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A thesis on some medical subject and the passing a satisfacto.y examination before the faculty and the board of examiners will also be required.
A course of lectures in any recognized school will be accepted as one of the terms required by the college, but the last course before graduation must have been attended at this college.
(V.) CHANGES SUGGESTED. The subject of improvement in medical education is one which has occupied the thoughts of the profession for thirty years. The American Medical Association, ever since its organization, has paid special attention to this matter, appointing yearly committees on the subject, and printing report after report in its transactions. Somo of the most eminent names, living and dead, on the rolls of the profession have recorded their opinions on the subject, and the labors of many great physicians and surgeons for many years, in the lecture-room and the hospital, have been devoted to the practical training of the medical student.
Many valuable recommendations and many important improvements have during the present generation been made; but, notably, nearly all these improvements and recommendations have reference to the medical college, their departments of instruction, length of terms, text-books, practical anatomical and clinical opportunities, and only to a very limited extent with regard to preparatory or to post-graduate instruction. It is proper here to say that, in the writer's opinion, the most valuable recent suggestions in the American Medical Association have been made by the committees, of which Messrs. Chris. C. Cox, M. D., LL. D., Thomas Antisell, M. D., and A. B. Palmer, A. M., M. D., were chairmen.
For want of space, it will not be possible to separately mention recommendations heretofore made from those for which the writer of this article is responsible. In fact the scheme here presented is so little novel in most of its features, and most of its opinions have been so often expressed and indorsed by the voice of the profession, that it seems somewhat singular that more has not been practically accomplished.
And here it is proper to mention that no good can come from any attempt to revive any of the old legal discriminations between practitioners of different schools ; partly because scientific, like religious belief, should be perfectly free, and if a practitioner pleases his patients he always will be able to make a living out of them. The attitude of government in all such private mutual relations should be perfectly impartial; and it is questionable even whether courts of law should encourage suits for malpractice; because malpractice depends in most instances on ignorance, and the most certain and satisfactory prevention of it is reached by legally enforcing a thorough education. To this matter, however, further allusion will be hereafter made.
1. What, then, is the duty of the profession in regard to ante professional study? No medical college of high character in the country pretends to be satisfied with the qualifications of its matriculates in general. No eminent professional man in any of the systems denies that a good preliminary education is of the greatest advantage to a medical student; yet very little care is taken to train the faculties of observation, memory, and reason scientifically and thoroughly for the work they will have to do. The profession expects its students to read and remember many text-books; to see many cases with numerous and complicated symptoms; to administer many drugs of the most varied powers and applications in the most varied doses and combinations; and all this without any attempt to train his mind to see, compare, and reason on the facts. What part do mathematics and logic, the instruments for training the human reason, take in educating an ordinary practitioner? How many have been drilled in linguistics, so that their memory, their taste, and their power of selecting and expressing their ideas, bear any but the slighest comparison to the importance of their vocation? What provision is there in an ordinary medical course for becoming acquainted, to any useful extent, with any of the collateral sciences—the contiguous regions of nature tangential to the circle of human life! Practically none.
There should be required by every medical college, of every candidate for matriculation, that he shall have studied some definite length of time, and shall pass an examination in the following subjects: in the common branches, reading, writing, arithmetic, modern geography, English grammar, and American history; the college should also examine the candidate in, or cause him to study, as preliminary to examination, the elements of inorganic chemistry, natural philosophy, natural history, logic, and general history; and should see that he possesses an ability to translate and construe some author in Latin or French or German, and that he has a fair knowledge of the principles of drawing.
All this should be preliminary to the study of medicine proper. There is nothing that cannot be mastered in two years by any intelligent youth who has previously studied in a common school. There is nothing
demanded by it at all difficult of attainment in any decent high school or academy. Nor should it be at all difficult for any medical college to establish such a training school for the young men who will enter its subsequent instruction. It is needless to expatiate here on the advantage of such previous study. The University of Michigan demands more in some directions of its medical matriculates, and does not seem to lack students. Harvard Medical School places some knowledge of Latin and philosophy among its requisites for graduation, which means (or should mean) pretty much the same thing as requiring it as an item in the preliminary training, the three years' medical course being so filled with professional studies that it is practically impossible to study Latin also during that period.
2. The profession also owes it to itself, and the public which it serves, to see that the medical colleges of the country do thoroughly what they have undertaken. Three courses of lectures, of at least twenty weeks each, should be a qualification for graduation, in which anatomy, physiology, hygiene, therapeutics, organic chemistry, toxicology, medical jurisprudence, obstetrics and its collateral subjects, materia medica, surgery and physic, should be the branches taught, and they should be taught practically as well as by lectures.
Anatomy should be taught regionally as far as possible, and dissections of the part lectured on should be demonstrated from by the lecturer, and each dissection should be repeated by the class, under the supervision of the demonstrator, before the next lecture is delivered. Instead of discouraging the dissections by charging for each subject used in the demonstrator's room, the colleges should boldly demand a fee for practical anatomy, which will enable it to supply anatomical material to any extent demanded. This and the positive enforcement of dissections by every member of the class should be leading features in the revised system of medical education.
Physiology should be thoroughly illustrated by microscopic and chemical appliances, and by vivisections. Some time in each week should be devoted to a thorough written examination on the experiments and specimens exhibited by the lecturer, and the chemical tests used should be repeated by each member of the class personally before the lecturer.
Chemistry (after a rapid review of the inorganic portion) should be so taught as to mean something to the student, which it does not now. In fact, it is almost impossible to suggest amendments to a method of teaching so radically vicious as the way in which chemistry is ordinarily treated in our medical colleges. A knowledge of the inorganic part of our common text-books should be rigorously exacted before the student is matriculated. This should be reviewed by the class with experiments, and chemistry in its relations to physiology, materia medica, and toxicology taught in the amplest manner, and with all the necessary practical appliances. Every experiment by the lecturer should be repeated in his presence during weekly examinations, and ail important reactions should be tabulated by the class on the blackboard. The antiquated nomenclature so long in vogue should be abolished, and every effort made to convince the students that chemistry is really a vital part of the science of medicine. There should be a fee for this chemical instruction sufficiently large to justify the gratuitous supply of chemicals and apparatus, and, like the anatomical, it should be obligatory on every student.
Materia medica should be taught with the drugs before the students. They should be thoroughly instructed in their physical properties, uses and doses, and the method of preparing the various forms in which medicines are administered, their physiological and therapeutic action should be illustrated by experiments, and, when possible, by clinical instruction.
Hygiene should be thoroughly treated in all its relations to the morality and prosperity of communities and individuals, as well as with regard to its efficiency in the prevention and cure of diseases.
This division of the instruction should occupy the first course of lectures, and at the end there should be a rigorous examination of the class in the subjects so studied. It may be well here to remark that every examination at the end of a term should be conducted by a board of examiners chosen by some authority outside of the college; and the members of this board should be men of such reputation and so remunerated for their trouble as to make certain that their examination shall be deliberate, thorough, and impartial.
Having thus studied through one winter, the class during the succeeding summer should be directed to revise the subjects they have been taught. They should be directed to make themselves further acquainted with medical botany, to practice anatomical drawing, to familiarize themselves with the use of the microscope and chemical apparatus. They may be set under proper medical supervision to study certain portions of some subjects in the next course; as, for example, the mechanism of the female pelvis in relation to midwifery; the effects of muscular attachments in fractures and dislocations; symptomatology, especially as regards the pulse and tongue; general causes of disease; minor surgery and surgical appliances. The main point is, that explicit directions as to the use of his time should be given to every student. His reading thus has a definite object, and surely no one should know what the student ought to study so well as the professors who have had him in charge for several months. Much time is wasted in idleness or misapplied labor under the present system, which would, if properly employed, go far to complete the foundation for a good medical education.
During the second course of lectures, the class should have thorough instruction in the theory and practice of physic, surgery, midwifery, and female diseases, with a selection of illustrative clinical cases, not numerous in number, but so presented as to furnish the facts. It is true that almost any clinical instruction is better than none; but in no department of medical instruction is the old saying, “the half is more than the whole,” truer than here. One case carefully explained to and personally examined by a student is worth much more than a dozen seen by him in a crowd of listeners; à careful explanation, with the difficulties of the case in view, is much better for the student than many cases of the difficulties of which he has not become aware. selection, therefore, of clinical cases is recommended, and there should be weekly examinations on the subjects considered and the cases' exhibited. The use of medical, surgical, and obstetric instruments and appliances should be demonstrated on the cadaver as well as clinically. Surgical and pathological anatomy should be taught in connection with surgery and practice, if it be deemed inadvisable to teach them during the first course of lectures, and toxicology should receive attention.
After a thorough examination on the studies of the session, the members of the class should again receive explicit directions as to their reading.
During the third course of lectures special attention should be paid to clinical instruction in medicine, surgery, and midwifery; reports of each case seen should be required from every student; they should be exercised in diagnosis and treatment in practical midwifery, and, under the professor's directions, in minor surgery, if not in capital operations. Medical jurisprudence should be thoroughly taught, and something of the nature of the moot courts of the law schools would be a good 'training school for this branch of instruction. Lectures and clinics on diseases of the eye and ear should also be given. In short, every practical application possible should be made, and, at the end of the course, there should be a very thorough examination on the studies pursued, with a review examination in the studies of the two previous courses.
Having completed this study and passed the examinations, the candidates should be graduated with the degree of bachelor of medicine, and the degree of doctor should not be conferred till after at least three years' honorable praotice.
2. Duty of the State. The ruling power should have enough interest in this matter to insure the proper action; and this is, as before stated, not to discriminate between the different systems in existence, but to insist that every person, regular, eclectic, or homeopathic, who practices medicine or surgery shall have studied a specified time in a specified way, and passed specified examinations before boards selected by the executive. There might be common boards for most of the branches, and special boards for examination in materia medica and practice. The State law should specify the number, duration, and minimum instruction to be given by the medical colleges of every system alike. The degree of M. B. would then mean something more than that of M. D. does now. The public would feel assured that the practitioner of medicine was an educated man, whatever his theory might be, and the profession would gain in general culture, breadth of mind, and in the respect of mankind more than it would lose of the present kind of professional dignity.
In regard to the proper attitude of the courts toward the profession there could much be said. In many States there seems to be a disposition to encourage suits for malpractice against doctors, even when they are instituted as a means of extortion. Courts should be very careful in this matter, and it is hoped that the course pursued in the late case of “Walsh vs. Sayre” in New York will be hereafter generally adopted, and that the question of malpractice will be submitted to medical experts, leaving the amount of the damages, if there has been malpractice, to the decision of the court and jury, as at present. It is an outrage to expose the professional character and standing and the purse of a physician to the greedy assaults of unscrupulous men, leaving the decision of the question solely to a medically-uneducated jury.
It will be observed that medical colleges have not been directly addressed on the subject of this reform in education. As this is not an appeal to them, but an article for public perusal, it is perhaps not necessary to say very much in apology for this neglect. But in reality there has been a steady and totally ineffectual pressure brought to bear on the colleges by the better part of the profession for thirty years, in order to obtain better preliminary training, a lengthening of the lecture terms, or an increase in their number, and an enlargement and improvement in the subjects of instruction.
The medical colleges of the country are mostly joint-stock corporations, who furnish as little medical education as they can sell at the highest rate they can obtain. Their number is excessive, and the competition between them very keen. They are consequently disinclined to introduce any new features which may scare students of low acquirements away, or which may add seriously to the expenses of the institution.
Nor are medical students free from a large share of responsibility for the present condition of things. They are in such haste to graduate that they are impatient of
even the amount of instruction they are now forced to receive, and scores of men begin practice every year all over the country who have never heard a lecture at all, or, at the most, have attended but one course.
But the public, with a wise instinct, is beginning to say, in unmistakable language, that it demands a thorough education in its medical men. Let the members of tho profession call to mind how many of their brethren of late years have, after some years' study in Europe, gained almost instantly a remunerative practice.' What does this mean, except that the public is shrewd enough to believe that a thorough education, such as a man can get in Europe, is a better qualification for successful practice than the hurried and imperfect training he generally obtains here?
Brethren, let us gibbet the ignorance inside our profession as well as the quackery outside. Let us get over the idea that a man who butchers his mother tongue is good enough for a healer of mankind. Let us win from the intellects of men the consideration we used to demand from their manners. Let us add to the charity which blossoms in our hearts the knowledge that our work and our times demand. Let us train our minds for the consideration of the problems we have to study, as other professions are trained. Let us widen our intellectual vision and increase our material for thought. So shall the science of medicine, enlarged, purified, and triumphant, at last emerge from the conflicts of the schools above the petty jealousies of the hour, comprehensive and beneficent as the air.
CHAS. WARREN, A. B., M. D.
At the annual meeting of the American Normal Association, held at Cleveland, Ohio, August 15, 1870, the following papers were presented, and were very fully discussed, the
general doctrines of each being warmly approved. They were referred to a committee, to be reported upon at a future meeting of the association, with reference to action upon the plan presented by Professor Phelps. Having been kindly furnished by their authors-for the use of this Bureau, they are commended to the careful perusal of educators.
THE MEANS OF PROVIDING THE MASS OF TEACHERS WITH PROFESSIONAL
By S. H. WHITE, Esq., Principal of City Normal School, Peoria, Illinois. The most reliable statistics place the total number of teachers in twenty-three States, the omitted ones being Alabama, Arkansas, Delaware, Florida, Georgia, Louisiana, Mississippi, Nebraska, North Carolina, Oregon, South Carolina, Tennessee, Texas, Virginia, and the Territories, at 164,729. It is estimated that the number in the whole country is 200,000.
According to the report of the State superintendent of common schools of Pennsylvania for the year 1868–69, 15 per cent. of the teachers engaged for that year had had no experience in their work, and 15 per cent. more had had an experience of less than a year. Thirty per cent., then, of the teachers of that State are new to the work each year.
The opinions of other State superintendents have been asked upon this point. So far as they have been expressed, they are that from 10 to 50 per cent. of the teachers in their respective States are annually supplied from those who have had no experience.
It is probably safe to say that, taking all sections of the country into consideration, this number would be about 40 per cent.
The total number of pupils attending State normal schools for the year named is 5,884. In case all the students in normal schools become teachers, we have still 97 per cent. of the inexperienced teachers of the country entirely destitute of any instruction from State normal schools. From the best data available, it is estimated that the number of teachers receiving special instruction in city and private normal schools, normal classes, and by other means, is about equal to the number in the State normal schools3 per cent.
That ninety-four out of every hundred enter the ranks but slightly comprehending the laws of physical and mental growth, and of development in harmony with those laws, that they are entirely without any special preparation for the work before them, and that they have but slight appreciation of its magnitude and responsibilities, aré facts worthy the earnest attention of all who desire the highest development of our people.
Two questions present themselves for consideration:
I. Can the present system of State normal schools be extended so as to supply the want of trained teachers for the common schools? The annual expense of a school which will send out-not necessarily graduate--250 pupils, is from $15,000 to $20,000. Allowing that after States have become settled and their communities established, not more than 30 per cent. of the teachers change to other employments annually, the State of Illinois would need 24 such schools ; Michigan 12; Pennsylvania 20; Massachusetts 10. The annual expense of these schools would be, to Illinois not less than $360,000; to Michigan $180,000 ; to Pennsylvania $300,000; tó Massachusetts $150,000. However profitable such an investment might be to these States, it would be impossible now, or at any time in the near future, to persuade the people to make so large appropriations for this purpose.
II. Is it desirable that normal schools, as at present organized, should be so multiplied even were it possible? In the normal schools of Massachusetts, having a course extending through two years, about one-half the students complete the course ; in the Illinois Normal University, having a three years' course, about three-fourths of the students remain a year or less; in the Kansas Normal School about four-fifths of the pupils leave by the expiration of the first year. These institutions, the youngest of
, which has a history of five years, may be considered as fair representatives in this respect of the whole class of normal schools. May we not consider, also, that their experience indicates the situation and the urgent need of the great mass of the teachers of the country! Do not those needs point to a graded system of normal schools? If from one-nalf to four-fifths of the pupils in the well-established schools of the country do no more than complete the studies of one year, what is the advantage of establishing schools with a two or three years' course for them to attend ?
If only one-half to one-twentieth of the pupils entering a school complete the course, why should there be any greater than such a proportion of schools of the highest grade? It is apparent that the experience of the country demands the establishment of a system of normal schools which shall embrace in their course of study only branches taught in common schools, with some instruction in methods and school management.
It is quite useless to suppose that the large portion of the teachers of the country to which reference has been made, will be willing to devote more time to the preparation for their work.
It is urged then that the present system of State normal schools for the preparation of all teachers to teach is impossible, because of its expense to the State; because their course of study is not adapted to the circumstances of the great mass of teachers. It is claimed that a system of graded normal schools will more cheaply and more completely meet the wants of the great majority of teachers. In support of this claim the item of diminished expense to the individual may be urged. The necessity of many teachers too frequently interrupts that course of study for the purpose of gaining a living, forbids their traveling far to reach school, or being at great expense for board, &c., while there. If schools are established at points accessible, at short distances, where students can have facilities for obtaining supplies from home, these objections will be largely obviated. Each school would offer its advantages to an entirely different class of teachers without diminishing perceptibly the attendance upon another. About 80 per cent. of the pupils of the Massachusetts State normal schools live within twenty miles of their respective institutions. The same state of affairs is largely true in other States. Of the 69 pupils attending the Peoria County Normal School, in Illinois, during the past year, not more than two would otherwise have attended the State Normal University, about sixty miles distant.
Whatever the plan adopted, the preliminary steps of building, &c., should be as light as possible. A western educator conveyed a forcible truth when he said: “A Bunker Hill Monument, with a few school-rooms at its base, doesn't pay.
. If a debt is to be incurred, as is generally the case, it were better that the towers, the Mansard roofs, the porticos, &c., be omitted. If the money is in hand, it were better to expend it inside the building, in procuring libraries, means of illustration, and giving more liberal salaries to teachers. The expenditure of $250,000 or $300,000 to furnish buildings and grounds for a State normal school, is not securing the greatest amount of aid from the money. Every cap-stone to the tower of an extravagant school-house has prevented the laying of the foundation-stone to many less pretentious structures, of the same sort. The school should be fitted with accommodations for from 75 to 100 pupils. By the curtailment of the cost, what would have been expended in erecting one large and extravagant building, would suffice for from two to four smaller ones, with accommodations, in the aggregate, for at least double the number of pupils.
As has been already estimated, the course of study in these schools should be primary in character, embracing but little more than the studies required by law to be taught in the common schools. The fact that about 40 per cent. of the teachers of the country teach not more than a year, and then make some other occupation their pursuit for life, is convincing proof that they look upon the business of instruction as å mere make-shift, and that they will make no greater effort to fit themselves for it than public opinion requires. Let it be required of these teachers to thoroughly know