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Finally let us consider the statistics of the year 1889-90. One hundred and ten institutions have reported to this Bureau, 78 of which report definitely the number of students having a degree in letters or science or that they have no student possessing such a degree. In these 78 schools 15 per cent of the matriculates had obtained a degree before entering upon the study of medicine. The absolute figures are, 16 schools with no students enrolled who had obtained a literary or scientific degree, 62 schools with 1,382 students having a degree; total enrollment in the 78 schools, 9,389. Adding to the enrollment of the 78 schools the enrollment of the 32 which answer Don't know," "No data," etc., the total enrollment of the 110 schools reporting is 13,793. Comparing the enrollment in these 110 schools with the number of matriculates reported by the 78 schools as having degrees, the result is that 10 per cent of the enrollment in the medical schools of the country were possessors of a degree in letters or science. Considering the States by sections and including only the 78 schools which report 15 per cent of their matriculates having a degree in letters or science, it is found that 18 per cent of the matriculates in the medical schools of the North Atlantic Division had a degree in letters or science. 13 per cent of the South Atlantic division, 18 per cent of the South Central division (including Tulane University, estimated at 25 per cent), 9 per cent of the North Central Division, and 9 per cent of the Western Division. These figures show a diminution for the schools of the North and an increase for those of the South.
Considering the statistics of the cleven individual medical schools as before,
Harvard Medical School
College of Physicians and Surgeons (Columbia College) a
Medical department of the University of the City of New York.
a These figures are taken from the president's report for 1890. The medical department made no report on the blanks prepared for replies from such schools sent out by this Bureau. Average per cent.
From the foregoing statements it appears that there has been a slight reduc tion in the number of matriculates (17 in every 100 in 1881, 15 in 1890) at medical schools, who had received a degree in letters or science; while the statistics of the eleven departments of universities (where one would expect a large per cent of the matriculates to have obtained degrees) show that there has been an increase of but 1 per cent in the matriculates who had obtained a degree in letters or science. Indeed in the instance of the College of Physicians and Surgeons (the medical department of Columbia College) of New York City a decrease of 2 per cent is shown when the per cent of enrollment for the decade 1870-1880 (37 per cent) is compared with that for 1880-1890 (35 per cent); or comparing the per cent for the first half of the decade 1880-1890 with the second half, a reduction of over 3 per cent is shown.
The question, then, is: Has there been no improvement in the scholarship of the matriculates at medical schools?
The first of several questions asked on the form of inquiry sent out at the close of the school year 1889-90 was "Have you noticed during the last decade that the students of later years were in a scholastic sense better prepared to enter upon the study of medicine than those who preceded them?" Of the 86 "regular" schools reporting, 75 answer the question, 67 in the affirmative and 8 in the negative. Of 7 eclectic" schools only 1 answers "no." Of 13" homeopathic" schools, 12 answer yes, 1 fails to answer.
How are these facts to be reconciled? Statistics show that the number of matriculates having a degree is not increasing relatively to attendance (see
diagram 15, Chapter X), and yet the medical schools are almost unanimous in asserting that there has been an improvement in the scholarship of the matriculates. Is this unanimous report as to advanced scholarship to be attributed to an increased attendance at the secondary schools of the country? Are more graduates of high schools matriculating at medical schools? If we compare the attendance of secondary schools (exclusive of public high schools and departments of normal schools and of institutions for superior instruction) for 1880-81 with that for 1888-89 we find that there has been an increase in the attendance of schools for secondary instruction of 13 per cent. If we compare the attendance at the public high schools of one hundred and thirty-two cities in 1880-81 with the attendance in the public high schools of those cities in 1887-'88 an increase of 37 per cent is shown. Or, speculating upon the subject from the still more general standpoint of population and considering that the public high school is always a feature of urban life, it may be concluded that the increase of 7 per cent in urban population during the decade 1880-1890 has increased the high-school attendance of the country at large.
Some confirmation of the idea that the improvement in the scholarship of matriculates at medical schools is due to high schools is found in the great protest against secondary and collegiate education because it tends to overcrowd the learned professions, especially those of law and medicine. But a protest is entirely too insecure a foundation to build a theory upon. What is necessary is information as to the localities whence the matriculates at medical schools come, whether from towns and cities or from the rural districts, for public high schools with few exceptions are located in centers of population and rest on a system of grades beneath them from which they are fed. The public high school of the rural districts it should be said is, in many cases, the State normal school or agricultural college.
In examining the reports made to the Bureau some expressions are found that corroborate what has been suggested above. A medical school of California, in answering the question as to a better scholarship, answers, "Decidedly so," and adds:"18 had attended universities, academies, or colleges, 12 were graduates of high schools, 17 were graduates of State normal schools, or held educational diplomas or first-grade certificates, and 40 passed examinations." A southern school, in denying improvement, adds: "The common-school system has destroyed the private schools, and only an elementary education can be had outside." (There is no normal school in this correspondent's State.) The medical department of a celebrated university of the Northwest replies: "Our students average far better now than formerly, as nearly all who enter now [who are not possessors of a degree] are graduates of high schools;" while one of the foremost universities of the Southwest reports in the affirmative, adding, "many oour matriculates being graduates of high schools or universities." A college of Ohio makes a very striking answer in saying: "Yes, as to students who entef under 25 years of age; no, as to those over 25 years; " and a Southern collegr answers: "I have noticed an improvement in this respect, but it must be rememe bered that the students from the South now seeking admission to our colleges received their education (literary) during the decade following the war when educational matters were chaotic."
Of 110 schools, 88 answer the question: "Has the average age of matriculates advanced?" Two-thirds of these answers are no, and 10 of them say the average has diminished. The Hospital College of Medicine (Central University) reports the age of seniors in 1880 as 26, in 1885 as 28, and in 1890 as 27. One college reports "age diminished; mental caliber advanced."
THE CHARACTER OF THE CHANGE IN THe course DURING THE DECADE AS REPORTED BY THE DEANS OF THE SEVERAL SCHOOLS.
In reply to a general question as to the character of the changes during the decade in the medical curriculum, especially in regard to practical instruction, onefourth of the schools answer "no change," or ignore the question. The general tenor of the affirmative responses may be classified under two heads, to wit, increase of the time devoted to the study of medicine, and increase in the time devoted to laboratory and chemical instruction. The answers as to the time devoted to study may be classed under two heads, one class of answers showing a very decided movement to increase the course from two to three years and to grade it, and the other a tendency to prolong the session from five or six to eight months. The replies indicate a strong tendency to introduce laboratory instruction, chemistry and histology being the subjects most frequently mentioned. Clinical in
struction also appears to be a subject in which improvement has been made. Entrance examinations, higher requirements for graduation, and recitations from text-books are only mentioned four or five times in each case. It is not to be supposed that all these subjects should occur to the gentlemen who answered the inquiry as they read the question on the blank. One thing would suggest itself to one and another to another. What appeared to each at the moment as most important was jotted down in all space allowed for the answer. It is, therefore, surprising to find so many, though relatively few, answering the question in the same way.
With this preliminary view of the character of the advance during the decade, and a reference to the summary of the condition of medical instruction in 1881, let us attempt to ascertain its condition in 1890.
The first question that naturally is asked is, "What is considered to be a good preparation for admittance to practice medicine?" The regulations of the U. S. Army require the candidate to pass in the following subjects:
I. The physical examination will be rigid; and each candidate will, in addition, be required to certify that he labors under no mental or physical infirmity, nor disability of any kind which can in any way interfere with the most efficient discharge of any duty which may be required."
II. Oral and written examinations on subjects of preliminary education, general literature, and general science. The board will satisfy itself by examination that each candidate possesses a thorough knowledge of the branches taught in the common schools, especially of English grammar, arithmetic, and the history and geography of the United States. Any candidate found deficient in these branches will not be examined further. The examination on general science will include chemistry and natural philosophy, and that on literature will embrace English literature, Latin, and history, ancient and modern. Candidates claiming proficiency in other branches of knowledge, such as the higher mathematics, ancient and modern languages, etc., will be examined therein, and receive due credit or their special qualifications.
III. Oral and written examinations on anatomy, physiology, surgery, practice of medicine, general pathology, obstetrics and diseases of women and children, medical jurisprudence and toxicology,, materia medica, therapeutics, pharmacy, and practical sanitation.
IV. Clinical examinations, medical and surgical, at a hospital, and the performance of surgical operations on the cadaver.
Due credit will be given for hospital training, and practical experience in surgery, practice of medicine, and obstetrics.
The Illinois board of health, so well known by its activity in investigating the value of medical diplomas, has a schedule of minimum requirements of ten subjects-anatomy, physiology, chemistry, materia medica, and therapeutics, theory and practice of medicine, pathology, surgery, obstetrics, and gynecology, hygiene, and medical jurisprudence.
But these curricula are a mere framework, so to speak, to be clothed with flesh according to the taste and conscientiousness of the instructors and examiners. Nor is the order indicated in which these special studies should be pursued, much less the reason why they should be pursued at all. If we turn to France we may obtain some information on both these points.
It is well known that professional instruction in France has been remodeled during the last ten or twelve years. The reform began with the schools or faculties of medicine, and in 1878 the following decree was issued by the minister of public instruction:
ARTICLE 1. The course of study leading to the degree of doctor of medicine lasts four years. Of this period the first three years may be spent in the faculties' [i. e., schools taught by the faculty using that word in our sense] or in the schools of full exercise [i. e., schools taught by a corps of instructors who can not grant degrees], or in preparatory schools of medicine and pharmacy [i. e., those which only educate for an inferior grade of physician or pharmacist]. The studies of the fourth year can only be pursued in a faculty or a school of full exercise.
"ART. 2. * * * The student undergoes five examinations and sustains a thesis. The second, third, and fifth examinations are divided into two parts. Examinations at the end of each year are suppressed.
"ART. 3. The five examinations are as follows: First, physics, chemistry, medical natural history. Second, part 1: Anatomy and histology; part 2: Physiology. Third, part 1: Surgery, accouchements, operative medicine; part 2: Medicine (pathologie interne), general pathology. Fourth: Hygiene, medical
jurisprudence, materia medica, and pharmacology. Fifth, part 1: Surgical and obstetrical clinics (clinique externe et obstétricale); part 2: Clinical medicine, practical evidence of work in pathological anatomy (clinique interne, épreuve pratique d'anatomie pathologique).
Thesis: The candidate sustains this test upon a subject chosen by himself. "ART. 4. The first examination comes off between the fourth inscription and the fifth [i. e., after 12 or 15 months of study]; the first part of the second examination between the tenth and twelfth inscriptions and second part between the twelfth and fourteenth inscriptions. The third examination can not be taken before the expiration of the sixteenth trimonthly period of study. Every candidate who shall not have passed the first examination by November at the latest shall be adjourned to the end of the year and can take no inscription during the course of that year.
ART. 5. Candidates for the doctor's degree, the students of the schools of fulbexercise and the preparatory schools, are examined before the faculties at the times stated in the preceding article; the first examination, however, may be taken, after the twelfth inscription. In such cases they must stand both parts of the second examination before taking the thirteenth inscription, but the student following this course is subjected during each semester beginning with the second year of studies to interrogations the results of which are transmitted to the faculties that they may be considered in the final examination for the degree.
ART. 6. The inscriptions for the degree of officer of health (the lower medical grade) shall in no case be converted into an inscription for the doctor's degree. This conversion, however, may be authorized in the case of officers of health who have practiced medicine during two years at least.
"ART. 7. Practical work in the laboratory, dissection, and hospital attendance are obligatory. Each annual period of work in the laboratory, and in dessecting covers a semester. The hospital attendance (le stage près des hospitaux) shall be two years at the least."
When satisfied that an attempt at reform is not merely a whim or the ignorance of the reformer, the intelligent inquirer immediately asks to know the grounds upon which the change is made. What then is the motive that has induced the French legislature to modify the law of 1803? M. Wurtz,' as a member of the superior council of public instruction, gives several in reporting on the desirability of adopting the provision contained in the above decree. His remarks are in brief as follows:
The old law of 1803 prescribed that an examination should be made at the end of each of the first three years of the course (without value in obtaining the degree however), and then five examinations more when the fourth and last year of study had been completed. In 1825 the examinations at the end of the year were abolished and the five final examinations distributed through the course of four years. But this was found to bring the examinations too near together and to cause the student to slight his studies (la scolarité était abrégée), inasmuch as the most important examination (on clinical surgery and medicine and accouchements) was put off until the last year. This caused a new regulation in 1816, which, rejecting the examinations for the degree at the end of the whole course, instituted examinations at the close of each year. Although these annual examinations kept the student busy, thirty years of experience had shown their weakness as tests of capacity and as a means of discipline. The object in drawing the above law was to divide the four years of study into periods, in such a manner that each period would be devoted to several related subjects and could be closed with a test examination on those subjects.
The question then became a purely pedagogic one. In what order should the periods follow each other? The degree of bachelier ès lettres testified to the medical student's literary qualifications, and the modified degree of bachelier ès sciences testified to his proficiency in the natural and physical sciences. Should the student, possessing such intellectual maturity and such knowledge of those sciences which are the necessary introduction to the study of medicine, proceed immediately to the study of anatomy and physiology, which are the foundation of med cine? No, says M. Wurtz, the medical student must study physics, chemistry, and natural history in a course that is neither a repetition nor even a development of his scientific studies in a lycée. The student is now to study these subjects as applied sciences, and to them he is to devote one year.
Dean of the Paris Faculty of medicine from 1866 to 1874, member of the institute, professor of chemistry at the Sorbonne, senator of France, etc., etc.
But will one year fix these subjects indelibly, especially if the first examination is the only one upon them? This was precaution the old programme had taken by keeping up the examination on physics and chemistry to the end of the course. But what followed? The first examination was frequently weak; the students were careless and the examiners indulgent; while towards the end of the course it was intolerable for the student to take his mind from his proper professional work to rectify the neglect of the first year of his course. The new programme attempts to remedy this, says M. Wurtz. The applications of the sciences to physiology, to hygiene, and to pathology [subjects of the second and third examinations] have now become so important, that it is easy to introduce in the programmes corresponding to the examinations many questions touching the application of pure science to the subjects of these examinations.
To prevent crowding the programme of the examination-a fault of the old examination scheme-an innovation was made which is the distinguishing characteristic of the new one. The second, third, and fifth examinations are divided into two parts. In the middle of the third year of the course, and eighteen months after the first examination, the candidate undergoes the first part of the second examination; at the close of the third year he undergoes the second part, after taking the twelfth inscription. In the second part of this second examination the chemistry of digestion, respiration, nutrition, composition of the blood, etc., is studied, as also the physical phenomena of hearing, seeing, and respiration as a source of heat, all very much specialized, it is true, but fruitful because of the solid foundation laid in the first year. The division of the two professional examinations, in the practical sense of the term-the third and fifth-was demanded by the faculties of medicine; for it was thought that it was too much to ask that both parts of these examinations be taken in immediate succession. It was found that under the old scheme mediocre candidates would neglect one part of the examination and prepare for the others, counting upon the benevolent intervention of an easily satisfied examiner and the indulgence of the others.
But there is another position from which the subject of teaching may be viewed. At an early meeting of the French society for the study of subjects related to higher instruction the question "of what faculties should a university be composed" was formally put to the society by its president. Dr. Le Fort, of the celebrated faculty of medicine of Paris, on this occasion, after stating the views of his faculty as far as the matter related to the faculty of medicine, proceeded to express his own, as follows:
"The place to study medicine is in the hospital and only in the hospital. Some medical savants devote themselves to laboratory study. Nothing can be better. But for the physician, who should above all things learn to care for and, if hə. can, cure his patients, the only school is the hospital. There may be courses in hygiene and medical jurisprudence, but there can be no theoretical course in medicine, none in surgery; there is only a course of clinics, and the professor at the same moment teaches the students the theory (of which they have obtained the principal notions from the books) and the practice."
Dr. Le Fort, speaking for himself and not for the faculty with which he is connected, may have been induced to speak so very practically in view of his opposition to bringing a faculty of medicine under the control of a contemplated "University Senate:" but it can not be denied that public opinion is with him. His position seems to be, to judge from his remarks, that instruction in medicine consists of two operations-getting the principal notions out of the books ad seeing practical work done and hearing it explained at the hospital.
It is quite supposable, however, that the curriculum of a medical school has the especial object to assist the student to obtain the principal notions from the books and to obtain them correctly. At all events, we shall assume that in America the original intention of the lecture course was to perform this service (generally imperfectly performed by the physician under whom a student has been placed), that by degrees, where possible, the hospital became the field for professional sight-seeing, and in many cases a good deal more, and that during the last decade the laboratory has been added to the instruction of the lectureroom and the clinic, as the biologist opened up a science of histology.
In conducting the following inquiry, as to the curriculum, then, three points will be considered. The manner in which the student obtains the "principal notions" of medicine from the books, clinical instruction and dissecting, and laboratory work. The curriculum of the schools having a graded course will be used as best adapted to the purpose in hand.