomy is 
practically limited to dissecting, with some drawing and modeling, the professor 



PENNSYLVANIA 295 

being a practitioner. There is no museum beyond necessary specimens for patho- 
logical work. There is a library at the College Club. Students in dentistry, pharmacy, 
and medicine mingle in a number of classes. Student assistants are freely used. Ex- 
cept in bacteriology, little or no effort is made to cultivate original scientific 
activity; great stress is laid on effective drill. 

Clinical facilities : The school has entire control of its own hospital, of 180 available 
beds, which is in close proximity to the other buildings. The Maternity Hospital is 
near by. Ward and section methods are in use. Classes are also held in the usual 
manner at other hospitals. 

The dispensary attendance is large. 

Date ofvitit: March, 1909. 

(4) TEMPLE UNIVERSITY, DEPARTMENT OF MEDICINE. Organized 1901. 
Entrance requirement: Less than a four-year high school education. 
Attendance: 136. 

Teaching- staff: 85, of whom 15 are professors, 70 of other grade. There are no full- 
time teachers. 

Resources available for maintenance: Fees only, amounting to $17,000 (estimated). 

Laboratory facilities : These are entirely inadequate and in some departments quite 
wretched. There is an ordinary elementary laboratory for chemistry ; a single room 
with slight equipment for histology, pathology, and bacteriology, and only a 
demonstration outfit for physiology. The dissecting-room is in bad condition. 
There is a small museum and a library of several thousand volumes of miscellaneous 
character, but no other teaching accessories. Dental, pharmacy, and medical stu- 
dents mingle in the same classes. 

Clinical facilities : The school has access to two small hospitals, whose work is almost 

four-fifths surgical. The dispensary has a large attendance. 
Date of visit: March, 1909. 

(5) HAHNEMANN MEDICAL COLLEGE AND HOSPITAL. Organized 1848. An independent 
institution. 

Entrance requirement: Less than a four-year high school education, probably much 
less, for most of the credentials were passed on by the secretary. 

Attendance: 182, 61 per cent from Pennsylvania. 

Teaching staff: 72, of whom 27 are professors, 45 of other grade. One teacher devotes 
his entire time to the school. 

Resources available for maintenance: Fees, amounting to $18,500. 



296 MEDICAL EDUCATION 

Laboratory facilities: The school possesses an ordinary laboratory for general chem- 
istry; a second, with slight equipment, for histology and physiology ; and another, 
fairly equipped, for pathology and bacteriology. The dissecting-room is clean and 
odorless. Both regular and homeopathic pharmacy are taught. There is a large 
and very well kept museum. 

Clinical facilities: The school is connected with the Hahnemann Hospital, containing 
some 150 beds; but no ward clinics are held. Patients are wheeled into the amphi- 
theater. Students have no access to the clinical laboratory. 

The dispensary has a large attendance, and there only, for the most, the student 
comes into close contact with patients. 

Dot* of visit: March, 1909. 

(6) WOMAN'S MEDICAL COLLEGE OF PENNSYLVANIA. Organized 1850. An independent 
institution. 

Entrance requirement: A high school education or its equivalent. 
Attendance: 125. 

Teaching staff: 52, of whom 25 are professors, 27 of other grade. One teacher de- 
votes entire time to the schools; several others teach laboratory subjects elsewhere 
as well. 

Resources available for maintenance: Fees, amounting to $15,480, and income from 
endowments, amounting to $13,820. 

Laboratory facilities : Simply, but intelligently, equipped and conscientiously used 
laboratories are provided for physiology, bacteriology and pathology, histology 
and embryology, chemistry, pharmacy, and anatomy. There is striking evidence 
of a genuine effort to do the best possible with limited resources. There are a use- 
ful library and a good museum. 

Clinical facilities .-The school is now building a new hospital, part of which is already 
in use. This, with a temporary building, accommodates 27 beds. There is, besides 
a maternity of 16 beds, and an out-patient obstetrical service. Ward work, with 
assignment of individual cases, is regularly carried on. Supplementary opportuni- 
ties are obtained at several other institutions. There is a fair dispensary service. 

Dot* of visit: March, 1909. 

(7) PHILADELPHIA COLLEGE AND INFIRMARY OF OSTEOPATHY. Established 1898. An 
independent institution. 

Entrance requirement: Nominal. 

Attendance: 126. 

Teaching stajf: 18, of whom 11 are professors, 7 of other grade. 



PENNSYLVANIA 297 

Resources available for maintenance: Fees, amounting to $18,900 (estimated). 

Laboratory facilities : These are utterly wretched. They comprise a laboratory for 
histology, in which a small centrifuge is the only visible object of interest; a small 
laboratory for elementary chemistry in a dark cellar; and an intolerably foul dissect- 
ing-room in a dark building, once a stable. If there is any provision for pathology, 
physiology, or bacteriology, any books, or museum, or other teaching accessories 
except a few crude drawings, a model, and a skeleton, all was successfully concealed. 
Three separate class-rooms are provided, containing necessary furniture only. 

Clinical facilities: The infirmary, the address of which is not given in the catalogue, 
is some blocks distant; it contains three beds and has, it is claimed, 200 patients 
who come twice or thrice weekly for treatment. The catalogue announces that its 
students have the "privilege of witnessing operations at the University Hospital, 
Jefferson Hospital, etc." This is not the case. These students are intruders, with- 
out rights or privileges of any description whatsoever. 

Date of visit : January, 1910. 

PITTSBURGH: Population, 570,065. 

(8) UNIVERSITY OF PITTSBURGH, MEDICAL DEPARTMENT. Organized 1886; affiliated with 
the University of Pittsburgh in 1892, it became an organic department thereof 
in 1909. 

Entrance requirement: Four-year high school education or its equivalent. 
Attendance: 315. 

Teaching staff: 103, of whom 43 are professors, 60 of other grade. Five instructors 
give their entire time to the school. There is one research assistant. 

Resources available for maintenance: Fees, amounting to $48,500. 

Laboratory facilities : The school has within a year undergone a complete transfor- 
mation. A more thorough piece of house-cleaning within so short a period is hardly 
credible. A year ago, before the University of Pittsburgh obtained control, the 
so-called laboratories were dirty and disorderly beyond description. Since the pre- 
sent management took hold last fall, the admission of students has been much 
more carefully supervised ; the building has been put in excellent condition ; labo- 
ratories for chemistry, physiology, bacteriology, and pathology have been remod- 
eled and equipped with modern apparatus for both teaching and research; foreign 
and domestic periodicals have been subscribed for; a study-room in good order has 
been instituted in place of the lounging-room where last year " four dozen wooden 
chairs were broken." Whole-time instructors of modern training and ideals have 
been secured. This is the more remarkable, as only fees have been available. De- 
spite the necessary defects of schools relying wholly on fees, the experience of this 



298 MEDICAL EDUCATION 

institution confirms our contention that the conscientious and intelligent use of 
fees would alone greatly improve existing conditions in most schools. 
A new building is in process of erection. 

Clinical facilities: The school has access to several hospitals in which an abundance 
of material is available, subject, however, to the usual limitations. The clinical 
instruction is therefore here, as generally elsewhere, put together of disconnected 
parts. This does not, however, apply to obstetrics; for the school controls a ma- 
ternity hospital of 34 beds, which, quite slovenly a year ago, has also been trans- 
formed in the last few months. It is neat, clean, well managed, and has been im- 
proved by the addition of a new delivery-room, sterilizing outfit, etc. It is in charge 
of a resident obstetrician of modern training. 

The dispensary has been similarly reorganized. A permanent nurse has been 
installed. Records are now in order; the rooms and equipment are attractive and, 
in the main, adequate. 

Date ofvuit: February, 1910. 

(9) THE PHILADELPHIA POLYCLINIC. A postgraduate independent school. 
Entrance requirement .'The M.D. degree. 

Attendance: Short courses, ranging from six weeks to six months in length, are given, 
the attendance varying from time to time. The annual attendance is perhaps 150. 

Teaching staff': 129, of whom 29 are professors, 100 of other grade. 
Resources available for maintenance: Fees and donations. 

Laboratory facilities : The school has what no other postgraduate school in the coun- 
try possesses, a laboratory building in which its classes in clinical microscopy, 
operative surgery, etc., are conducted. The instruction is of a practical character, 
aiming to meet the needs of physicians whose training has been defective. No ani- 
mals are used and no active research is in progress. There are few books and peri- 
odicals in reach. 

Clinical facilities: The Polyclinic Hospital, an excellently conducted institution, con- 
tains 81 beds available for teaching purposes. Ward classes receive demonstrative 
instruction. 

The present dispensary consists of a suite of rooms quite inadequate to the 
amount of material to be handled. A new building is in process of erection. 

Date ofvitit: February, 1910. 

General Considerations 

MEDICAL education in the state of Pennsylvania presents no unusual problems from the 
standpoint of theory. It is easy enough to decide what ought to happen. From a practi- 
cal point of view, however, the situation is exceedingly difficult. The medical schools 



PENNSYLVANIA 299 

are in some respects strong institutions ; moreover, education, philanthropy, and pol- 
itics have become so interwoven that they make a combination too intricate to be 
readily dissolved. 

The state is without an educational system ; and the legislature has recently re- 
fused to pass a bill aiming to organize the common, secondary, and normal schools 
of the state. Ordinary educational values are therefore still obscure and confused. 
Though the last legislature improved the law regulating medical education to the 
extent of making a four-year high school course or its equivalent the legal minimum, 
the educational disorganization of the state makes its enforcement problematical. 

There is still another source of apprehension on this score. The real standard de- 
pends on who evaluates the "equivalent. 11 The agents to whom this function has been 
officially delegated in the past have conceded much to the wishes real or supposed 
of the schools. The Pittsburgh representative has been extremely lax; his "equiva- 
lent" to the four-year high school education has not been equal to a two-year high 
school education. The present incumbent at Philadelphia is newly appointed; con- 
ditions described in the text refer to previous years. Finally, some of the schools have 
been using their own judgment in dealing with credentials, referring only such as 
they did not accept themselves. It is impossible to ascertain how those referred were 
distinguished from those accepted in the medical school office. 

If, now, a genuine four-year high school standard is enforced, out of the eight 
undergraduate schools in the state only two will avoid very serious damage: the Uni- 
versity of Pennsylvania and the Jefferson Medical College, the former already beyond 
the standard in question, the latter probably strong enough to stand the shrinkage 
which would result, for a large part of its enrolment now meets the requirement. 
The University of Pittsburgh is fully alive to the necessity of procuring endowment 
in order to meet the inevitable deficit, and will stand or fall on that issue. The other 
five schools have no future; their enrolment is so largely the make-believe equivalent 
that enforcement of a real four-year high school standard will seriously threaten 
their existence even at their present level of efficiency ; progress would be altogether 
impossible. 

The situation so far simplified by an actual entrance standard, another topic presses 
for consideration. The state of Pennsylvania has for years been engaged in distribut- 
ing large sums to private and semi-private charities. These largesses have enabled 
several of the Philadelphia schools to build and partly to maintain their own hospi- 
tals. That this policy is thoroughly objectionable and demoralizing is beyond dis- 
pute. The state has neither right nor business to make presents to private corpora- 
tions that it can neither regulate nor control. And the level of civic life in Pennsyl- 
vania has been greatly lowered by the log-rolling and favoritism that the possibilities 
of " pulP have created. One would be perhaps not over-sanguine to expect that the 
bounty and subsidy system will one day be replaced by strict payment for services 
rendered, so strict, that the hospitals will, as in New York, lose rather than gain 



300 MEDICAL EDUCATION 

by the operation. The unendowed medical schools of the state cannot survive such a 
wholesome treatment of the state's philanthropic obligations. The extension of their 
hospitals would be prohibited; even their maintenance would be imperiled. 

It is thus clear that a reasonable not a high standard of admission and a 
righteous public policy in dealing with charities would soon reduce the schools of 
the state to two, the University of Pittsburgh, provided it secures endowment, and 
the University of Pennsylvania, whose resources available for medical education would 
also require to be increased. Fortunate indeed would it be, if broad views might 
bring about this increase in part through consolidation of the three large schools 
of Philadelphia, one or two of the three being liquidated as a means of liberating a 
considerable sum, applicable thenceforth to the development of the single surviving 
school. Into such a scheme inevitable, in any case, unless the independent schools 
accomplish the heretofore impossible task of procuring endowment the Polyclinic 
would easily falL The day of independent and elementary postgraduate instruction is 
rapidly passing; the postgraduate school of the future will crown a substantial under- 
graduate school of medicine. The outcome here suggested can be averted only if the 
independent schools secure endowment, for which there is no precedent in America, 
or if some university outside Philadelphia form an alliance there. There is just now 
no academic institution in the state whose resources would warrant this step. What- 
ever these medical schools now offer, they would, singly or combined, shortly prove 
a drain on any university endeavoring to apply to medicine the standards and ideals 
cultivated in its other departments. Moreover, as two schools one at Pittsburgh, 
the other at Philadelphia can supply the state with physicians, no other university 
is justified in entering the field unless its resources, free to be applied to medicine, are 
sufficient to insure as a consequence a real advance in medical knowledge and practice. 



SOUTH CAROLINA 

Population, 1,510,566. Number of physicians, 1141. Ratio 1: 1324. 1 
Number of medical schools, 1. 

CHARLESTON: Population, 56,659. 

MEDICAL COLLEGE OF THE STATE OF SOUTH CAROLINA. Founded 1823. An independent 
institution. 

Entrance requirement : Nominal. 
Attendance: 213. 

Teaching staff: 34, of whom 11 are professors, 23 of other grade. There are no whole- 
time teachers. 

1 Folk's statistics make the ratio 1 : 1168. 



SOUTH DAKOTA 301 

Resources available for maintenance: Fees, amounting to SI 9,447 (estimated). 

Laboratory facilities : Comprise very meager equipment for elementary chemistry, 
pharmacy, and anatomy the dissecting-room in bad condition. The instructor in 
pathology and bacteriology has a fair private laboratory, to which students have 
no access ; student work in those subjects is mostly confined to looking through 
the microscope at slides that he prepares. There is no museum, except old papier- 
mache and wax models, no library, except some antiquated publications. It is with- 
out other teaching aids. 

Clinical facilities: The school has access to the Roper Hospital, an unusually at- 
tractive institution of about 200 beds a mile distant. There were 80 patients at 
the time of the visit. Complaint is made that it is difficult to induce graduates to 
serve as internes. Obstetrical work is rare. 

There is no school or other organized dispensary. 

Date of visit: February, 1909. 

SOUTH DAKOTA 

Population, 498,077. Number of physicians, 607. Ratio, 1: 821. 
Number of medical schools, 1. 

VERMILION: Population, 2183. 

UNIVERSITY OF SOUTH DAKOTA COLLEGE OF MEDICINE. Organized 1907. A half-school. 
An organic department of the state university. 

Entrance requirement: 2 years of college work. 
Attendance: 7. 

Teaching staff: 5 professors and 5 instructors, who take part in the work of the de- 
partment. 

Resources available for maintenance: The department shares in the general funds of 
the university. No separate budget is prepared. Fees amount to $660. 

Laboratory facilities : The necessary equipment is at hand for painstaking routine 
instruction in the laboratory branches. A library and museum have been started. 
Date of visit: November, 1909. 

General Considerations 

THE two Dakotas have taken time by the forelock:, before any vested proprietary in- 
terest could be created, they have fixed the state practice requirement at two years 
of college work, thus fortifying the medical department of the state university. The 
state, though thinly settled, is prosperous, and no anxiety is felt that the high stan- 



302 MEDICAL EDUCATION 

dard will deplete the medical profession of the state. On the contrary, it has been 
adopted as a means of protecting a people already supporting twice as many doctors 
as it needs. 

Though the students are few, the present provision for their teachers is on too 
unpretentious a scale. Unfortunately, like all the western states, South Dakota is 
already scattering its financial resources among half a dozen competing state institu- 
tions. Of its seven tax-supported institutions of higher grade, three give the A.B. 
degree and the others desire to do so. It will prove decidedly unfortunate if these 
institutions are not in their infancy coordinated, so as to form a genuine system 
rather than a number of separate, warring units. A population of half a million in 
a new country will do well to sustain one substantial state college with departments 
of law, medicine, etc. It can do that only by concentrating its outlay. 



TENNESSEE 

Population, 2,248,404. Number of physicians, 3303. Ratio, 1 : 681. 
Number of medical schools, 9. 

CHATTANOOGA: Population, 34,773. 

(1) CHATTANOOGA MEDICAL COLLEGE. Organized 1889. The medical department of 
the University of Chattanooga. 

Entrance requirement: Nominal. 

Attendance: 112. 

Teaching staff": 25, of whom 11 are professors, 14 of other grade. 

Resources available for maintenance: Fees, amounting to $4290. 

Laboratory facilities: The school occupies a small building, externally attractive; the 
interior, dirty and disorderly, is almost bare, except for a fair chemical laboratory 
in good condition. The dissecting-room contains two tables; the single room 
assigned to histology, pathology, and bacteriology contains a few old specimens, 
mostly unlabeled, and one oil-immersion microscope. The instructor explained that 
they "study only non-pathogenic microbes; students do not handle the patho- 
genic." There is nothing further in the way of laboratory outfit ; no museum, books, 
charts, models, etc. 

Clinical facilities : Amphitheater clinics are held at the Erlanger Hospital, which 
averages about 50 free patients. Students may not enter the wards. Perhaps ten 
obstetrical cases annually are obtainable, students being "summoned," just how 
is not clear. The students see no post-mortems, no contagious diseases, do no blood 



TENNESSEE 303 

or urine work, and do not always own their own text-books. They use quiz-com- 
pends instead. 

There is no dispensary. 

This is a typical example of the schools that claim to exist for the sake of the poor 
boy and the back country. 

Date of visit : January, 1909. 

KNOXVILLE : Population, 38,328. 

(2) TENNESSEE MEDICAL COLLEGE. Organized 1889. A stock company; nominally the 
medical department of Lincoln Memorial University. 

Entrance requirement: Nominal. 

Attendance: 82, 70 per cent from Tennessee. 

Teaching staff: 31 , of whom 26 are professors, 5 of other grade. 

Resources available for maintenance: Fees, amounting to $4994. 

Laboratory facilities : The school building is externally attractive; within, dirty. In 
the basement is a small laboratory for inorganic chemistry. A few microscopes, a 
microtome, and some sterilizing apparatus no cultures or pathological specimens 
were visible constitute the laboratory for pathology, bacteriology, and histology. 
The dissecting-room is ordinary ; there are no books, museum, charts, etc. 

Clinical facilities : The school adjoins a neat hospital, recently constructed, which 
proves, however, to be simply the private hospital of the faculty for which student 
fees help to pay. It has an average of 40 patients, with no free wards. Five clinics 
weekly are scheduled, but it is admitted that "they are not always held." Practi- 
cally, students "are called" when a case happens along which the doctor can ar- 
range to have them see. Obstetrical instruction is limited "to a few deliveries 
before the class." 

There is no dispensary. 

Date of vitit : January, 1909. 

(3) KNOXVILLE MEDICAL COLLEGE. Colored. Established 1900. An independent insti- 
tution. 

Entrance requirement: Nominal. 

Attendance: 23. 

Teaching staff": 11, of whom 9 are professors. 

Resources available for maintenance: Fees, amounting to $1020 (estimated). 

Laboratory facilities : None. The school occupies a floor above an undertaker's esta- 
blishment. 



304 MEDICAL EDUCATION 

Clinical facilities: None. It was stated by a student that twice between October 1 and 
January 28 "a few students were taken to the Knoxville College Hospital."" 
There is no dispensary. 

The catalogue of this school is a tissue of misrepresentations from cover to cover. 
Date ofvifit : January, 1909. 

MEMPHIS: Population, 140,145. 

(4) COLLEGE OF PHYSICIANS AND SURGEONS. Organized 1906. A stock company, now 
calling itself the medical department of the University of Memphis, a fictitious 
affair. 

Entrance requirement: None. "Accept students and try them out." 
Attendance: 77. 

Teaching staff: 47, of whom 22 are professors, 25 of other grade. 
Resources available for maintenance: Fees, amounting to $7400 (estimated). 

Laboratory facilities : The school occupies an excellent building, recently erected, fees 
being largely consumed in helping to pay for it. The dissecting-room is of modern 
design, consisting of small rooms with hot and cold water; but the work was con- 
ducted on antiquated lines, cadavers being in wretched condition. The chemical 
laboratory is good and quite adequate to instruction in elementary chemistry. 
Equipment for pathology and bacteriology is less than fair; for physiology, prac- 
tically nothing. There are few books, no museum, charts, etc. 

Clinical facilities: The schedule shows seven one-hour clinics (5 in surgery, 2 in medi- 
cine) per week at the City Hospital during one-half of the school year. At the date 
of the visit, perhaps 40 beds were thus accessible. Students "look on" at the ob- 
stetrical cases. 

A suite of rooms in the college building is set aside for a dispensary. 

Date of visit: November, 1909. 

(5) MEMPHIS HOSPITAL MEDICAL COLLEGE. Organized 1880. A stock company. 
Entrance requirement: Nominal. 

Attendance: 442. 

Teaching staff": 35, of whom 12 are professors, 23 of other grade. 

Resources available for maintenance: Fees, amounting to $34,600 (estimated). The 
condition of the school laboratories shows what becomes of this sum. 

Laboratory facilities : The school occupies an excellent building, heavily mortgaged. 
It is new and well kept. The chemical laboratory is good and adequate to ele- 
mentary chemistry. An excellent room is assigned to dissecting, but the cadavers 



TENNESSEE 305 

are putrid. One laboratory, with slight equipment and little material, answers for 
all microscopic work. It is obvious that large classes have paid in considerable 
sums that have been used to pay for an expensive building, not to provide even 
fair teaching facilities. The course of instruction is not graded. 

Clinical facilities : The schedule shows nine one-hour clinics a week at the City Hospi- 
tal, where the available material is divided between the two schools. At the date 
of the visit, perhaps 40 beds were thus accessible to each. Students "look on" at 
the obstetrical cases. The course of instruction is not graded ; the amount of mate- 
rial is absurdly inadequate for the huge classes. 

There is a dispensary in the school building. Its equipment is slight; there are 
no systematic records. The amount of material cannot possibly suffice for the 
student body; and there is nothing to indicate effective use, as far as it goes. 

Dale of visit: November, 1909. 

(6) UNIVERSITY OF WEST TENNESSEE, MEDICAL DEPARTMENT. Colored. Organized 
1900. 

Entrance requirement: Nominal. 

Attendance: 40. 

Teaching staff: 14, all of whom are professors. 

Resources available for maintenance: Fees, amounting to $2000 (estimated). 

Laboratory facilities: There is meager equipment for chemistry, pharmacy, and mi- 
croscopy. Otherwise the rooms are bare. 

Clinical facilities: The students have access to eight or ten beds, twice weekly, in a 
small hospital close by. 

There is a dispensary, without records, in the school building. 
Date of visit: November, 1909. 

NASHVILLE: Population, 107,076. 

(7) VANDERBILT UNIVERSITY MEDICAL DEPARTMENT. Established 1874. An organic 
department of the university. 

Entrance requirement: Less than high school graduation, though a fair proportion 
of the students have had some college work. 

Attendance: 200. 

Teaching staff: 40, of whom 17 are professors, 23 of other grade. The dean of the 
school is the professor of chemistry in the academic department an undesirable 
arrangement at a time when medical education is so rapidly changing form. No 
instructor devotes entire time to the medical department. 



806 MEDICAL EDUCATION 

Resources available for maintenance: Fees, amounting to $26,250. This sum, adequate 
to provide fair laboratory instruction, is not devoted to education alone. The 
medical department, although organically part of the university, is under contract 
to wipe out with its fees the cost of the building it occupies, and meanwhile it pays 
the university interest at six per cent on the unpaid balance. 

Laboratory facilities : The school possesses satisfactory laboratories for pathology, 
bacteriology, and histology, and an energetic instructor has charge of them. A 
creditable beginning has been made in experimental physiology. Chemistry is well 
provided by the university. Anatomy is bad the work being conducted on anti- 
quated lines in a foul dissecting-room. There is a useful museum and a fair library. 

Clinical facilities : The school has converted the basement of its own building into a 
ward of 35 beds; and has access to the City Hospital (65 beds) besides. The 
amount of material thus available is too restricted. 
There is a dispensary with a fair attendance. 

Date ofvifit: January, 1909. 

(8) UNIVERSITIES OF NASHVILLE AND TENNESSEE MEDICAL DEPARTMENT. A combina- 
tion under limited contract, formed in 1909, expiring 1912. One of the two in- 
stitutions represented is the State University of Tennessee (Knoxville), the other 
the University of Nashville, a university in name only. 

Entrance requirement: Less than high school graduation. 
Attendance: 207. 

Teaching staff: 55, of whom 26 are professors, 29 of other grade. The distribution 
of chairs is significant : there are four professors of medicine, four professors of 
surgery (not including gynecology), and one whole-time teacher. 

Resources available for maintenance: Fees, amounting to $26,000 (estimated), and 
subscriptions from the two universities, amounting to $8100 in cash. Of the two 
universities, the University of Tennessee is supported by legislative appropria- 
tion; the University of Nashville has an endowment of $60,000, yielding $3600 
annually. 

Laboratory facilities: These comprise a poor laboratory for elementary chemistry, 
an outfit, in part new, for bacteriology, pathology, histology, and physiology, and 
a poorly kept dissecting-room. There is a small museum. 

Clinical facilities : The building formerly used by the medical department of the Uni- 
versity of Tennessee has been converted into a hospital with a capacity of 70 beds. 
In view of the brief period that has elapsed since the merger, this improvement 
in clinical resources is most commendable, for the hospital is completely controlled 
by the school. The school has access to the City Hospital besides. 



TENNESSEE 307 

The first floor of the college hospital building is used as a dispensary. Though 
its equipment is still slight, it represents a great advance over the conditions that 
preceded. 

Date of visit : January, 1909. 

(9) MEHARRY MEDICAL COLLEGE. Colored. Organized 1876. The medical department 
of Walden University. 

Entrance requirement: Less than a four-year high school education. 

Attendance: 275. 

Teaching- staff 1 : 26, of whom 12 are professors, 14 of other grade. 

Resources available for maintenance: $23,946, representing income from endowment 
of $35,000, subscription from the Freedman's Aid Society, and fees, the last item 
being $20,310. 

Laboratory facilities : The school possesses fair laboratories for chemistry and physi- 
ology and highly creditable laboratories for bacteriology, histology, and patho- 
logy, the outfit including animals, microscopes, microtome, and pathological ma- 
terial in excellent order. A separate frame building, well kept, is devoted to anatomy. 
The equipment and general conditions reflect great credit on the zeal and intelli- 
gence of those in charge of the school and its several departments. 

Clinicalfacilities : These are restricted. The school has access to Mercy Hospital, 32 beds. 

Date of visit : January, 1909. 

General Considerations 

THE state of Tennessee protects at this date more low-grade medical schools than 
any other southern state. It would be unfair and futile to criticize this situation 
without full recognition of local conditions. A standpoint that is entirely in order 
in dealing with Cincinnati, Chicago, or St. Louis is here irrelevant. The ideals held 
up must indeed be the same; but their attainment is much further in the future. 
The amount of money available for medical education is small ; the preliminary re- 
quirement must be relatively low. Practically all that can be asked of Tennessee is 
that it should do the best possible under the circumstances. 

This it does not do. The six white schools value their separate survival beyond all 
other considerations. A single school could furnish all the doctors the state needs 
and do something to supply the needs of adjoining states as well. Low as the en- 
trance standard must be, it has been made lower in order to gather in students for six 
schools where one would suffice. The medical schools solicit and accept students who 
have not yet made the best of the limited educational opportunities their homes pro- 
vide; and to this extent, not only injure the public health, but depress and demo- 
ralize the general educational situation. 



308 MEDICAL EDUCATION 

The same is true in reference to laboratories and clinics. However small the sums 
applicable to building and equipping laboratories, conditions are needlessly aggra- 
vated when six plants are equipped instead of one. Fees that ought now to be used 
in providing better teaching are still paying for expensive buildings in Memphis and 
Nashville. The city hospitals of both places, small at best, are divided between two 
schools, though they do not furnish enough material for one. 

Those who deal with medical education in Tennessee are therefore making the 
worst, not the best, of their limited possibilities. Their medical schools, treated on 
their merits, would speedily reduce to one : the utterly wretched establishments at 
Chattanooga and Knoxville would be wiped out; the more showy, but quite mer- 
cenary, concerns at Memphis would be liquidated. The University of Tennessee, with 
an annual income that does not as yet suffice for the legitimate needs of its own plant 
at Knoxville, should abandon for the present the effort to develop at Nashville a 
school that it can neither control nor support. The time may come when there will be 
a call for the state university to enter the field. But that time is not now. For the 
present it is dividing its own forces and hindering the most effective use of such re- 
sources as Nashville affords. The whole field is strangely confused : Lincoln Memorial 
University (which is an industrial school, not a university) at Cumberland Gap 
shelters a medical school at Knoxville; the University of Tennessee at Knoxville 
shelters an entirely superfluous school at Nashville. 

If our analysis is correct, the institution to which the responsibility for medical 
education in Tennessee should just now be left is Vanderbilt University; for it is 
the only institution in position at this juncture to deal with the subject effectively. 
This does not mean that Vanderbilt has now any large sums of money available or 
that it should inaugurate impossible entrance standards. It can do neither, for the 
general situation countenances neither. The suggestion merely recognizes the facts 
that one school can do the work ; that Vanderbilt occupies in Nashville the point of 
vantage; that, in the public interest, the field should be left to the institution best 
situated to handle it. 

On the other hand, any such arrangement imposes upon Vanderbilt a very distinct 
responsibility. It would have to nurse its enrolment: having determined just how 
large a school local needs require, it must fix and enforce the strictest entrance re- 
quirement compatible therewith. At the present time this standard would be less than 
four-year high school graduation; but whatever it be, if only it is real and definite, 
it will operate to brace up general conditions. Improved teaching should compensate 
student defects. To this end, every effort should be made to secure endowment specifi- 
cally applicable to the medical department; in the interval, fees must be employed not 
to wipe out old obligations, however incurred, but to improve the school. The contract 
between Vanderbilt University and its medical department should be canceled. The 
practitioner teachers must make good their ambition to advance medical education 
by being content with the indirect advantage accruing from school connections. If 



TEXAS 309 

the entire fee income is used to equip the laboratories, to employ full-time teachers 
in the fundamental branches, to fit out and organize a good dispensary, there will 
still remain defects and makeshifts enough; but the school will wear a different as- 
pect than is presented by any institution in the state to-day. 

Let it be said ungrudgingly that these suggestions are offered in no spirit of 
unkindness. The State University and Vanderbilt have had their hands full. They 
have worked valiantly amidst conditions that might well appal the strongest hearts. 
They deserve no blame for the past, provided only they unselfishly and vigorously 
cooperate in forgetting it. In the last few years right courses of action in medical 
education have for the first time been defined. A decade hence it will be fair to look 
back and ask whether the universities of the state have followed them. 

Of the three negro schools in the state, two are without merit. The third Me- 
harry is a most creditable institution. The reader is referred to chapter xiv, "The 
Medical Education of the Negro," for a fuller discussion of its needs and deserts. 



TEXAS 

Population, 3,780,574. Number of physicians, 5789. Ratio, 1 : 653. 
Number of medical schools, 4. 

DALLAS: Population, 56,119. 

(1) BAYLOR UNIVERSITY COLLEGE OF MEDICINE. Organized 1900. Since 1903 the me- 
dical department of Baylor University. 

Entrance requirement : Nominally a three-year high school course or its equivalent. 
Attendance: 53. 

Teaching staff: 29, of whom 16 are professors, 13 of other grade. All the teachers 
are practitioners. 

Resources available for maintenance: Fees, amounting to $7735 (estimated). The 
school has not thus far been assisted by the university. 

Laboratory facilities : The school possesses a new laboratory adjoining the hospital to 
be noticed below ; but at the date of the visit it was still quite bare. The dissecting- 
room was in good condition ; a fair chemical laboratory and a meagerly equipped 
laboratory for pathology and bacteriology had been installed. There was nothing 
else, and no assurance of funds with which to provide additional laboratories or 
to maintain those already in part provided. 

Clinical facilities : Adjoining the laboratory building is a new hospital of some 200 
beds, in which the school has access to two free wards containing 32 beds, and to 



310 MEDICAL EDUCATION 

ail additional negro ward of 22 beds in a pavilion close by. There is no clinical 
laboratory. Clinical opportunities are obtained at two other institutions, but no 
infectious diseases and little obstetrical work are obtainable. The clinical oppor- 
tunities are thus decidedly inadequate. 

A dispensary is just beginning. 
Dale of visit: November, 1909. 

(2) SOUTHWESTERN UNIVERSITY MEDICAL COLLEGE. Organized 1908. Nominally the 
medical department of Southwestern University, which is protected by contract 
against liability for its debts. 

Entrance requirement : Nominally a three-year high school course or its equivalent. 
Attendance: 68. 

Teaching staff': 32, of whom 17 are professors, 15 of other grade. All are practitioners. 
Resources available for maintenance: Fees only, amounting to $7150 (estimated). 

Laboratory facilities : The school possesses a new building, externally attractive but 
wretchedly kept. It contains a disorderly and incomplete chemical laboratory, a 
small amount of new physiological apparatus, a single laboratory fairly well 
equipped for pathology and bacteriology, and an ordinary dissecting-room. There 
is a " reading-room " with nothing to read. The lecture-rooms are bare, except for 
chairs ; in a corner of one of them is an abused manikin. 

Clinical facilities : Amphitheater clinics in surgery are held once weekly at an insti- 
tution across the street, where perhaps 50 beds, mostly surgical, are accessible, and 
one afternoon a week at the City Hospital, one and a half miles distant. No in- 
fectious diseases are obtainable. Neither hospital contains a clinical laboratory. 
Clinical opportunities are therefore decidedly inadequate. 
A dispensary is just starting. 

Date of visit: November, 1909. 

FORT WORTH: Population, 27,096. 1 

(3) FORT WORTH UNIVERSITY MEDICAL DEPARTMENT. Organized 1894. A nominal de- 
partment of a local " university." 

Entrance requirement : Nominally a three-year high school course or its equivalent. 
Attendance: 100. 

Teaching" staff": 47, of whom 14 are professors, 33 of other grade. All are practitioners. 
Resources available for maintenance: Fees only, amounting to $10,500 (estimated). 
Laboratory facilities : These comprise a dissecting-room, ordinary laboratories for 
1 N"t estimated by U. S. Census Bureau. 



TEXAS 311 

chemistry and bacteriology, and a single laboratory with routine outfit for patho- 
logy and histology; recent provision on a small scale has been made for physiology. 
The class-rooms are bare except for a reflectoscope and a defective skeleton. There 
are a small museum of unlabeled specimens and a small library. 

Clinical facilities : The basement of the school building makes a wretched hospital of 
50 beds, 20 of them free. There is no clinical laboratory. One surgical clinic weekly 
is held at a private hospital two miles distant. 

For the dispensary a fair attendance is claimed, but no complete index is kept. 

Date of visit : November, 1909. 

GALVESTON: Population, 37,834. 

(4) UNIVERSITY OF TEXAS, DEPARTMENT OF MEDICINE. Organized 1891. An organic 
department of the state university. 

Entrance requirement: A four-year high school education, passed on by the state 
university. 

Attendance: 206. 

Teaching staff: 26, of whom 9 are professors, 17 of other grade. Three professors and 
seven instructors give entire time to the department. All instructors are on salary. 

Resources available for maintenance : The department is carried by the general funds 
of the university. Its budget calls for 863,342, of which $6500 are derived from 
fees; the hospital budget requires $39,611 besides. 

Laboratory facilities : The school has a complete series of admirable teaching lab- 
oratories, covering anatomy, physics, chemistry, physical chemistry, pathology, 
bacteriology, histology, and embryology. There is a large pathological museum, 
beautifully kept, every specimen classified, labeled, and indexed; and a notable 
anatomical museum in which special preparations are most advantageously ar- 
ranged for teaching use. The library is good and is in regular receipt of foreign 
and domestic journals; animals in abundance are on hand. Competent helpers are 
provided for each floor. No effort, however, is made in the direction of research. 

Clinical facilities : A university hospital of 155 beds adjoins the laboratories. Its or- 
ganization is along sound lines the service with a single chief being continuous, 
but students have not as yet been actively utilized in the wards. As elevated stan- 
dards improve the student body, this innovation will become more feasible. 

For lack of assistants, the dispensary is not so thoroughly organized. The at- 
tendance is fair. 

Date of visit: November, 1909. 



312 MEDICAL EDUCATION 

General Considerations 

TEXAS is indubitably a state destined to a great development; its educational insti- 
tutions must from time to time be readjusted to take account of its expanded needs. 
It is neither wise nor possible to provide now for requirements that will a genera- 
tion hence become imperative. Sufficient for the people of Texas to-day to meet in 
the most effective way possible their own needs. 

There is now only one educational institution in the state capable of maintaining 
a medical school whose graduates deserve the right to practise among its inhabi- 
tants; there is only one medical school in the state fit to continue in the work of 
training physicians. That institution is the state university; the medical school is 
its department at Galveston. The other three schools are without resources, without 
ideals, without facilities, though at Baylor the conjunction of hospital and labora- 
tory might be made effective if large sums, specifically applicable to medical edu- 
cation, were at hand, which is not, however, the case. 

There is no indication on the face of things that any of the three inferior schools 
can live through the dry period to the opportunities of the future. Their enrolment 
is small; and the state is badly overcrowded with just the kind of doctor that they 
are engaged in producing. Should the loopholes in the present state standard be 
stopped up, all three would quickly disappear. 

The course of the state university needs to be carefully considered. Whether a 
college requirement will soon be wise is a question to be pondered. The institution 
has not yet exhausted the possibilities of the high school standard; its laboratories 
admirable for undergraduate teaching need further development on the productive 
side; its hospital must be enlarged; more effective teaching methods can be intro- 
duced into it; the dispensary is not yet effective. It is worth asking whether from the 
four-year high school basis the university will not be wise to get complete control 
of the field, driving out the low-grade schools, educating the people of the state to 
regard it as their main source of supplies in the matter of doctors and the active con- 
servator of public health, before endeavoring to push ahead to a higher standard, 
which may not be so well adapted to local conditions in a relatively new country. 

Meanwhile, to the outsider it seems a regrettable mischance that located the 
medical department away from the university. Were it placed at Austin, it would 
apparently gain in every way : the town is as large, and various state institutions there 
would strengthen its clinical opportunities; it would be easier to attract and to hold 
outsiders in teaching positions; the stimulus of the university would assist the growth 
of a productive spirit. Whether at Galveston the school will ever be creative is a 
question ; should it become so, isolation increases the liability to slip back into an 
unproductive groove. Perhaps it is not yet too late for the people of the state to con- 
centrate their state institutions of higher learning in a single plant. 



VERMONT 313 

UTAH 

Population, 336,122. Number of physicians, 359. Ratio, 1: 936. 
Number of medical schools, 1. 

SALT LAKE CITY : Population, 65,464. 

UNIVERSITY OF UTAH, DEPARTMENT OF MEDICINE. Organized 1906. A half-school. An 
organic part of the state university. 

Entrance requirement: One year of college work. 
Attendance: 18. 

Teaching staff: 6 professors and 10 of other grade, who take part in the instruction. 
The professors are all university teachers, of whom 3 give their entire time to me- 
dical subjects. 

Resources available for maintenance : The department is supported out of the general 
funds of the university. It costs approximately $10,000; its income in fees is $1405. 

Laboratory facilities: Laboratories are adequately equipped for the routine instruc- 
tion of small classes in anatomy, physiology, physiological chemistry, chemistry, 
histology, pathology, and bacteriology. The spirit is excellent. A few books, scien- 
tific journals, charts, etc., are at hand ; a museum has been begun. More liberal 
support, however, is necessary if the department is to justify its high entrance 
standard. 

It is to be hoped that whenever clinical instruction is started in Salt Lake City, 
it may be only for the purpose of completing the half-course now offered ; in that 
event Utah need never know the proprietary medical school. 

Date ofvitit : April, 1909. 

VERMONT 

Population, 353,739. Number of physicians, 663. Ratio, 1 : 534. 
Number of medical schools, 1. 

BURLINGTON: Population, 22,690. 

UNIVERSITY OF VERMONT COLLEGE OF MEDICINE. Organized 1822. Now an organic part 
of the university. 

Entrance requirement : Less than a four-year high school education. 
Attendance: 156, 42 per cent from Vermont. 

Teaching staff: 33, of whom 18 are professors, 15 of other grade. Thirteen teachers 
are non-resident, among them the professors of medicine, obstetrics, pediatrics, 



314 MEDICAL EDUCATION 

physiology, and pathology. Some of the non-resident teachers go to Burlington 
weekly ; others give a concentrated course covering several weeks. The entire teach- 
ing staff never meets. There is one full-time teacher, in the department of 
anatomy. 

Resources available for maintenance : Fees, amounting to $21,388. The state has lately 
appropriated $10,000. 

Laboratory facilities : The school has an attractive new laboratory building adequate 
to routine teaching of anatomy, pathology, histology, bacteriology, physiology, and 
chemistry. No research is in progress. There is no library, no museum, few teaching 
accessories, and no animals on the premises. 

Clinical facilities : Two hospitals with 200 ward beds are in a limited way available, 
but the material is predominantly surgical: medical and obstetrical cases are rela- 
tively few. Infectious diseases are in the main didactically taught. There is little 
bedside work, patients being examined by assigned students in a small room and 
subsequently demonstrated in the amphitheater. The combined Senior and Junior 
classes attend a majority of the clinics in internal medicine and general surgery. 
The dispensary has a small attendance. 

Date of visit : May, 1909. 

[For general considerations see "New England," p. 22$.\ 

VIRGINIA 

Population, 2,032,567. Number of physicians, 2215. Ratio, 1: 918. 
Number of medical schools, 3. 

CHARLOTTESVILLE: Population, 7307. 

(1) UNIVERSITY OF VIRGINIA, DEPARTMENT OF MEDICINE. Organized 1827. An organic 
department of the university. 

Entrance requirement: One year of college work in sciences. 
Attendance: 89, 53 per cent from Virginia. 

Teaching stajf: 31 teachers, of whom 12 are professors, 19 of other grade, take part in 
the work of the department. The laboratory branches are taught by 8 instructors 
who give their entire time to them. 

Resources available for maintenance: The budget of the department calls for $52,195, 
including hospital deficit; it is met out of the funds of the university. The income 
in fees amounts to $10,060. 

Laboratory facilities : Up to three years ago the department was a didactic school. 



VIRGINIA 315 

Since then it has been revolutionized: good teaching laboratories in all necessary 
branches, with increased provision for research, have been equipped and put in 
charge of enthusiastic teachers of modern training and ideals. The main present 
lack is a suitable building and an adequate medical library. 

Clinical facilities: The University Hospital of 100 beds (80 of them ward beds) is 
the laboratory of the clinical teachers. 1 Its relation to the medical school and its 
organization for teaching purposes leave nothing to be desired. Though the mate- 
rial has not yet reached proper proportions, it is increasing and is skilfully and 
effectively used to train the student body in the technique and methods of scientific 
medicine. The surgical side is in this respect more highly organized than the 
medical. 

There is a small dispensary. 

Date of visit: February, 1909. 

RICHMOND: Population, 111,078. 

(2) MEDICAL COLLEGE OF VIRGINIA. Organized 1838. 

Entrance requirement: Less than a four-year high school education. The registration 
office is most systematically conducted. 

Attendance: 206. 

Teaching staff': 61, of whom l(p are professors, 45 of other grade. There are no teach- 
ers giving their entire time to medical instruction. 

Resources available for maintenance: Fees, amounting to $22,490, and an annual state 
appropriation of $5000. 

Laboratory facilities : The school occupies an imposing building with ordinary labora- 
tories for pathology, histology, bacteriology, physiology, and chemistry. The dis- 
secting-room is in poor condition. There is a fair museum and an attractive library 
with some recent books, in charge of a librarian. 

Clinical facilities : These are inadequate. Close by is the Memorial Hospital, with 
about 40 beds available for teaching. Supplementary facilities are enjoyed in the 
City Hospital and elsewhere. 

The dispensary occupies an excellent suite of rooms and has a fair attendance. 

Date of visit: February, 1909. 

(3) UNIVERSITY COLLEGE OF MEDICINE. Organized 1893. An independent institution. 
Entrance requirement: Less than a four-year high school education. 
Attendance: 121, 63 per cent from Virginia. 

1 A recent gift of $50,000 is now available for the extension of the hospital. 



316 MEDICAL EDUCATION 

Teaching staff": 74, of whom 22 are professors, 52 of other grade. 
Resources available for maintenance: Fees, amounting to $14,975. 

Laboratory facilities: The school was recently destroyed by fire and now occupies 
temporary laboratory quarters. 

Clinical facilities: These are inadequate. The school adjoins its own hospital, with 
less than 50 beds available for teaching. Supplementary facilities are enjoyed 
elsewhere. An out-patient obstetrical service is well organized. 
The dispensary has a fair attendance. 

Datt ofv'ult: February, 1909. 

General Considerations 

THE destruction by fire of the University College of Medicine at Richmond should 
precipitate the consolidation of the two independent schools. Separately neither of 
them can hope greatly to improve its present facilities, which, weak in respect to 
laboratories and laboratory teaching, are entirely inadequate on the clinical side. 
Their present hospitals utilized together, though still unsatisfactory, would at any 
rate be much more nearly adequate than is either hospital taken by itself; and the 
combined fees would furnish much better laboratory training than either school now 
gives. A single independent school of the better type might still have in Virginia a 
brief term of prosperity, the more so as the medical department of the University 
of Virginia is on a considerably higher basis. 

The rapid improvement of the medical department of the University of Virginia 
in the last three years is one of the striking phenomena of recent medical school his- 
tory. The limitations of Charlottesville have been acutely felt; the university is pur- 
suing the course calculated to surmount them. It faces indeed a much greater out- 
lay than it has yet made, for larger clinics in internal medicine and obstetrics must 
be developed. The alternative of a remote department diminishes difficulty of one kind 
only to create difficulty of another. A remote department at Norfolk or Richmond 
would of course command abundant clinical material; but could it preserve univer- 
sity ideals? The present resources of the university are not large enough to stand the 
strain of such liberal support as a remote department needs if it is to be genuinely 
productive. The experience of a few years warrants the belief that a clinic in most 
lines, for a school of 200 students, can be developed at Charlottesville if the univer- 
sity can afford it. Graduating classes of 50 easily suffice for Virginia's demand. At 
any rate, so much is evident: in Virginia, as elsewhere, the teaching of medicine will 
fall to the universities; and at this writing, the only institution available is the Uni- 
versity of Virginia. 



WISCONSIN 317 

WEST VIRGINIA 

Population, 1,135,206. Number of physicians, 1608. Ratio, 1:706. 
Number of medical schools, 1. 

MORGANTOWN, Population, 2779. 

WEST VIRGINIA UNIVERSITY COLLEGE OF MEDICINE. Organized 1902. A half-school. 

An organic department of the university. 
Entrance requirement: A four-year high school education, though applicants not thus 

qualified are admitted as special students. 

Attendance: 18. 

Teaching staff: 7 professors, who take part in the instruction offered, two of them 
giving their entire time to this department. 

Resources available for maintenance: The department is carried by the university. Its 
income in fees is 81000 (estimated). 

Laboratory facilities: The school is fairly equipped to do elementary work in anatomy, 
chemistry, histology, pathology, and bacteriology ; less well in physiology. There 
is no library, no museum, no charts, no models, or other teaching accessories. The 
work and interest are limited to routine. 

The school has an "affiliation" with the College of Physicians and Surgeons of 
Baltimore, an independent institution over which West Virginia University has 
neither control nor influence. [See Maryland (2).] 

Date of visit: March, 1909. 

WISCONSIN 

Population, 2,356,874. Number of physicians, 2518. Ratio, 1 : 936. 
Number of medical schools, 3. 

MADISON : Population, 28,438. 

(1) UNIVERSITY OF WISCONSIN COLLEGE OF MEDICINE. Organized 1907. A half-school. 
An organic part of the university. 

Entrance requirement: Two years of college work, including sciences, rigidly enforced. 
Attendance: 49. 

Teaching staff: 23 instructors, who take part in the work of the department, of whom 
17 give their entire time to it. 



318 MEDICAL EDUCATION 

Resources availablefor maintenance: The department is maintained out of the general 
funds of the university. Its budget calls for $40,625. 

Laboratory facilities: Though temporarily housed, the laboratories, complete in num- 
ber, are admirably equipped with respect to both teaching and research. A suc- 
cessful effort has been made to provide facilities worthy of students on a two-year 
college basis and of teachers deserving opportunities for progressive work. The 
department lacks only a building which shall bring its parts together. 

Date ofvifU: May, 1909. 

MILWAUKEE: Population, 337,117. 

(2) MILWAUKEE MEDICAL COLLEGE. A stock company, organized 1894, and now nomi- 
nally the medical department of Marquette University. 

Entrance requirement: A four-year high school education or its equivalent. 
Attendance: 168, 91 per cent from Wisconsin. 
Teaching staff": 67, of whom 30 are professors, 37 of other rank. 
Resources available for maintenance: Fees only, amounting to $22,680. 

Laboratory facilities: Meager facilities are provided for the teaching of pathology 
and bacteriology; there is the usual chemical laboratory; anatomy is better than 
ordinary. Experimental physiology and toxicology are taught at Marquette Col- 
lege near by; the equipment is slight. 

Clinical facilities: These are extremely weak. The school adjoins Trinity Hospital, 
which is practically part of the same corporation. It has 75 beds, largely occupied 
by pay patients and given up almost wholly to surgery; teaching is limited to 
amphitheater clinics ; weekly clinics are also held at the County Hospital, five 
miles distant. 

An ill equipped dispensary in the college building has an attendance varying 
from ten to twenty a day. A card index is now kept. 

Date ofvitit: February, 1910. 

(3) WISCONSIN COLLEGE OF PHYSICIANS AND SURGEONS. Organized 1893. An indepen- 
dent institution, nominally the medical department of Carroll College. 

Entrance requirement: A four-year high school education or its equivalent. 
Attendance: 60, 85 per cent from Wisconsin. 

Teaching staff": 66, of whom 26 are professors, 40 of other grade. No teacher devotes 
his entire time to the school. 

Resources availablefor maintenance: Fees only, amounting to $8675 (estimated). 
Laboratory facilities: The school occupies an attractive building which contains an 



WISCONSIN 319 

ordinary laboratory for elementary chemistry, another poor and very disorderly, 
without animals for bacteriology; the room given to histology and pathology 
is clean, contains a small amount of well kept material, and is adequate to routine 
elementary work. Anatomy is very poor; there is not even a complete skeleton. 
No other teaching adjuncts are at hand. No provision is made for even demonstra- 
tive work in experimental physiology. 

Clinical facilities: These are utterly wretched. The school gives amphitheater clinics 
only, at a Catholic hospital across the street, practically all of whose work is in 
surgery. Acute medical cases are seen, if at all, twice a week at the County Hos- 
pital, five miles off. A neat dispensary, with poor records and with no laboratory 
or other equipment, adjoins the school building. 

Date ofvitit: February, 1910. 

General Considerations 

WISCONSIN presents a simple problem : the two Milwaukee schools are without a re- 
deeming feature. It is claimed that the examiner representing the state board enforces 
a four-year high school standard; but it has been impossible to procure any informa- 
tion at all from this official, though repeated efforts have been made to do so. Neither 
of the schools meets the most lenient standards in respect to laboratory outfit or 
teaching; and as for clinical facilities they are hardly more than nominal. 

A western state so admirably organized on the educational side, furnishing ex- 
cellent college opportunities without cost to the student, is surely in position to 
meet Minnesota and Indiana in the matter of practice standards. The requirement of 
a year or two of college work as preliminary to practice would quickly leave the med- 
ical department of the state university in sole control. 

This department has wisely resisted efforts to make of it a divided instead of a half 
school; nothing worse could ever happen to it than that it should be rounded off with 
a clinical end at Milwaukee, made up, perhaps, in part out of the two schools now 
there. When the time comes for the completion of the department, it must be com- 
pleted at Madison. The difficulties due to the size and residential character of the 
town are not insuperable. There is not the least doubt that wise administration can 
develop on the site of the university a medical school large enough to train the doc- 
tors of the state. But its scope will run far beyond this primary duty ; for it will in- 
evitably be a producing department. Assuredly, Wisconsin, fortunate beyond almost 
all other states in the concentration of its higher institutions of learning, will not be 
guilty of the folly of detaching in whole or part the medical department from the 
university whose ideals it can share and help to create. 



CANADA 

ALPHABETICALLY ARRANGED BY PROVINCES 
Population, 6,945,228. Number of physicians, 6736. Ratio, 1 : 1030. 
Number of medical schools, 8. 

MANITOBA 
WINNIPEG: Population, 150,000. 

(1) MANITOBA MEDICAL COLLEGE. Organized 1883. The medical department of the 
University of Manitoba, the connection being in process of becoming organic. 

Entrance requirement: The University Matriculation Examination or its actual 
equivalent. The medical course covers five years. 

Attendance: 115. 

Teaching staff: 41, of whom 22 are professors, 19 of other grade. 

Resources available for maintenance: Fees, amounting to $14,000. 

Laboratory facilities: Instruction in chemistry, bacteriology, histology, and pathology 
is competently given by the University of Manitoba. Other branches are carried on 
by the medical faculty. The equipment is adequate to routine instruction, new, 
and steadily increasing. There is a beautifully kept collection of several hundred 
wet specimens. Appearances indicate a conscientious and intelligent employment 
of such resources as the school has had. 

Clinical facilities: The excellent Winnipeg General Hospital of 400 beds adjoins the 
school. The school faculty is practically the staff of the free wards. The relation 
between school and hospital is admirable. Students work freely in wards, clinical 
laboratory, operating-rooms, obstetrical ward, etc. 
There is a good dispensary. 

DaU of visit: May, 1909. 

NOVA SCOTIA 
HALIFAX (NovA SCOTIA) : Population, 45,000 (estimated). 

(2) HALIFAX MEDICAL COLLEGE. Organized in 1867. An independent school with a pe- 
culiar relationship to Dalhousie University, which provides satisfactorily instruc- 
tion in chemistry, physics, and biology, during part of the first two years of the 
five-year course. In respect to all else the medical school is an independent in- 
stitution, though its students are practically all examined for their degree by Dal- 
housie University. The university thus furnishes part of the first two years' teaching 
and is the final examining body ; with the intervening years it lias nothing to do. 



CANADA 321 

Entrance requirement : .On a par with that of Dalhousie University. 
Attendance : 63, 90 per cent from Nova Scotia. 

Teaching staff: 33, of whom 16 are professors. There are no full-time instructors. 
(This does not include the instructors in the scientific branches furnished by Dal- 
housie University.) 

Resources available for maintenance: An annual appropriation of $1200 from the 
provincial government and fees amounting to about $5000. Three-fourths of the 
fees are distributed among the professors ; one-fourth provides, with the govern- 
ment grant, for all other expense. A bequest yielding $200 per annum supports 
the college library. 

Laboratory facilities : This disposition of funds is reflected in the condition of the 
medical college : it possesses an ordinary, ill smelling dissecting-room and a single 
utterly wretched laboratory for pathology, bacteriology, and histology. A micro- 
scope is provided for each student. Though this same " laboratory " serves for the 
provincial board of health, no animals are used. There is no museum worthy the 
name, and no laboratory work in physiology or pharmacology. The laboratory sci- 
ences have been starved that small dividends might be paid to generally prosper- 
ous practitioners. 

Clinical facilities: Clinical instruction is provided at the Victoria General Hospital, 
a government institution of some 200 beds, open to the medical school. About 70 
per cent of the cases are surgical. The staff appointments are made by the gov- 
ernment for its own reasons ; the medical college is forced to confer professorships 
on these appointees. Ward classes are conducted ; individual cases are assigned, 
and the student's notes become part of the hospital records. Instruction in clinical 
microscopy is very limited. 

Obstetrical opportunities barely suffice. Autopsies are performed in the presence 
of students, who report on them. The college has no dispensary, but students are 
required to attend the city dispensary, an institution within which the medical 
school has no authority. The attendance is fair. 

It has been stated above that except during part of the first two years Dalhousie 
University has no teaching responsibility for or connection with Halifax Medical 
College. On the other hand, students of Halifax Medical College are examined by 
the medical faculty of Dalhousie University and obtain the Dalhousie medical de- 
gree. The question may fairly be asked : What is the value of the Dalhousie degree 
in medicine, won by students whose opportunities have been provided by Halifax 
Medical College ? The connection is, from the standpoint of Dalhousie University, 
highly objectionable. 

Date of visit : October, 1909. 



322 MEDICAL EDUCATION 

ONTARIO 
KINGSTON: Population, 20,000. 

(3) MEDICAL DEPARTMENT OF QUEEN'S UNIVERSITY. Organized 1854. The relation of 
the medical department to the university is anomalous, marking a period of transi- 
tion that is likely soon to result in complete integration. 

Entrance requirement : Heretofore somewhat below that of the arts department of 
the university, though students must comply with the requirements of the pro- 
vince in which they expect to practise. The medical course covers five years. 

Attendance : 208, 71 per cent from Ontario. 
Teaching staff ': 38, 16 being professors. 

Resources available for maintenance : Income in fees, $19,978. A fixed percentage of 
fees is annually expended on buildings, equipment, and maintenance. The re- 
mainder belongs to and is disbursed by the medical faculty. 

Laboratory facilities : The laboratory building is new and the equipment is adequate 
to intelligent routine work. At present, physics, chemistry, and physiology are 
taught in the university, in return for which the university receives a part of the 
fees of the students instructed. Full-time professors in anatomy and pathology are 
provided by the medical school. A museum is in process of formation. There is a 
small collection of books and periodicals in the faculty room, open to students. 

Clinical facilities : The clinical facilities are limited. The school relies mainly on the 
adjoining Kingston General Hospital, in which its faculty practically constitutes 
the staff. The average number of beds available is 80, but they are well used. In 
addition to ward work, students are required to work up individual cases in cor- 
rect form, including the clinical laboratory aspects. There is a ward for infectious 
diseases. Obstetrical cases are too few. Post-mortems are secured mainly at the 
Rockwood Insane Asylum. Two supplementary hospitals provide additional illus- 
trative clinical material. The opportunities for out-patient work are slight. 

Date of visit: October, 1909. 

LONDON: Population, 41,500. 

(4) WESTERN UNIVERSITY MEDICAL DEPARTMENT. Established 1881. Practically an 
independent school. 

Entrance requirement: Nominal. The student, for his own protection, is expected to 
fulfil the requirements of the place in which he intends to practise. The medical 
course covers four years. 

Attendance: 104. 



CANADA 328 

Teaching staff: 20, of whom 8 are professors, 12 of other grade. 

Resources available for maintenance: Fees, amounting to $11,590 (estimated). 

Laboratory facilities: These consist of a single room called the laboratory of patho- 
logy, bacteriology, and histology, whose equipment consists of microscopes and 
some unlabeled specimens, no microtome, cut sections, incubator, or sterilizer 
being visible, a wretched chemical laboratory, and an ordinary dissecting-room. 
There is no outfit for physiology, pharmacology, or clinical microscopy, and no 
museum deserving the name. There are a few hundred books, locked in cases to 
which the janitor carries the key. 

Clinical facilities: These are entirely inadequate. They are confined almost wholly to 
a small number of beds in the municipal hospital. 

The school has no dispensary. 
Date of visit: October, 1909. 

TORONTO: Population, 328,911. 

(5) UNIVERSITY OF TORONTO FACULTY OF MEDICINE. Established 1887. An organic 
department of the university. 

Entrance requirement: The Junior Matriculation Examination, strictly enforced. The 
course covers five years. 

Attendance: 592. 

Teaching 1 staff": 68, of whom 27 are professors, 41 of other grade. Ten professors 
with fifteen assistants give their entire time to teaching and research. 

Resources available for maintenance : The department is supported out of the general 
funds of the university, its cost being considerably in excess of fees received. The 
latter amount to $64,500. 

Laboratory facilities : The laboratories are in point of construction and equipment 
among the best on the continent. Increasing attention has recently been devoted 
to the cultivation of research. There are both general and departmental libraries, 
an excellent museum, and all necessary teaching accessories. 

Clinical facilities: The school has recently perfected a very intimate relationship with 
the new Toronto General Hospital, by which its faculty obtains complete control 
of the clinical advantages of some 500 beds. Students have free access to all wards, 
clinical laboratory, dispensary, etc. Other large local hospitals general and special 
are also available. 

Date ofvurit: March, 1909. 



824 MEDICAL EDUCATION 

QUEBEC 
MONTREAL: Population, 267,730. 

(6) McGiLL UNIVERSITY MEDICAL FACULTY. Established 1824. An organic depart- 
ment of the university. 

Entrance requirement: The University School Leaving Examination, strictly enforced. 
The medical course covers five years. 

Attendance: 328. 

Teaching staff: 99, of whom 19 are professors, 80 of other grade. Ten instructors de- 
vote their entire time to teaching. 

Resources available for maintenance: The department has separate endowments ag- 
gregating 350,000 and is assisted out of the general university funds. Its fees 
amount to 43,750; its budget, $77,000. 

Laboratory facilities: The laboratories having been recently injured by fire, the school 
is now waiting the completion of its new buildings, for which ample funds have 
been secured. Meanwhile its temporary quarters, well equipped for both teaching 
and research in all departments, show what energy and intelligence can accomplish 
in the face of disaster. The anatomical and pathological museums are among the 
most famous on the continent. The school possesses an excellent library and all 
necessary teaching accessories. 

Clinical facilities : These are excellent. The school enjoys a most favorable relation 
to two large hospitals, of about 500 beds, besides several other institutions. Stu- 
dents work freely in all the wards and clinical laboratory. 
The dispensary service is large and admirable. 

Date o/vifit: March, 1909. 

(7) LAVAL UNIVERSITY MEDICAL DEPARTMENT. Organized 1878. The university con- 
nection is not intimate. 

Entrance requirement: Indefinite, depending on the prospective location of the student. 
The medical course covers five years. 

Attendance: 217. 
Teaching staff': 8. 

Resources available for maintenance: Fees, most of which are distributed among the 
teachers. 

Laboratory facilities: Chemistry is given by the university. Anatomy is limited to 
dissecting. A single laboratory with meager equipment is assigned to pathology, 



CANADA 325 

bacteriology, and histology. There is a library and a small collection of speci- 
mens, not all labeled. 

Clinical facilities: The school has access to two hospitals, containing together 250 

beds. The dispensary has a fair attendance. 
Dale of visit: March, 1909. 

QUEBEC: Population, 70,000. 

(8) LAVAL UNIVERSITY MEDICAL DEPARTMENT. Organized 1848. An organic part of 
Laval University. 

Entrance requirement: Indefinite, depending on the student's prospective location. 
As most graduates locate in the province French being the language of in- 
struction they must comply with the provincial requirement. The medical course 
covers five years. 

Attendance: 92. 

Teaching- staff": 22. 

Resources available for maintenance: Fees and an appropriation by the university. 

Laboratory facilities: Instruction in chemistry and physics is provided by the univer- 
sity; in the medical building, recent, though not extensive, laboratory provision 
is made for anatomy, histology, bacteriology, and pathology. There is no experi- 
mental physiology or pharmacology. A library for students and a museum have 
been started lately. The buildings are admirably kept. 

Clinical facilities: Clinical instruction in medicine, surgery, and pediatrics is given 
at the Charity Hospital (Hotel Dieu), to the free wards of which the faculty serves 
as staff. The amount of material is limited in quantity; the staff rotates monthly. 
The hospital contains a clinical laboratory, in which instruction is given in con- 
nection with ward work. The fifth year, now required, and a proposed reorganiza- 
tion of staff and teaching arrangements promise to improve the instruction. Ob- 
stetrical opportunity is abundant. 

The dispensary has a sufficient attendance. 

Date of visit: October, 1909. 

General Considerations 

IN the matter of medical schools, Canada reproduces the United States on a greatly 
reduced scale. Western University (London) is as bad as anything to be found on this 
side the line; Laval and Halifax Medical College are feeble; Winnipeg and Kingston 
represent a distinct effort toward higher ideals; McGill and Toronto are excellent. 
The eight schools of the Dominion thus belong to three different types, the best 
adding a fifth year to their advantages of superior equipment and instruction. 



326 MEDICAL EDUCATION 

At this moment the needs of the Dominion could be met by the four better Eng- 
lish schools and the Laval department at Quebec. Toronto has practically reached 
the limits of efficiency in point of size; McGill and Manitoba are capable of consid- 
erable expansion. The future of Kingston is at least doubtful. It could certainly 
maintain a two-year school ; for the Kingston General Hospital would afford patho- 
logical and clinical material amply sufficient up to that point. But the clinical years 
require much more than the town now supplies. Its location halfway between 
Montreal and Toronto, on an inconvenient branch-line greatly aggravates the diffi- 
culties due to the smallness of the community. The rapid development of the North- 
west Territory will undoubtedly hasten the growth of the Winnipeg school; other 
institutions will in time be established nearer the Pacific coast as the country grows 
in population. 

The legal standard in the Dominion has not thus far been high ; but it has prac- 
tically been elevated a year by the general movement to prolong the course to five 
years. Meanwhile, the high quality of instruction offered by McGill and Toronto to 
students who enter on less than a four-year high school education proves that our 
trouble in the United States has been at bottom not less one of low ideals than of 
low standards. Indeed, where ideals are low, there are no standards; and where ideals 
are high, the standard, even though low, is at any rate so definite that it furnishes a 
sure starting-point towards a clearly apprehended goal. The low standard school in 
the United States has had no such starting-point and no such goal. 



APPENDIX 

TABLE SHOWING NUMBER IN FACULTY, ENROLMENT, 
FEE INCOME, BUDGET OF SCHOOLS BY STATES 



INSTITUTION 
(Half-schools marked *) 


Num- 
ber of 
Pro- 
fes- 
sors 


Number 
of 
Other In- 
structors 


Number 
Students 


Total 
Annual 
Income 
from Fees 


Annual 
Budget* 


ALABAMA 
1. Birmingham Medical College 


18 


12 


185 


$ 14 550 * 




2. University of Alabama, Medical Department 


g 


17 


204 


17 300* 




ARKANSAS 
8. University of Arkansas, Medical Department 


18 


17 


179 


14.100 l 




4. College of Physicians and Surgeons (Little Rock) 


25 





81 


6 450* 




CALIFORNIA 
5. College of Physicians and Surgeons (Los Angeles) 


28 


18 


32 


4075 1 




6. California Eclectic Medical College 


26 


1 


9 


1 060 1 




7. Los Angeles College of Osteopathy 


19 




"Afore than 


37 600 l 




8. Pacific College of Osteopathy 


19 


19 


250" 
85 


12 760 l 




0. Oakland College of Medicine and Surgery 


13 


19 


17 


2 760 l 




10. Hahnemann Medical College of the Pacific 


13 


22 


23 


2,685 * 




11. College of Physicians and Surgeons (San Francisco) 


23 


30 


70 


7.716 ' 




12. Leland Stanford Junior University, College of Medicine 


16 


5 


16* 






13. University of California, Medical Department 


12 


48 


36 


7,004 


$33,396 


COLORADO 
14. University of Colorado, School of Medicine 


25 


20 


86 


4.043 


28.000 


15. Denver and Gross College of Medicine (University of Denver) 


44 


35 


109 


12.624 l 




CONNECTICUT 
16. Yale Medical School 


14 


50 


138 


16,325 


43,311 


DISTRICT OF COLUMBIA 
17. George Washington University, Department of Medicine 


26 


44 


117 


21,833 


23,779 


18. Georgetown University, Department of Medicine 


20 


54 


89 


11.000 




19. Howard University, Medical Department 


22 


30 


205 


26,000 


40,000* 


GEORGIA 
20. Atlanta College of Physicians and Surgeons 


20 


31 


286 


28,000 




21. Atlanta School of Medicine 


17 


27 


230 


20,000 ' 




22. Georgia College of Eclectic Medicine and Surgery 


14 


6 


66 


6.666 * 




23. Hospital Medical College 


16 




43 


3,960 l 




24. Medical College of Georgia (University of Georgia) 


18 


15 


99 


6.835 




ILLINOIS 
25. Rush Medical College (University of Chicago) 


89 


141 


488 


60.485* 


82.462 














Forwarded 


562 


665 


3.142 


$343,699 

















1 Estimated. * First year in operation. 

3 Absence of information under this heading may mean one of several things : in proprietary schools there is no budget, because no plant 
are made, necessary expenses are met and the balance is divided or is used to reduce debts ; in many university departments the expense 
incurred, while much greater than fee income, is so involved with expense incurred for other laboratory purposes that it cannot be sepa- 
rated. In such instances, it cannot be definitely stated what the cost of the department is. 
* Includes state appropriation of $5000 which pays for scholarships. 
8 First two years. University of Chicago : $33.000. Third and fourth years. Rush Medical College : t87J5. 



INSTITUTION 
(Half-*choola marked ) 


dum- 
ber of 
Pro- 
fe*- 
ort 


Kumber 
of 
Other In- 
structors 


Number 
Students 


Total 
Annual 
Income 
from Fees 


Annual 
Budget 




562 


665 


3 142 


$343 699 




ILLINOIS (COXTWCTO) 
28. Northwestern University Medical School 


64 


89 


522 


89076 


$88,861 


J7 College of Physicians and Surgeons (University of Illinois) 


42 


156 


517 


80 155 ' 




American Medical Missionary College 




See 








J8. Hahnemann Medical College and Hospital of Chicago 


38 


Michigan 
46 


130 


14,300 l 




29. Chicago College of Medicine and Surgery 


87 


84 


366 


43,430' 




SO. Bering Medical College 


30 


14 


32 


3,360 * 




31. Illinois Medical College ; 


38 


35 


69 


9,175 l 




Si. Bennett Medical College 


21 


21 


181 


19,380 ' 




S3 College of Medicine and Surgery Physio-medical 


33 


9 


33 


2,935 ' 




34. Jenner Medical College 


28 


9 


112 


12,880' 




$3 National Medical University 


36 




150 


22 500' 




M. Reliance Medics! College 


23 


21 


83 


9,945' 




37. Littlejohn College of Osteopathy 


43 




75 


11,250 ' 




INDIANA 
38. Indiana University, School of Medicine 


99 


76 


266 


31,240 ' 




30. 'Valparaiso University, Medical Department 






25 






IOWA 
40. Drake University College of Medicine 


16 


29 


1O6 


9505 


12 417 


41. Still College of Osteopathy 


13 


2 


115 


17.250' 




42. State University of Iowa, College of Medicine 


12 


20 


267 


13,707 


35,216 * 


43. State University of Iowa, College of Homeopathic Medicine 


10 


15 


42 


1,864 


6,453* 


KANSAS 
44. University of Kansas, School of Medicine 


24 


39 


89 


5,030 


40,000 


45. Western Eclectic College of Medicine and Surgery 


30 


2 


21 


1,600' 




40. Kansas Medical College (Washburn College) 


81 


16 


65 


4876 




KENTUCKY 
47. University of Louisville, Medical Department 


40 


50 


6OO 


75,126 




48. Southwestern Homeopathic Medical College :. 


12 


15 


13 


1,100' 




40. Louiiville National Medical College 


17 


6 


40 


2,660 ' 
















Forwarded 


1.289 


1.269 


7,061 


$825 942 

















Estimated. 



* The university hospital budget it $SS,lk5. 



Hospitnl budget, $781.7. 



INSTITUTION 
(Half-schools marked *) 


Num- 
ber of 
Pro- 
/- 
sort 


Number 
of 
Other In- 
structor* 


Number 
of 
Students 


Total 
Annual 
Income 
from Feet 


Annual 
Budget 


Carried forward 


1 289 


1 269 


7 061 


$826 942 




LOUISIANA 
50. Tulane University of Louisiana, Medical Department 


17 


58 


439 


67,600 


$101.781 


51. Flint Medical College 


3 


9 


24 


1 3OO 




MAINE 
52. Medical School of Maine (Bowdoin College) 


14 


21 


81 


8.100 


16,700 


MARYLAND 
53. Johns Hopkins University, Medical Department 


23 


89 


297 


60542 


102 429 


54. College of Physicians and Surgeons (Baltimore) 


21 


38 


252 


39 000 l 




55. University of Maryland, School of Medicine 


24 


37 


316 


44 630 




56. Baltimore Medical College 


20 


43 


892 


33.424 




57. Woman's Medical College of Baltimore 


18 


13 


22 


2 000' 




58. Maryland Medical College 


21 


18 


95 


7,460 l 




58. Atlantic Medical College 


12 


35 


43 


3 905 * 




MASSACHUSETTS 
60. Harvard University Medical School 


23 


16O 


285 


72,037 


261.389 


61. Boston University School of Medicine 


29 


85 


90 


12,762 ' 




62. Tufts College Medical School 


33 


70 


384 


59.O93 




63. College of Physicians and Surgeons (Boston) 


30 


15 


172 


10,000 l 




64. Massachusetts College of Osteopathy 


19 


16 


90 


11.4O0 1 




MICHIGAN 
65. University of Michigan, Department of Medicine and Surgery 


22 


41 


389 


34,093 


83.00O 1 


66. University of Michigan Homeopathic College 


15 


12 


80 


4.515 


16.400* 


67. American Medical Missionary College 


22 


10 


75 


4,778 ' 




68. Detroit College of Medicine 


25 


79 


161 


22,000 l 




69. Detroit Homeopathic College 


17 


18 


34 


3.010 l 




MINNESOTA 
70. University of Minnesota College of Medicine and Surgery 


49 


71 


174 


16,546 


71.886 


MISSISSIPPI 


12 


7 


100 


7,600' 






14 


13 


39 


3,600 


16.000 


MISSOURI 
73 * University of Missouri School of Medicine 


8 


6 


47 


2.820 


31,000 
















1,783 


2,171 


11,142 


11 367 757 

















' Estimated. 



l Not including university hospital budget of $70,000. 



'Hospital budget, $31,000. 



INSTITUTION 
(Half-schools marked *) 


K 'um- 
ber of 
Pro- 
fes- 
sors 


dumber 
of 
Other In- 
structors 


dumber 
Students 


Total 
Annual 
Income 
from Feet 


Annual 
Budget 




1 783 


2,171 


11 142 


fl 367 767 




MISSOURI (CoxnircKD) 
74. University Medical College 


30 


35 


174 


17 60O 1 




75 Kansas City Habnemann Medical College .. 


33 


g 


59 


5 900* 




75. Central College of Osteopathy 


20 




40 


4,600 * 




77 American School of Osteopathy 


12 


11 


560 


89,600 l 




78. Ensworth Medical College 


32 


8 


72 


7,060 l 




79 Washington University, Medical Department .. 


48 


51 


178 


21,000 


361,265* 


80 St. Louis University School of Medicine 


39 


82 


243 


26,630 l 


37,000* 


81 St. Louis College of Physicians and Surgeons 


25 


24 


224 


16,035 l 




61. Barnes Medical College 


39 


25 


124 


12,400 l 




83. American Medical College 


25 


3 


28 


8,801 * 




84. Hippocratean School of Medicine 


30 


8 


81 


3,315 * 




NEBRASKA 
M. Univfmity of Nchraikn, College of Medicine 


38 


46 


122 


4,905 


20,612 


88 Lincoln Medical College (Cotner University) 


34 




42 


3 794 l 




87. John A. Creighton Medical College (Creighton University) 


28 


21 


175 


17,850 * 




NEW HAMPSHIRE 
88. Dartmouth Medical School (Dartmouth College) 


17 


7 


68 


6,583 * 




NEW YORK 
80. Albany Medical College (Union University) 


16 


78 


180 


20,276 




80. University of Buffalo Medical Department 


38 


59 


193 


31,984 




81. College of Physicians and Surgeons, New York City (Columbia University) 
98. Cornell University Medical College 


38 
32 


138 
100 


812 

207 


75.600 
24,410 


239.072 3 
) 209.888 ( ^ 


9S. Eclectic Medical College of the City of New York 


16 


29 


96 


8,311 


' 32,840 (Ithac 


94. Ford ham University School of Medicine 


82 


40 


42 


7,330 ' 




95. Long Island College Hospital 


9 


85 


360 


61,398 




9ft. New York Homeopathic Medical College 


31 


84 


159 


18,658 




97. New York Medical College for Women 


23 


22 


24 


2.545 




98. University and Bellevue Hospital Medical College (New York University) 
99. Syracuse University, College of Medicine 


87 
16 


127 
42 


408 
161 


76,115 
28,861 


87.116 














Forwarded 


2.52O 


3.254 


15.4O4 


$1,963.118 

















1 Et imated. 



1 Hospital budget, $90.000. 



'Including Sloane Maternity Hospital and Vanderbilt Clinic. 



INSTITUTION 
(.Half-schools marked *) 


Num- 
ber of 
Pro- 
fes- 
sors 


Number 
of 
Other In- 
structors 


Number 
of 
Students 


Total 
Annual 
Income 
from Fees 


Annual 
Budget 




2 520 


3 264 


15 404 


$1 953 118 




ORTH CAROLINA 
K). * University of North Carolina, Medical Department 


10 


5 


74 


6.6OO 


1 12 000 


1. North Carolina Medical College 


19 


13 


94 


8 345 ' 




2. Leonard Medical School (Shaw University) 


8 


1 


125 


2 846 




>S. *Wake Forest College, School of Medicine 


6 




53 


2,225 




ORTH DAKOTA 
14. *State University of North Dakota, College of Medicine 


9 


7 


9 


450 


6 300 


HIO 
5. Ohio-Miami Medical School (University of Cincinnati) 


50 


76 


197 


26,345 




*6. Eclectic Medical Institute 


12 


12 


86 


7,500* 




7. Pulte Medical College 


24 


12 


16 


1,325 a 




8. Cleveland College of Physicians and Surgeons 


18 


41 


89 


9.520 1 




9. Cleveland Homeopathic Medical College 


30 


31 


46 


5,750 ' 




0. Western Reserve University, Medical Department 


18 


82 


98 


11,000 


63,000 


1. Starling-Ohio Medical College 


32 


28 


220 


27,500 l 




2 Toledo Medical College 


16 


32 


32 


3,240 J 




KLAHOMA 
3. *State University of Oklahoma, School of Medicine 


9 




22 


600 




4. Epworth University College of Medicine 


28 


14 


51 


4285 1 




REGON 
5. University of Oregon, Medical Department 


14 


27 


72 


8,000 * 






15 


1 


29 


3,580 l 




ENNSYLVANIA 


26 


131 


546 


104,612 


131.255* 


8. Jefferson Medical College 


22 


100 


591 


102,995 




9. Medico-Chirurgical College of Philadelphia 


23 


86 


480 


48.281 * 




!0. Woman's Medical College of Philadelphia 


25 


27 


125 


15,480 




1 Hahnemann Medical College, Philadelphia 


27 


45 


182 


18.500 




2 Temple University, Department of Medicine 


15 


70 


136 


17,000 * 




3 Philadelphia College of Osteopathy 


11 


7 


126 


18.900 > 




!4. University of Pittsburgh Medical Department 


43 


60 


315 


48,500 
















Forwarded 


3,030 


44.62 


19.218 


$2,456.397 

















Estimated. 



1 Exclusive of hospital and dispensary. 



INSTITUTION 
(Half-schools marked *) 


Num- 
ber of 
Pro- 

/*- 
tors 


Number 
of 
Other In- 
structors 


Number 
of 
Students 


Total 
Annual 
Income 
from Fees 


Annual 
Budget 




3,030 


4,162 


19,218 


$2,456,397 




SOUTH CAROLINA 
125 Medical College of the State of South Carolina 


11 


23 


213 


19447 




SOUTH DAKOTA 
1M 'University of South Dakota, College of Medicine 


5 


5 


7 


660 




TENNESSEE 
127 Chattanooga Medical College (University of Chattanooga) 


11 


14 


112 


4,290 ' 




Ijg, Tennessee Medical College (Lincoln Memorial University) 


26 


5 


82 


4,994 




129 Knoxville Medical College 


9 


2 


23 


1.020 1 




130 College of Physicians and Surgeons (Memphis) 


22 


26 


77 


7.400 ' 






12 


23 


442 


34,600 ' 




192 University of West Tennessee Medical Department 


14 




40 


2,000 * 




ISA. Universities of Nashville and Tennessee, Medical Department 


26 


29 


207 


26,000 ' 




134. Vanderbilt University, Medical Department 


17 


23 


200 


26,250 




135 Meharry Medical College (Walden University) 


12 


14 


275 


20.310 


$23,946 


TEXAS 
ISfl Baylor University College of Medicine 


16 


13 


53 


7,735 * 






17 


15 


68 


7,150 * 




138. Fort Worth University, Medical Department 


14 


33 


100 


10,600 ' 




ISO. University of Texas, Medical Department 


e 


17 


206 


6,500 


63.342 ' 


UTAH 
140. * University of Utah, Department of Medicine 


6 


10 


18 


1,405 


10,000 


VERMONT 
141 University of Vermont College of Medicine .. 


18 


16 


156 


21,388 




VIRGINIA 
142. University of Virginia, Department of Medicine 


12 


19 


89 


10,060 


52,196 s 


14S. Medical College of Virginia 


16 


46 


2O6 


22,490 * 




144. University College of Medicine 


22 


62 


121 


14.976 




WEST VIRGINIA 
149. * West Virginia University, College of Medicine . 


7 




18 


1,000* 




WISCONSIN 
140. University of Wisconsin, College of Medicine 


7 


16 


49 




40,625 


147. Milwaukee Medical College (Marquette University) 


30 


37 


168 


22,680 * 


















3,369 


4.697 


22,148 


$2.729,251 

















1 Estimated. 



1 Hotpital budget. $39,611. 



1 Including hospital deficit. 



INSTITUTION 

(Half-schools marked *) 


Num- 
ber of 
Pro- 
fes- 
sors 


Number 
of 
Other In- 
structors 


Number 
Students 


Total 
Annual 
Income 
from Fees 


Annual 
Budget 


Carried forward . . 


3,369 


4 597 


22,148 


$2,729,251 




WISCONSIN (CONTINUED) 
148. Wisconsin College of Physicians and Surgeons 


26 


40 


60 


8,675 




MANITOBA 
149. Manitoba Medical College (University of Manitoba) 1 


22 


19 


115 


14,000 




NOVA SCOTIA 
150. Halifax Medical College (Dalhousie University) 


16 


17 


63 


5,000 


$6,200 


ONTARIO 
151 University of Toronto, Faculty of Medicine 1 


27 


41 


592 


64,500 




152 Queen's University, Medical Faculty 1 


16 


22 


208 


19,978 




153 Western University. Medical Department* 


8 


12 


104 


11 590 




QUEBEC 
154 McGill University, Medical Faculty 1 


19 


80 


328 


43,750 


77.000 


f Montreal 


8 




217 ~\ 






L55: Laval University, Medical Department 1 -I 


22 




92 / 


















Total 


3,533 


4,828 


23,927 


$2.896,744 


, 















Five-year course. 



1 Four-year course. 



INDEX 



INDEX 



ACCREDITED high schools, 31. 

Admission requirements in medical schools, 10, 

11, 22-38, 47-50, 168. 
Alabama : / 

University of Alabama, 85, 90, 123, 126, 

139, 185. 

Birmingham Medical College, 36, 122, 185. 
Alabama, University of (see under Alabama). 
Albany Medical College, Union University 

(see under New York). 
American College of Osteopathy (see under 

Missouri). 

American Medical Association, 10. 
American Medical College (see under Missouri). 
American Medical Missionary College (see un- 
der Michigan). 
Anatomy, 61, 83. 

Apportionment of studies in medical schools, 76. 
Apprenticeship system, 3, 9. 
Approved high schools, 31. 
Arkansas : 

University of Arkansas, 10, 12, 86, 120, 

141, 151, 187. 
College of Physicians and Surgeons, Little 

Rock, 7, 12, 114, 187. 

Arkansas, University of (see under Arkansas). 
Army Medical School, Washington, D.C. (see 

under District of Columbia). 
Atlanta College of Physicians and Surgeons 

(see under Georgia). 

Atlanta School of Medicine (see under Georgia). 
Atlantic Medical College (see under Maryland). 
Autopsies at medical schools, 84, 88. 

BACTERIOLOGY, 67, 85. 

Baltimore Medical College (tee under Mary- 
land). 

Bardeen, C. R., 58 (note). 

Barker, L. F., 58 (note). 

Barnes Medical College (see under Missouri). 

Baylor University (see under Texas). 

Bellevue Hospital, New York City, 84, 110, 
131, 275. 

Bennett Medical College (see under Illinois). 

Bigelow, Henry J., 9. 

Billings, John S., 46. [26. 

Biology, teaching of, in medical education, 25, 

Birmingham Medical College (see under Ala- 
bama). 



Boards of medical examiners, state, 167-173. 
Bond, Thomas, 4, 7. 

Boston University (see under Massachusetts). 
Bowdoin College, Medical School of Maine 

(see under Maine). 
Brooklyn Postgraduate Medical School (see 

under New York). 
Budget of a medical school, 129-133. 
Buffalo, University of (see under New York). 

CABOT, R. C., 8, 99. 
California : 

University of California, Los Angeles, 115, 

121, 141, 189. 
University of California, San Francisco, 28, 

29, 72, 73, 119, 150, 192, 195. 
California Medical College, 120, 140, 190. 
Hahnemann Medical College of the Pacific, 

10, 159-161. 

Leland Stanford Junior University (Cooper 

Foundation), 28, 29, 72, 84, 114, 193, 196. 

Los Angeles College of Osteopathy, 164, 190. 

College of Medicine and Surgery, Oakland, 

82, 85, 115, 191. 

Pacific College of Osteopathy, 164, 166, 191. 
University of Southern California, 141. 
College of Physicians and Surgeons, Los 

Angeles, 12, 82, 188. 
College of Physicians and Surgeons, San 

Francisco, 39, 81, 86, 194. 
California, University of (see under California). 
California Medical College (see under California). 
Canada, proper distribution of medical schools 
in, 150. [souri). 

Central College of Osteopathy (see under Mis- 
Chattanooga, University of (see under Tennes- 
see). 
Chemistry, teaching of, in medical education, 

25, 26, 83, 87. 

Chicago, University of (see under Illinois). 
Chicago College of Medicine and Surgery, Val- 
paraiso University (see under Illinois). 
Chicago Ear, Eye, Nose, and Throat College 

(see under Illinois). 

Chicago Polyclinic (tee under Illinois). 
Cincinnati, University of, Ohio-Miami Medical 

College (see under Ohio). 

Cleveland Homeopathic Medical College (te* 
under Ohio). 



340 



INDEX 



Clinical teaching, 91-93, 102, 105, 111, 119. 
College work as preliminary to medical educa- 
tion, 23-28. 
Colorado : 

University of Colorado, 21, 39, 72, 107, 119, 

150, 197. 

University of Denver, Denver and Gross 
College of Medicine, 12, 39, 78, 81, 82, 88, 
113, 115, 118, 121, 141, 197, 199. 
Colorado, University of (tee under Colorado). 
Columbia University, College of Physicians and 

Surgeons (tee under New York). 
Cook County Hospital, 110, 218, 219. 
Conditions on admission to medical schools, 29. 
Connecticut : 

Yale University, 5, 8, 10, 28, 29, 38, 39, 72, 

111, 117, 118, 121, 134, 147, 199, 263. 
Cornell University (tee under New York). 
Cost of a medical education, 43. 
Cost of a medical school, 128. 
Creighton, John A., Medical College (tee under 
Nebraska). 

I ) \ i HOI-SIE University, Halifax Medical College 

(tee under Nova Scotia). 

Dartmouth College (tee under New Hampshire). 
Davis, Nathan Smith, 10. 
Delafield, Francis, 11. 

Denver, University of, Denver and Gross Col- 
lege of Medicine (tee under Colorado). 
Detroit College of Medicine (tee under Michi- 
gan). 

Detroit Homeopathic College (tee under Michi- 
gan). 

Didactic system of teaching medicine, 9, 22. 
Dispensary, 95, 96, 120-123, 160, 163. 
Dissecting, 84, 87, 88. 
Distribution of physicians, 15-18, 143-156. 
District of Columbia : 

Army Medical School, 202. 

George Washington University, 22, 31, 32, 

39, 112, 201. 
Georgetown University, 13, 39, 81, 82, 84, 

85, 139, 201. 
Howard University, 147, 151, 181, 202, 203, 

282 

Navy Medical School, 203. 
Divided medical schools, 72-75. 
Drake, Daniel, 7. 

Drake University (tee under Iowa). 
Dudley, Benjamin, 15. 



ECLECTIC Medical College (tee under New 

York). 

Eclectic Medical Institute (tee under Ohio). 
Eclectic medical sect, 158, 162, 163, 172. 
Eliot, President, 12. 

Ensworth Medical College (tee under Missouri). 
Epworth University (tee under Oklahoma). 
Examinations for admission to medical schools, 

31. 

FEES at medical schools, 44, 77, 81, 133, 137, 

166. 
Financial administration of medical schools, 

125-142. 

Flint Medical College (tee under Louisiana). 
Fordham University (tee under New York). 
Fort Worth University (tee under Texas). 

GEORGETOWN University (tee under District of 

Columbia). 

George Washington University (tee under Dis- 
trict of Columbia). 
Georgia : 

Atlanta College of Physicians and Sur- 
geons, 22, 37, 39, 85, 88, 203. 
Atlanta School of Medicine, 36, 85, 88, 204. 
University of Georgia, 10, 13, 36, 88, 139, 

141, 205, 207. 
Georgia College of Eclectic Medicine and 

Surgery, 120, 123, 204. 
Hospital Medical College, Atlanta, 123, 162, 

205. 

Georgia, Medical College of (see under Georgia). 
Georgia, University of (tee under Georgia). 
Georgia College of Eclectic Medicine and Sur- 
gery (tee under Georgia). 
German medical schools, cost of, 130. 
Grady Hospital, Atlanta, Georgia, 36. 

HAHNEMANN Medical College, Chicago, Illi- 
nois (tee under Illinois). 

Hahnemann Medical College and Hospital, 
Philadelphia, Pennsylvania (tee under Penn- 
sylvania). 

Hahnemann Medical College of the Pacific (tee 
under California). 

Halifax Medical College, Dalhousie University 
(tee under Nova Scotia). 

Harvard University (tee under Massachusetts). 

Hektoen, Professor, 66. 

Hering Medical College (tee under Illinois). 

High school development in the south, 40. 



INDEX 



Hippocratean College of Medicine (tee under 
Missouri). 

History of medical education, 52, 53. 

Homeopathic medical sect, 158-162, 172. 

Hospital Medical College, Atlanta, Georgia (see 
under Georgia). 

Hospital Medical School, 95-103, 106-120, 160. 

Howard University (see under District of Co- 
lumbia). 

Hubbard, Dr. George W., 181. 

ILLINOIS: 

Bennett Medical College, 33, 87, 88, 117, 

210, 216. 

University of Chicago, Rush Medical Col- 
lege, 28, 43, 72, 76, 107, 109, 114, 119, 
136, 178, 207, 217-219. 

Chicago Ear, Eye, Nose, and Throat Col- 
lege, 215. 

Chicago Polyclinic, 176, 215. 

Hahnemann Medical College, 82, 84, 118, 
120, 159, 160, 161, 214, 216. 

Hering Medical College, 112, 160, 161, 213, 
216. 

University of Illinois, College of Physicians 
and Surgeons, 12, 19, 38, 39, 80-82, 84, 85, 
109, 114, 140, 208, 217-219. 

Illinois Medical College, 7, 33, 87, 211, 216. 

Reliance Medical College, 33, 211, 216. 

Illinois Postgraduate School, 216. 

Jenner Medical College, 33, 87, 122, 176, 

211, 216. 

Littlejohn College of Osteopathy, 87, 165, 

214, 216. 

College of Medicine and Surgery : Physio- 
Medical, 36, 117, 122, 213, 216. 
National Medical University, 33, 86, 87, 

120, 212, 216. 
Northwestern University, 12, 28, 31, 39, 77, 

79, 84, 108, 109, 136, 144, 208, 217-219. 
Postgraduate Medical College and Hospi- 
tal, 215. 

Valparaiso University, Chicago College of 
Medicine and Surgery, 39, 81, 82, 117, 
209, 216, 221. 
Illinois, University of, College of Physicians and 

Surgeons (see under Illinois). 
Illinois Medical College (see under Illinois). 
Illinois Postgraduate School (tee under Illi- 
nois). 
Immigration in medical schools, 38, 39. 



Indiana: 

Indiana University, 28, 72, 75, 107, 119, 

148, 220. 

Valparaiso University, 221. 
Indiana University (tee under Indiana). 
Infectious diseases, teaching of, 117. 
Internal medicine, clinical teaching of, 92-96, 

106-124. 
Iowa: 

Drake University, 117, 121, 222, 225. 

State University of Iowa, 28, 72, 107, 135, 

149, 159, 223-225. 

Still College of Osteopathy, 165, 223. 
Iowa, State University of (tee under Iowa). 

JEFFERSON Medical College (tee under Pennsyl- 
vania). 

Jenner Medical College (tee under Illinois). 
Johns Hopkins University (tee under Maryland). 
Jordan, E. O., 59 (note). 

KANSAS : 

University of Kansas, 28, 72, 73, 114, 116- 

119, 122, 149, 226. 

Washburn College, Kansas Medical Col- 
lege, 10, 88, 116, 118, 141, 227. 
Western Eclectic College of Medicine and 

Surgery, 11, 122, 227. 
Kansas, University of (tee under Kansas). 
Kansas City Hahnemann Medical College (tee 

under Missouri). 
Kansas City Hospital, 6. 
Kansas Medical College, Washburn College 

(see under Kansas). 
Kentucky : 

University of Louisville, 34, 84, 115, 

229-231. 

Louisville National Medical College, 230. 
Southwestern Homeopathic Medical Col- 
lege, 161, 230. 

Knoxville Medical College (tee tMwfcrTennessee). 
Kuhn, Adam, 4. 

LABORATORY branches of medical instruction, 

71. 

Laboratory equipment, 85, 86. 
Laboratory instruction, establishment of, 11. 
Laval University, Montreal (tee under Quebec). 
Laval University, Quebec (tee under Quebec), 
Leland Stanford Junior University (w under 

California). [olina). 

Leonard Medical College (tee under North Car- 



342 



INDEX 



Lexis, W., 93 (note). 

Libraries at medical schools, 82. 

Licensure, examination for, 169. 

Lincoln Medical College (see under Nebraska). 

Lincoln Memorial University, Tennessee Med- 
ical College (tee under Tennessee). 

Littlejohn College of Osteopathy (see under Illi- 
nois). 

Long Island College Hospital (see under New 
York). 

Los Angeles College of Osteopathy (see under 
California). 

Louisiana : 

Flint Medical College, 181, 232. 
Tulane University, 30, 41, 77, 79, 82, 111, 
135, 142, 148, 231, 233. 

Louisville, University of (see under Kentucky). 

Louisville National Medical College (see under 
Kentucky). 

MAINE: 

Bowdoin College, Medical School of Maine, 
31,81, 116, 119, 122-124,138, 147, 170,233. 
Manhattan Eye, Ear, and Throat Hospital 
Postgraduate School (see under New 
York). 
Manitoba : 

University of Manitoba, 108, 150, 320, 326. 
Manitoba, University of (see under Manitoba). 
Marquette University (see under Wisconsin). 
Maryland : 

Atlantic Medical College, 39, 160, 161, 237, 

239. 

Baltimore Medical College, 39, 81, 236. 

Johns Hopkins University, 11, 12, 28, 37, 

38, 72, 76, 79, 83, 85, 100, 106, 107, 111, 

115, 121, 133, 134, 142, 143, 178, 234, 239. 

University of Maryland, 5, 38, 39, 43, 80- 

84, 107, 136, 236, 239. 
Maryland Medical College, 10, 39, 87, 237. 
College of Physicians and Surgeons, Balti- 
more, 39, 80-82, 84, 85, 107, 136, 235, 239, 
317. [118, 237. 

Woman's Medical College of Baltimore, 10, 
Maryland, University of (see under Maryland). 
Maryland Medical College (see under Maryland). 
Massachusetts : 

Boston University, 31, 82, 121, 138, 159-161, 

241. 

Harvard University, 5, 7-9, 11. 12, 28, 29, 
32, 38, 43, 47, 72, 76, 81, 109, 110, 121, 
134, 142, 144, 147, 151, 172, 240, 263. 



Massachusetts (continuf<l) . 

Massachusetts College of Osteopathy, 164, 

242. 

College of Physicians and Surgeons, Bos- 
ton, 81, 120, 172, 242, 262. 
Tufts College, 7, 31, 33, 37-39, 109, 110, 116, 

121, 136, 144, 151, 263. 
Massachusetts College of Osteopathy (see under 

Massachusetts). 

Massachusetts General Hospital, 5. 
McDowell, Ephraim, 15. 
McGill University (see under Quebec). 
Medical College of the State of South Carolina 

(see under South Carolina). 
Medical College of Virginia (see under Virginia). 
Medicine and Surgery, College of, Oakland, 

California (see under California). 
Medicine and Surgery: Physio-Medical, Col- 
lege of, Chicago, Illinois (see under Illinois). 
Medical School of Maine, Bowdoin College (see 

under Maine). 

Medical work in college course, 29. 
Medico-Chirurgical College of Philadelphia (see 

under Pennsylvania). 
Meharry Medical College, Walden University 

(see under Tennessee). 
Memphis, University of, College of Physicians 

and Surgeons (see under Tennessee). 
Memphis Hospital Medical College (see under 

Tennessee). 

Mexico, University of, 3 (note). 
Michigan : 

American Medical Missionary College, 119, 
211, 244. [245, 246. 

Detroit College of Medicine, 35, 86, 117, 
Detroit Homeopathic College, 122, 161, 246. 
University of Michigan, 21, 28, 29, 32, 37, 
39, 72, 74, 78, 100, 106, 109, 111, 119, 128, 
134, 135, 159, 160, 243, 244, 282. 
Michigan, University of (see under Michigan). 
Minnesota : 

University of Minnesota, 28, 37, 38, 43, 47, 

51, 72, 78, 85, 107, 112, 134, 247. 
Minnesota, University of (see under Minnesota). 
Mississippi : 

University of Mississippi, 73, 249. 
Mississippi Medical College, 10, 36, 39, 86, 

87, 120, 123, 178, 249. 

Mississippi, University of (see under M ississippi ). 
Mississippi Medical College (see under Missis- 
sippi). 



INDEX 



343 



Missouri : 

American College of Osteopathy, 119, 140, 

253. 

American Medical College, 11, 87, 123, 257. 
Barnes Medical College, 11, 81, 88, 109, 

122, 256. 

Central College of Osteopathy, 87, 252. 
Ensworth Medical College, 10, 82, 123, 254. 
Hippocratean College of Medicine, 86, 119, 

257. 
Kansas City Hahnemann Medical College, 

83, 252. 

Postgraduate Hospital School, 258. 
University of Missouri, 28, 37, 72, 75, 251. 
St. Louis College of Physicians and Sur- 
geons, 11, 86, 88, 115, 118, 122, 140, 256, 

258, 259. 
St. Louis University, 78, 79, 112, 114, 115, 

255, 258, 259. 
University Medical College, 87, 109, 117, 

251. 
Washington University, 106, 108, 111, 135, 

254, 258. 

Missouri, University of (see under Missouri). 
Morgan, John, 4. 

"Mortality" in medical schools, 37, 38. 
Museums at medical schools, 82. 

NUMBER of physicians, 13-18, 147-151. 
Nashville and Tennessee Medical Department, 

Universities of (see under Tennessee). 
National Medical University (see under Illinois). 
Navy Medical School, Washington, D. C. (see 

under District of Columbia). 
Nebraska : 

John A. Creighton Medical College, 22, 31, 
32, 80, 81, 83, 85, 88, 114, 116, 118, 151, 
260, 261. 
Lincoln Medical College, 12, 86, 120, 123, 

141, 260. 
University of Nebraska, 28, 72, 73, 113, 

119, 149, 151, 259. 

Nebraska, University of (see under Nebraska). 
Negro, Medical schools for the, 180, 181. 
New England, medical instruction in, 261. 
New England, number of doctors needed, 147. 
New Hampshire : 

Dartmouth College, 5, 39, 72, 116, 118, 123, 

124, 147, 170, 263, 264. 
New York : 

Brooklyn Postgraduate Medical School, 8, 
132, 176, 273. 



New York (continued) : 

University of Buffalo, 5, 19, 37, 39, 82, 1 14, 
123, 125, 138, 267. 

Columbia University, College of Physicians 
and Surgeons, 5, 8, 9, 11, 21, 32, 47, 72, 
74, 76, 84, 107-110, 112, 115, 121, 131, 

134, 268, 275, 276. 

Cornell University, 28, 29, 37, 47, 72, 75, 
76, 84, 109, 110, 115, 119, 121, 131, 134, 
178, 268, 275-27T. 

Eclectic Medical College, New York, 11, 
86, 87, 117, 122, 271. 

Fordham University, 28, 115, 270. 

Long Island College Hospital, 39, 80, 82, 
121, 125, 138, 266. 

Manhattan Eye, Ear, and Throat Postgra- 
duate School, 274. 

New York Homeopathic College and Hos- 
pital, 159-161, 272. 

New York Medical College and Hospital 
for Women, 115, 117, 160, 271. 

New York Polyclinic Medical School and 
Hospital, 174, 175, 274. 

New York Postgraduate School, 175, 273. 

New York University, University and Belle- 
vue Hospital Medical College, 11, 38, 39, 
79, 90, 109, 110, 121, 125, 126, 131, 134, 

135, 269, 275-277. 

Syracuse University, 28, 72, 79, 122, 137, 

272, 276. 

Union University, Albany Medical College, 

13, 80, 82, 112, 118, 121, 125, 138, 141, 265. 

New York Homeopathic College and Hospital 

(see under New York). 
New York Medical College and Hospital for 

Women (tee under New York). 
New York Polyclinic Medical School and Hos- 
pital (tee under New York). 
New York Postgraduate School (tee under New 

York). 

New York University, University and Bellevue 
Hospital Medical College (tee undtr New 
York). 
North Carolina : 

Leonard Medical College, Shaw Univer- 
sity, 138, 181, 280. 

University of North Carolina, 28, 279. 
North Carolina Medical College, 7, 22, 87, 

279. 

Wake Forest College, 72, 85, 280. 
North Carolina, University of (tee under North 
Carolina). 



344 



INDEX 



North Carolina Medical College (tee under 

North Carolina). 

North Dakota: [282. 

State University of North Dakota, 28, 72, 

North Dakota, State University of (tee under 

North Dakota). 

Northwestern University (tee under Illinois). 
Nova Scotia : 

Dalhousie University, Halifax Medical Col- 
lege, 19, 86, 88, 122, 139, 141, 150, 170, 
320, 321, 325. 
Number of medical schools, 6. 

OBSTETRICS, teaching of, 117. 
Ohio: 

University of Cincinnati, Ohio-Miami Med- 
ical College, 7, 283, 288, 289. 

Cleveland Homeopathic Medical College, 

122, 285. 

Eclectic Medical Institute, 11, 283. 

Pulte Medical College, 87, 140, 159-161, 

284. 
Starling-Ohio Medical College, 22, 81, 114, 

117, 118, 122, 136, 286, 288. 
Toledo Medical College, 5, 81, 86, 112, 115, 

140, 287. 

Western Reserve University, 28, 29, 47, 72, 
76, 90, 106, 108, 121, 126, 128, 151, 278, 
285, 288. 

Ohio-Miami Medical College, University of Cin- 
cinnati (see under Ohio). 
Oklahoma : 

Epworth University, 12, 117, 123, 141, 290. 
State University of Oklahoma, 86, 149, 151, 

289. 

Oklahoma, State University of (see under Okla- 
homa). 
Ontario : 

Queen's University, 39, 322. 
University of Toronto, 15, 30, 38, 41, 43, 
77-79, 108, 134, 150, 170, 178, 250, 282, 
323, 325, 326. 
Western University, 12, 13, 19, 35, 86, 117, 

123, 141, 150, 170, 322, 325. 
Oregon : 

University of Oregon, 39, 81, 84, 87, 122, 

139, 141, 151, 291. 
Willamette University, 12, 86, 87, 118, 120, 

123, 140, 292. 

Oregon, University of (tee under Oregon). 
Osier, Wm., 64, 95. 
Osteopathic medical sect, 158, 163-166, 172. 



PACIFIC College of Osteopathy (tee under