« AnteriorContinuar »
Beyond the ability to read the printed page, which may in a measure be a mere mechanical operation, certain intellectual attributes are requisite for getting the principal notions out of the books. In the first place (presupposing a logical arrangement of the text-book) it is highly advantageous for the student to have attained an intellectual maturity sufficient to enable him to understand the system on which the text-book writer has arranged his matter, and, in the second place, the mental alertness to recognize the parts of the arrangement and their relations as they are filled in, so that what is material may be given the study due to its importance and the lesser matters be noted as such. Perhaps not less important in this process of getting the ideas of an author out of his book and into one's own head is a cultivated perception of the meaning of phrases and sufficient continuity of thought to carry a term, or phrase, or sentence in the mind until the idea it contains as an isolated part of the discourse has been reduced to its proper value by the modifying phrases or sentences which generally accompany the principal part of a sentence or of a paragraph. Thus we see why in some quarters so much stress is laid on a thorough literary education as a preparation for the study of medicine. Even during the eighth decade of this century, when the theoretical or literary science of the class and lecture room had reached its maximum and was soon to begin to give way to laboratory instruction, the well known German evolutionist, Prof. Ernst Haeckel, could say from his own experience that "in comparing graduates of classical colleges (Gymnasien) and those of scientific colleges (Realgymnasien), I have always observed an intellectual superiority in the former, despite their defective knowledge, and have even found during the teaching of my own specialty, zoology, that the former enter more easily into the higher and more general problems of science than the latter. I am, therefore," he continues, "against the admission of Realschul graduates to the medical schools (faculties), and I base this conclusion on my own experience."1
But since the distinguished professor wrote these words a new class of medical schools has arisen in America. At the beginning of the decade there were three or four courses of study whose object was to prepare the student for the study of medicine. The course covered two years, and was chemical and biological in character. At Cornell the student intending to pursue a preparatory medical course was advised to secure a degree in letters or science; at Johns Hopkins the course led to the bachelor's degree (A. B.). To-day we find three or four times as many such courses, as will be shown later on. In the mean time let us examine into the manner in which the student (much the larger number) who has neither the experience of the preparatory school, or the ability to collect, digest, and formulate his knowledge given by higher literary education, is instructed by the American medical colleges.
Until comparatively recently the method of didactic (i. e., nonclinic) instruction, called repetitional, held almost undivided sway. The essence of this system of instruction is the well-known pedagogical-that is to say psychological-fact that repetition and attention are the most important elements in the acquisition of knowledge. The application of this not very obscure principle of pedagogy to medical instruction was made this way: There were so many "didactic" professors in the school. Each of these gave the same course of lectures every year. The student listened to them during his first year and again during his second year, and had he attended a third year he would have heard them for a third time. This system has been severely criticised during the ten years past. It has, especially of late, been rapidly giving place to the graded or progressive course, which can not be finished in a single year by a well-prepared, intelligent, and laborious student, as at a celebrated southern university. But it is instructive to hear what may be said for the repetition principle by a department of a large university of the northwest, which sought to retain the
1 To the same effect Dr. Zarncke, professor of modern languages and literature, when dean of the faculty of philosophy of the University of Leipzig, says: There is a second view, which I call the pedagogic view. There is no better means of training the mind than the thinking and observing that the study of the classic languages necessitates. There is something mysterious in this result, and still an experience of many years has confirmed it. I am a member of two examining boards, one of which examines young men who have received their training in a gymnasium on a classical basis, while the other young men are without this foundation. The latter are very often superior to the former in information (Kenntnissen), but when mental maturity is tested by written work the graduates of the gymnasium surpass those of other schools to such a degree that a comparison can scarcely be instituted."
repetition feature in conjunction with a progressive course of three years. This defense is as follows:
"The course of instruction consists of three collegiate years of nine months each. The work of the course is systematically arranged, and so graded that the more elementary branches and the practical courses are first taken by the student, while the more advanced courses and theoretical subjects are presented later in the course, so as to secure, as far as practicable, an orderly succession of studies; while the more fundamental subjects are presented a second time during the course, so as to secure a more perfect comprehension of their principles and relations, and to fix the facts more firmly in the mind. The hours of the required lectures are so arranged that but few are given at the same time, and every facility is afforded for students to attend the repetition of the principal lectures as often as may be thought profitable. The faculty recognize, what is evident in the experience of all medical students, that attendance upon lectures on the same subject a second time, after other related branches have been studied, is much more interesting and profitable than the first; and hence they require students to attend lectures on all the leading subjects more than once.
In the catalogue giving the reorganized course of four years, however, nothing is said of the repetitional features.
But more particularly to facilitate the comprehension of the text-book matter and impress the principal notions which it contains, two methods have been adopted in America in addition to the "didactic" lecture. These are the recitation and the "quiz," neither of which are employed in the schools of university grade in Europe. Indeed, in America the lecture system may be said to be gradually becoming complementary to the text-book, just as in Europe the seminarium or conference is becoming supplementary to a course of lectures. Thus we are informed by the Yale Medical School that "in reorganizing the school as an integral part of Yale University in 1884, the inherent defects in the older and still common method of instructing chiefly by didactic lectures were recognized and the methods now employed are similar to those in vogue in the other departments of the university. Didactic lectures are still employed as best in some branches, but recitations from assigned readings, with explanatory lec.ures, laboratory work, and personal instruction in the clinics constitute the main portion of the curriculum." At the Albany Medical College it is believed that instruction by recitation is as essential in medical as in literary colleges, and the faculty have greatly enlarged and extended this department of the teaching in this college. The recitations, which have hitherto been held during unoccupied hours in the evening, are now made part of the regular curriculum. Every study taught in the college by lectures is also made the subject of recitations, the ratio of the number of lectures to that of recitations being in general two to one.
The Long Island College Hospital, having the old system of lecture courses, has adopted a reading and recitation term, which begins at the close of the regular term and continues until June. It is designed to thoroughly prepare the student for attendance on the lectures of the ensuing regular term. Clinical instruction for advanced students is continued during the reading and recitation term. As the laws of the State of New York require three years' study of medicine, students are advised to commence their study at the beginning of the reading and recitation term.
The daily and weekly quiz appears to be but a modification of the examination at the end of the year or term without the breadth or formality of that ancient contrivance for testing the memory of the student or his ability to grasp the idea expressed by the words in the examination paper before him. At the University of Virginia it has been found that "the daily oral examinations on the subject of the previous lecture are of great value in stimulating the student to regular and systematic habits of study, and furnishing the professor an opportunity of discovering and removing the difficulties met with by the st dent." At the Medical College of Alabama still stronger language is used in favor of these daily oral examinations, and it announces that "so important is this method of impressing the leading facts considered in the lecture hour, and so useful is this method of instruction in obtaining systematic and accurate information considered, that members of the faculty will, after the middle portion of the term is reached, establish a daily quiz, which will be so arranged as not to interfere wi h any lecture or other duty, and will be of great interest, especially to those who contemplate applying for graduation."
As medicine principally deals with diseased conditions of the human body in an effort to restore it to health, it is not difficult to illustrate the lecture on anatomy, physiology, surgery, and even the practice of medicine by demonstrations,
specimens, models, and charts, and in this way even the "didactic" lecture has a semb ance to the clinic. Without dwelling further on the subject of the didactic lecture, we now pass to the clinic, which must be treated with equal brevity.
In his Life of Macaulay, Trevelyan gives an extract from his uncle's diary in which the historian gives the argument by which he dissuaded the Prince Čonsort from attempting to give the English universities a Continental form by introducing a faculty of medicine. Macaulay explained to the Prince the great difficulty there would be in getting distinguished physicians to exchange a princely revenue in London for the salary and retirement of a university professor at Oxford or Cambridge.
But there is another reason of still greater importance for locating a first-class school of medicine in a large city. The workingman feeds the hospital, and to enable a faculty of medicine to exist a great industrial center is necessary." This sentiment is supported by the testimony of the Harvard Medical School, which says that it was established in Boston in order to secure those advantages for clinical instruction and for the study of practical anatomy which are found only in large cities.
Practical instruction in medicine may be classed under two heads: There is, first, the nonpathological form, which goes by the name of dissection, and, second, the clinic, which may be subdivided into three forms, in one of which the subject is operated on in the amphitheater before the class; in the second the class, or a portion of it, is taken to the bedside, and in the third the advanced student acts as a physician or as an assistant.
The amount of work required in dissection is not uniform throughout the country and is still less uniformly stated. From 91 schools whose catalogues mention the work in dissection required for graduation, the following information has been obtained :
Must produce evidence of attendance in practical anatomy
Must present certificate that necessary dissections have been made.
A satisfactory course in practical anatomy..
Must produce evidence of having been adequately engaged in study of practical anatomy
The modification of the didactic lecture by the previously "assigned reading" by the Yale Medical School has been noted; it would appear that the method in vogue there for studying the framework of the human body is no less complete and systematic. This system of instruction in anatomy is as follows:
"As in the other fundamental branches of medicine, the instruction in anatomy is chiefly by means of recitations and laboratory work. The course extends through two years, with examinations at the end of each year. At the beginning of the course each student is provided with a box containing all parts of the skeleton for home study, and during the first term two weekly laboratory lectures are given on osteology and syndesmology, alternating with recitations from the text-book. After a thorough knowledge of the bones, ligaments, and muscular attachments has been obtained, the student enters upon laboratory work on the soft parts, in which eight hours weekly are required until the dissection of all parts of the body has been made. Preparations of the different Le Fort, at the meeting of the Parisian group of the Society for Higher Instruction in France.
parts are made, showing muscles, arteries, and nerves, satisfactory demonstrations of which must be given before the professor at their completion. Preliminary to the dissection of the human body, a brief laboratory course is pursued in the anatomy of the cat. All laboratory work is under the immediate instruction of the professor. The written examination at the close of the year is upon osteology, syndesmology, and the trunk viscera. The instruction the second year is by alternating lectures and recitations, and includes the remainder of systematic anatomy, with topographical and superficial anatomy, illustrated by preparations, models, and several hundred lantern slides."
At the University of Virginia the course in dissection appears to be carried out with equal thoroughness. "For the course in practical anatomy, dissecting material, obtained under the permissive law of the State, is abundantly supplied without cost to the student. Each medical student, however many sessions he may have attended, is required to dissect under the constant and careful supervision of the demonstrator. Attendance in the dissecting room is compulsory, a strict record being kept in the case of each student. Besides the oral examination which precedes each lecture, and the other examinations, each student is required to stand seven practical examinations, one upon osteology, four upon different parts of the muscular system, one on the viscera, and one on the vessels and nerves. These examinations are oral and private, each student being examined alone. They consist of the identification of the truths of anatomy on the bones, the cadaver, and the dissected cadaver, and are thus a perfect test of the student's acquaintance with the gross structure of the human body."
As the attendance at neither of these schools is large as compared with the attendance at the schools of Philadelphia, New York, and Chicago, the following course of dissection may more nearly represent what the great schools can do and the average school does do.
During each session every student of the first and second classes will be required to dissect all regions of the human body. The first dissection of a region will be mainly of the nature of a preliminary study, the student being required to examine the attachments and relations of muscles and the general course and situation of the great vascular and nervous trunks. The second dissection of a region will be as exhaustive as it is practicable to make it, all the structures being as completely displayed as the time at the disposal of the student will allow. The demonstrator of anatomy will examine the students from time to time during the progress of their dissections, and, if he finds that they have not properly displayed the structures or have no accurate knowledge of the parts dissected, he will require a new dissection of the same region upon another subject. He will certify to the professor of anatomy the satisfactory completion of each dissection. It is recommended to students of the third class that they perform upon the cadaver such surgical operations as may be practicable, such as ligations of arteries, amputations, etc. Material for this purpose will be furnished. Dissecting will commence October 15 and continue until the following March. The room will be open daily for students and the demonstrator or his assistants will be present. During the session there will be given special demonstrations of the brain, of the thoracic and the abdominal viscera, and also of other difficult or obscure regions of the body. The demonstrator and assistants will have general supervision and direction over all students while in the dissecting room. In two schools with very large attendance a rather novel course is pursued in aiding the student in his study of osteology. Instead of providing him with a complete skeleton, as at Yale, individual bones are loaned the student, as books are loaned at libraries. At the Columbia College school this "new and useful feature" is transacted in the "bone-room," where a large number of disarticulated skeletons are kept under an ostelogian, it is presumed. In the other school, the celebrated medical school of the University of Pennsylvania, the "bone-room ' is dignified by the technical term Osteo-syndesmological Laboratory.
Upon the question of clinical instruction the medical fraternity agree: Clinical instruction is necessary to fit the student for the practice of his profession. Following out this conclusion, a class of hospitals has arisen which in the strictest sense are clinical. In some cases hospitals have been attached, as it were, to a college, as in the case of the medical department of the Tulane University of Louisiana and the School of Medicine of the University of Maryland. In others the hospital has founded a school, as in the case of the Bellevue Hospital Medical College and the Woman's Medical College of the New York Infirmary, and in others the school has founded a hospital, as in the case of the University of Pennsylvania, of Michigan, and of Wooster; of the Jefferson Medical College and Medico Chirurgical College, both of Philadelphia; the Long Island College
Hospital, and of the homeopathic medical colleges and hospitals of New York and Philadelphia. As a general introduction to the programmes of clinical instruction which follow, the opinion held by the faculty of the Tulane University medical department will be used as expressing the views of every reputable school. "It is universally admitted that, without abundant anatomical and clinical material, no medical school, however numerous or eloquent its professors, can possibly fit its pupils for practical professional life. It is scarcely necessary to state that it is only in large cities that such advantages can be procured; but it is of paramount importance that the opportunities there afforded should be properly utilized; that the students should be required, under the direction of the teacher, to examine patients for themselves, to keep record of cases, to note daily changes which may occur, and thus acquaint themselves by personal observation with the progress and termination of diseases and accidents. The mere introduction of a patient into an amphitheater and the discussion of his case by the professor in the presence of a large class are no substitute for bedside instruction, and no reduction of lecture fees, not even their entire abolition, can possibly compensate for the lack of such opportunities."
In the medical department of the University of the City of New York, a very largely attended school, the graduating class is divided into sections of about twenty-five each, which receive separate instruction for one or two hours daily throughout the term. This instruction is under the immediate direction and management of nine professors and is carried on partly in the wards of Bellevue Hospital and partly in the college building. The students receive practical instruction in operative surgery upon the cadaver, in the examination of medical and surgical cases for the purpose of diagnosis, in the application of dressings and apparatus, and in the use of the laryngoscope and ophthalmoscope. In the hospital, students are taken to the bedside of the patient and are exercised in making diagnosis under the direction of the instructor, and in dressing wounds, and are enabled to watch the progress of cases. In the dispensary they have similar opportunities to become familiar with the methods of diagnosis, the treatment, and the course of those diseases which do not require confinement in bed. "The success of this system of instruction," says the faculty, "has been very marked in the past, and it has given much satisfaction to both students and teachers; it enables the students to become practically familiar with many of the things which they have learned from their text-books or in the lecture room, to cultivate their powers of observation, and to aid their memory. The importance which the faculty attaches to it is shown in the fact that it involves an increase in the time given to instruction of more than twenty hours each week."
To the same effect the School of Medicine of Columbia College speaks of the recent founding of the Vanderbilt Clinic and Sloane Maternity Hospital, as branches of the school, as being especially beneficial in enabling the school to organize a system of practical clinical teaching, whereby each member of numerous small classes may be brought into direct personal contact with the cases under examination. This teaching takes the following form under the title of "Practical Clinical Instruction:"
General medicine.-Diagnosis, including so-called physical diagnosis, and treatment. General surgery.-Diagnosis and treatment, including minor surgery, bandaging, and the application of antiseptic dressings.
Midwifery.-Attendance upon cases of labor at the Sloane Maternity Hospital by advanced students, under the direction of the obstetricians of the hospital.
Gynecology.-Practical instruction in diagnosis and treatment, including the use of instru
Diseases of children.-Diagnosis and treatment.
Diseases of the genito-urinary organs.-Diagnosis and treatment.
Diseases of the nervous system.-Examination of cases, including electrical tests; diagnosis and localization of lesions; electro-therapeutics.
Diseases of the skin.-Diagnosis and treatment.
Diseases of the eye.-Diagnosis, including the tests for errors of refraction and accommodation, and the use of the ophthalmoscope, and treatment.
Diseasees of the ear.-Diagnosis and treatment.
Diseas 8 of the throat.-Diagnosis and treatment, including the use of the laryngoscope and rhinoscope.
At the Yale Medical School the instruction is given in the New Haven Hospital and at the college dispensary.
"In the medical clinics at the dispensary the preliminary examination is made by a student, and this is reviewed and extended as far as necessary by the instructor; the latter explains the relations of the symptoms, makes the diagnosis, and gives the student in charge general directions for treatment; the student, subject to correction, gives the precise directions to the patient. All symptoms