586 MEDICAL EDUCATlON IN AMERICA.

ward entirely devoted to Syphilitic Disease, a detachedbuilding for Fever Cases, and an extensive Out-patientDepartment, with separate Clinics for Diseases of the Skin,Throat, Eye, Ear and Teeth.The hospital is visited daily at 8.30 A.M. by the resident

surgeon, and at 9 A.M. by the physicians and surgeons.The surgical wards are also visited each evening. ClinicalLectures are given by the physicians and surgeons duringthe session. There is accommodation in the hospital fortwo medical and six surgical resident clinical assistants,who, in addition to their rooms and furniture, are providedwith coals and gas.Fees.-Hospital Practice: Nine months, £12 12s. ; six

months, £8 8s.; three months, £5 5s. Dressership: £ 10 10s.each three months.

MEDICAL EDUCATION IN AMERICA.

AMERICAN UNIVERSITIES.

THERE are many universities in America, but the two greatteaching bodies, Harvard and Yale, stand out prominently-pre-eminently might almost be said-amongst them. These

two are the great universities of the East, and whatever theunlimited West may be going to do in the not distant future--and Chicago is said to have sworn to take no beating fromany city in anything-at the present time the intellectualcentres of the East are the intellectual centres of the UnitedStates. In considering, therefore, the medical educationoffered by Yale and Harvard to their alumni, we are con-sidering the American medical degrees which are of the mostrespectable standing and which are, presumably, as difficultas any to obtain.

Yale Medical School-In 1810 a charter was granted by Con-gresstothe PresidentandFellows of Yale College in Newhaven,Connecticut-now and since 1813 known as Yale University-and the President and Fellows of the Connecticut Medical

Society, authorising them to combine according to a certainscheme for the establishment of a medical school. Two yearslater the conjoint school was organised and in 1813 instruc-tion was begun. Degrees were conferred by the University ’,on the recommendation of a board of examiners consistingof an equal number of members of each corporation, and thedual arrangement for a time worked quite satisfactorily. Thisis shown by the fact that the medical graduates from Yaletook a prominent place from the first in the profession. Butas America grew the University became early aware of thenecessity for more stringent arrangements with regard tothe conferring of their medical degrees. Amongst otherdefects in the curriculum of that time the old systemof apprenticeship was perceived to be open to abuse.In 1879 a graduate course of instruction, preceded byan entrance examination, was instituted by the Universityauthorities, and in 1884 they, by amicable agreement withthe local medical society, took over the entire control of theschool. The medical school proper of Yale can therefore onlybe held to have been an integral part of the university fornine years. The school is very well housed. The buildingis not large, but it is quite adequate to meet the wants of thestudents, of whom, during the present academic year, thereare only seventy-six. The various laboratories are very welland conveniently furnished, and there is a liberal supply ofmicroscopes, anatomical specimens and bones placed at thedisposal of the various classes. There is a special laboratoryfor the study of bacteriology, containing a very completeequipment ot modern apparatus for carrying on investigationon the usual lines The course of study necessary to graduatein medicine at Yale University is preceded by an elementarymatriculation and extends over three years, and if this seems tous in England a very short period it must be remembered thatit is the usual length of a medical course in America and is alonger time than that demanded of their students, until veryrecent times, by many Transatlantic degree-granting institu-tions. Each year contains thirty-four working weeks. Inthe first year the student attacks chemistry, anatomy andphysiology-inclusive of histology-giving an equal pro-portion of time to the first two and half as much again to thelast. The amount of compulsory work-i. e., work under theeye of the lecturer or demonstrator-varies from twenty totwenty-five hours per week, but many of the classes requirefrom the members private preparation. In the second year,

as might be guessed from the shortness of the course, thestudent has a busy time, for he is engaged both in theschool and in general medical work. Instruction in anatomyand physiology is continued and courses of lectures uponmedicine, surgery, materia medica and obstetrics are

begun. He attends the General Hospital of Connecticutfor ward work and operations and the Newbaven Dis-

pensary for out-patient practice, both of which placesare, fortunately for him, quite near the school. Hishours of compulsory study range between twenty-five andthirty-two per week and it is clear that a very great deal ofreal hard work is expected of him. In the third year his con-nexion with the school ceases and he is engaged entirely inmedicine, surgery and obstetrics. The hours are rather lesssevere than in his middle year and he is evidently allowed toadmit a little individuality into his studies. The average cost

per annum to the student in fees is only$140, or about 28,If the school is adequately equipped the Newhaven Hospitalgives every opportunity that can be desired for learning thepractical side of the profession. The hospital-a very finebuilding and beautifully planned-is the chief hospital in alarge manufacturing city, which is also an important railroadcentre. The report of the governors for 1892 shows thatduring the year 983 patients were under treatment in thewards, and an analysis of their disorders proves that thosewalking the hospital had excellent chances of learning thediagnosis and treatment of all ordinary disease and of muchthat is rare. The list of operations was also a long andimportant one. A new operating theatre has been builtrecently and it is fitted with every requisite that can bedesired, whilst the arrangements for securing completeasepsis are elaborate to a degree. The examinations areheld at the close of each year on the studies of the year,and are practical and oral as well as written. The papersare alike in one respect-viz., that there are many questionsrequiring but short answers. Such papers are open to objec-tion. It may be easy for a competitor to obtain a high per.centage of marks upon a very superficial acquaintance withthe subjects, whilst a better-read student, who knows the workmore thoroughly, may be tempted to hamper himself bygiving more details than the time limit will permit; butcomment upon the standard of knowledge required by YaleUniversity of her medical graduates will be better consideredlater in comparison with that required by Harvard.Harvard Medical 83hool.-The Medical School of Harvard

is in Boston, some three miles away from the suburb of Cam-bridge, where the headquarters of the university are situated.It stands adjoining the public library in a group of finebuildings made up of the Museum of Fine Arts, the Instituteof Technology and the Natural History Museum, and besidesbeing splendidly adapted for lectures and laboratory instruc-tion it holds its own with its neighbours in architectura’

splendour. As no account of anything in America can everbe considered complete which does not include a dollarvaluation, it should be stated that the main pile was erectedat a cost of over 300,000 and that the pathologicallabora-tory-a recent addition-called for the expenditure of$40,000more. As might be expected, therefore, the histological andchemical laboratories are excellently furnished, whilst the

department of physiology is duly supplied with all the

apparatus necessary for the performance of the ordinarydemonstrations.The course required for the degree of M.D. Harvard is

preceded by an easy entrance examination and now coversfour years of thirty-four weeks each, having been extendedby one year in September, 1892. The order in which the

subjects are studied is similar to that prevailing in everymedical school. During the first year the instruction is givenentirely in the school and includes physiology with histology,4 ; anatomy, 3 ; and materia medica, 1. The figures denotethe proportional amount of time spent in lectures, demon-strations and practical work, and have been arrived at bysumming up the hours devoted to the different courses.

There is also some instruction in bacteriology and hygiene.During the first year the student’s hours of work per weekunder authority are twenty-three, but many of the lecturesrequire private preparation. During the second year phy-siology drops out and there are added to the course instruc-tion in pathology (both by lecture and by demonstration atnecropsies) and theoretical and practical tuition in medicineand surgery. The relative amount of time spent upon eacheubject is shown by the following figures : Surgery, 45;

1 For eleven months only, for no admissions were made duringNovember.

587MEDICAL EDUCATION IN AMERICA.

pathology and pathological anatomy, 4; medicine, 3’5;therapeutics and chemistry, 3 ; and anatomy, 2. The com-

pulsory hours of work per week are twenty-eight. Duringthis year the students are allowed to act as dressersand assistants in the out-patient department of the GeneralHospital of Massachusetts (Boston). The same general planprevails through the third year ; but anatomy is now omittedfrom the programme and the work of the school proper, asdistinguished from ward work, ceases, whilst a start is made inthe study of obstetrics and of diseases of children, pedanti-cally called "paediatrics." The times spent in medicine andsurgery are almost equal, whilst two-thirds of that amount aredevoted to the diseases of women and children. Under thehead of "medicine" have been included diseases of the brainand spinal cord, which in the Harvard course, however, aretreated as distinct subjects under the title of "neurology andmental diseases." " In the fourth year of the course attentionis given chiefly to different branches of the profession, andthe tendency to specialisation, shadowed forth by the divi-sion of nervous diseases-structural or otherwise-from the

general science, becomes more pronounced. The hours of

study per week in this year increase to thirty-six and one-sixth. During the last year it is left largely to the option ofthe student what branch of his profession he shall give par-ticular attention to. He must devote a certain amount oftime to the elected subject, and, whatever subject he chooses,he will have to submit to a special examination in it. Thehours of compulsory study per week fall again to 27, butit is clear that the advanced student is expected to do a gooddeal of work on his own account. The inclusive fee for theannual course is$200, or about £40. It has been noted thatthe school is splendidly fitted with modern appliances, andthe student at Harvard is as fortunate after he has emergedfrom the school as he is during his first year, for the facilitiesoffered at Boston for ward work are admirable. This willbe evident when it is understood that he is admitted tothe practice at the ten following institutions, eight ofwhich are within half a mile of the school and all of which arewithin one mile of each other :-

Institution. Number ofInst titution.

patients in 1892.1. Massachusetts General Hospital, Boston 29,0222. Boston Dispensary ............... 27,5463. City Hospital, Boston ............ 24,4234. Eye and Ear Infirmary, Boston ...... 17,044

’

5. Carney Hospital, South Boston ...... 8,7066. Children’s Hospital, Boston ......... 8,6227. Free Hospital for Women, Boston...... 5,1758. Lying-in Hospital, Boston ......... 1,5799. Lunatic Hospital, Boston ......... 511

10. McLean Hospital, South Boston ...... 328

The student is examined at the end of each year in thecourse proper to the year, and in all subjects the examinationis oral and practical as well as written. The papers are

throughout upon the same model. They are very long andthe answers expected can in most cases only be short andelementary, because the hours of examination are brief andthe questions cover such vast fields that only the man whoknows but little about the subject, unless he has gifts oflucidity and arrangement quite out of the common, could everanswer them in the allotted time. The papers are set almostentirely by the lecturers to the school upon the subjects oftheir own lectures, and the percentage of rejections is

exceedingly low.The only conclusions that can be arrived at from the con-

sideration of medical education at Yale and Harvard arethese : firstly, that Harvard is ahead of Yale ; and, secondly,that neither course approaches in thoroughness that providedby any of the teaching or examining bodies-university orotherwise—of Great Britain and Ireland or by the large con-tinental schools. The advantages of Yale are numerous. Thecourse should prove a sound introelzcction to professional know-ledge, for every attempt is made to give practical effect to thetheories taught. The students are neither so few that theelement of healthy rivalry is wanting nor so many that theycannot receive individual attention. The fees are low. The

opportunities for seeing disease of all kinds are excep-tionally good when the size of Newhaven and its hospitalis taken into account ; but the course is too short, inthe present state of medical knowledge, to enable even thecleverest and most precocious pupil to ruri alone. It is anintroduction-a ground plan upon which a well-constructedmedical education could be reared if time were given for theprocess ; but the character of the examination papers and

the t,1tl",,.; ot ttle theses which various studem& have presentedat the expiration of their three years’ study-e g., -JlattrlialInfluences transnzitted to Foetus in Utero and The Chemistryand ltletabolism. of Diabetes-sufficiently show that it is notin this modest way that the medical student of Yale sets towork. We find in the examination papers for the secondyear at Yale-that terrible second year, when the student is

keeping up his anatomy and physiology and making hisdébut in everything else-such questions as these Discnssthe cerebral ganglia and Give the therapeutic uses of elee-

tricity, and the time allowed in which to answer these

questions is under twenty minutes. It is quite possible that theaverage student in his second year could write out all he knewin response to such questions in less than twenty minutes, butdoes it serve any good purpose to set such questions ? The

only purpose it can serve is to make it appear that thestudent is passing an examination of great thoroughness andseverity ; and this is not a good purpose, for it is an appear-ance only.Harvard is better than Yale, inasmuch as the course is

longer ; but it is possible to find similar fault with Harvardwith equal justice. We know in London that when the time- -the shortest possible time-to be spent as a student underthe Royal Colleges of Physicians and Surgeons was four yearsthe average man found those years busy ones, though he wasonly asked to obtain in them a practical working knowledgeof medicine and surgery, and, of course, of the sciencesupon which these are more immediately based. Thereforeit is difficult for us to credit that the student of Harvardcan do more than this in his four years, from which itshould follow that the time devoted to the acquisition ofbacteriology in its elaboration, or of psediatricsas distinguishedfrom general therapeutics, must come out of the time thatwould have been better devoted to the thorough compre-hension and permanent retention of sound general principles.At Harvard, again, the practice prevails of allowing thelecturer and the examiner to be identical persons almostinvariably. Whilst no one can fail to see how admirableall the appliances for learning are at Yale and Harvard,how ingenious and modern the hospital fittings and howexcellently arranged the methods of study, it is not easyto believe that the average American student is so far aheadof the average English student that he can become ananatomist, a physiologist, an electrician and a bacteriologist, ageneral practitioner and a specialist in three or even fouryears of thirty-four weeks.

Yale and Harvard appear to English eyes to be theAmerican counterparts of Oxford and Cambridge, but thesimilarity is not very real. Most of the States have theiruniversities, and whereas Oxford and Cambridge draw theirundergraduates from all parts of the empire and its colonies,the universities of the United States of America dependalmost entirely for support upon the particular State whereinthe university is situated. In this way Harvard is the

university of Massachusetts and Yale that of Connecticut,and neither is a national institution in the sense that Oxfordand Cambridge are national institutions. The States ofMassachusetts and Connecticut, however, were colonised

early and their universities have acquired the dignity of age,as well as the facilities in method that are the outcome ofexperience. It is for this reason only that the medical

degrees of Yale and Harvard have a particular claim forconsideration and not because their possessors have any solidclaim to having successfully passed severer examining tests.Next in importance to the two New England universities comethe University and Colleges of New York and the University ofPennsylvania, and these bodies, with Yale and Harvard, maybe taken as constituting a fair representation of advancedAmerican education. There are in New York three institu-tions granting the degree of M.D.-viz., the University of theCity of New York, Columbia College (the College of Physicians

! and Surgeons) and the Medical College of the City of NewYork (Bellevue College).New York University.-The medical department is well

! and conveniently housed near the Bellevue Hospital, where’ the students do a large proportion of their clinical work,! whilst a dispensary that has been open for the past ten years’ within the building of the department provides excellent

material for out-pa,tient practice. The course required forL the degree of M.D. is preceded by an easy entrance examina-) tion and extends over three years, each year consisting of

winter term of twenty-eight weeks. During the first yearl or term the student’s time is almost equally divided between! anatomy, chemistry with materia medica, and physiologyl with histology. A large proportion of the work is practical

588 LONDON POST-GRADUATE COURSE.

and is done in the laboratories. In the second year instruc-tion in anatomy, save as surgically applied, ceases, but inphysiology, chemistry and materia medica it is continued,whilst surgery, medicine, obstetrics and pathology are added.As must always be the case in a three years’ course, thesecond year is over full. In the third year the school sub-jects drop out and the work in the others is largely carriedon by demonstrations directed rather towards special branchesof each science. The student is tested each year upon thestudies of the year, and if not actually examined by his ownlecturers marks received from them during the year for pro-ficiency in practical woxk are added to his final examinationmarks and help to decide the result for him. The cost of thewhole course is a little over .E110, and this sum includes feesfor matriculation and for the privilege of being examined. ’,New Tork Medical College.-The building is on the I

East River and also situated near the Bellevue Hospital,to which, and to the Charity Hospital upon the adjacentBlackwell’s Island, the College looks for facilities inclinical work. The course here also extends over three yearsonly, each year being divided into two terms--a winter termof twenty-four weeks and a spring term of twelve. Butattendance during the winter term only is required for

graduation. The student’s time is divided up in the sameway as it is in the New York University course, save thathe is expected to be present at general ward-instruction fromthe beginning of his course instead of only during his lasttwo years. This difference may be due to the laudable aimat Bellevue to make the school pre-eminently a clinical one,but is more likely to be a survival from the scheme of theCollege of two years ago, when of the three courses of lecturesonly two were compulsory for graduation. The examinationsare held at the close of every winter term or session and theinclusive cost of the three years’ course is about F,100.

The College of Physicians and Surgeons became two yearsago the Medical Department of Columbia College-the oldestand best endowed educational institution in the city-andthe authorities announce this year their intention of makingthe course requisite for the degree of Doctor of Medicinefour years. The scheme for this alteration is not yet pub-lished and cannot therefore be commented upon. The presentscheme is very similar to that of the other two New Yorkmedical schools.The University of Pennsylvania was the outcome of a

pamphlet by Franklin on the education of youth and receivedits charter from George II. in the year 1753; and the medicalschool, which was founded in 1765, with John Morgan-apupil of Hunter-as first professor, is the oldest in America.The education offered by the Department of Medicine of theUniversity of Pennsylvania, like that of Columbia College, isin a transition state. The Faculty of Medicine in the Univer-sity has recognised that the necessary field of medical studyhas now grown so large that it is no longer practicable togive an adequate course of instruction in three years, and ithas decided to adopt a four years’ course, starting from thisyear. Each year will be divided into two terms or sessions,a winter one of twelve weeks and a spring one of twenty.The first year will be occupied with chemistry, pharmacy,osteology and histology. In the second year dissection isto be continued and the anatomy and physiology will becomemore advanced, whilst the student will be expected to acquiresome knowledge of physical diagnosis in the wards. In thethird year, besides receiving general instruction in medicine,surgery and obstetrics, the student will continue toattend lectures upon anatomy. In the fourth year, inaddition to his attendance upon regular lectures, he will berequired to select two branches of his future profession forspecial study-e.g., neurology and dermatology-and to

pursue them particularly, and to present himself for specialexamination in them, in addition to the regular examinationfor the degree. The facilities for instruction in the Quakercity are numerous, for in addition to the library, museumsand laboratories of the University (wherein Philadelphia isby no means to be outdone by Boston), the hospital of theUniversity, with its new maternity wards, the PhiladelphiaHospital, the Children’s Hospital, the German Hospital,lately enriched by a bequest of$1,000,000, and the South-Eastern Hospital and Dispensary are all at the disposal ofthe student. The complete cost of the four years’ course,inclusive of matriculation fees, is a little less than £125.As has been said, there are numerous Universities in

America ; but Harvard and Yale, which enjoy the distinctionof ancient formation, and New York and Philadelphia, whichhave the position gained for them by their size and the

importance of the towns in which they are situated, are the

most important. So that, in considering medical educationin these institutions, a review is being made of the highestdevelopment of medical education in the States as a whole,although it happens that all the universities that have beenmentioned are on the eastern coast. Only one conclusion canbe arrived at upon comparing this education with that offeredby the universities and royal colleges of Great Britain to theirstudents. It is that it is not calculated to turn out practicalmen of the same calibre as are turned out on our side of theAtlantic. But it is equally clear that America does notintend to allow this position to remain unaltered. It is wellknown that sham education has flourished in Americawith peculiar vigour and that so-called universities and

colleges have been rife there whose degrees were of novalue, being obtainable in many places without work, and innot a few without any more formal proceeding than paymentof fees. The University of Pennsylvania deems it worthwhile to point out to its students that whereas persons whohave attended one year in a medical school will be admittedinto the second year at Philadelphia, upon complying withcertain conditions, the permission does not apply to studentsat homceopathic or eclectic institutions. Similarly the Collegeof Physicians and Surgeons of New York indicates in itscircular that the only courses of lectures recognised by it arethose delivered at properly organised colleges, and that thesignatures or diplomas of eclectic, homoeopathic or botaniccolleges are worthless. The necessity of printing such warn-ings shows that until lately the orthodox systems of educationhave been severely pressed upon by their bogus rivals. Thetemptation to make their time short and fees low, and so more orless to fight the enemy with their own weapons, must have beenvery great in a new and growing country; and to this temptationthe undue brevity of the medical course has been probablyowing, for no one can deny that a course of two sessions oftwenty-four weeks each is unduly brief, yet this was thelength of compulsory study at the Bellevue Medical Collegeuntil two years ago. But, now that these discreditabledegree-shops have been found out and condemned andthe orthodox bodies have rigidly decided to hold no com-munication with the heterodox, improvement is springing up,all round. Harvard and Pennsylvania Universities and theCollege of Physicians and Surgeons of New York haveadopted a four years’ course, and it is to be hoped andexpected that other educational bodies will see that such analteration in the present state of medical learning is imperative.The generosity of their supporters, the completeness of theirschools and the perfection of their hospitals will not excusethem.

LONDON POST-GEADUATE COURSE.

THIS course is specially arranged to meet the wants of thepractitioner and to enable him during his leisure time tobrush up his knowledge on subjects about which he maydesire further information. It has been both popular andsuccessful and has been attended by men from all parts ofthe Empire, from all branches of the Services, from theUnited States of America, as well as from foreign coun-tries. Members can enter for each or all of the courses oflectures for the term, for half the term, or for all the lecturesfor one week, and thus each can obtain just what he wants-and in the shortest possible time. The Vacation Courses havebeen attended by large numbers of practitioners and havebeen much appreciated. By this means men who wished tobring themselves abreast of the scientific knowledge of the dayhave been able to learn the elements of the tecknzque of bacterio-logy and the latest advances in hygiene in a fortnight’s dailycourse. The staffs of the following hospitals have associatedthemselves for teaching purposes-viz., The Hospital for Con-sumption and Diseases of the Chest, Brompton ; the Hospitalfor Sick Children, Great Ormond-street ; the National Hos-pital for the Paralysed and the Epileptic, Queen-square; theRoyal London Ophthalmic Hospital, Moorfields; the Hospitalfor Diseases of the Skin, Blackfriars ; the London ThroatHospital ; and the Bethlem Royal Hospital for Lunatics ; andcourses are given at the Bacteriological Laboratory, King’sCollege, at 101, Great Russell-street on Pathology, at theParkes Museum on Hygiene, and at the Cleveland-street SickAsylum on Clinical Medicine and Surgery. The fees are £1 1s,and £ 2 2s., according to the number of lectures in the course.Further information can be obtained from, and fees shouldbe paid to, Dr. Fletcher Little, Secretary, 32, Harley-street,Cavendish-square, W.