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VI.—THE MEDICAL SCHOOL OF THEUNIVERSITY OF PENNSYLVANIA.

!

Historical.

The School of Medicine of the University of Penn-sylvania is the oldest in the United States. It wasfounded in 1765 by Dr. John Morgan, who becameits first Professor of -Medicine, and who prophesiedits future strength in his opening address. Morganwas the pupil of John Hunter, and of William Cullen,of Edinburgh, and it was from Edinburgh that thenew school derived its chief inspiration. For a periodthe headquarters were at various places in the city- among others, in the Presidential House built forGeorge Washington-but in 1873 the school moved toa site adjoining the Philadelphia General Hospital,familiarly known as " Blockley." Then the UniversityHospital, the first hospital in the United Stateserected for the use of a medical school, was built,and since then the story has been one of continuousdevelopment. Various departments, suitably housed, have made their appearance, with appropriatelaboratories, and a large quarter of the city has become Ia medical centre. The Robert Hare Laboratory of IChemistry, erected in 1877 and at one time the homeof the Dental School, now houses the General ChemicalLaboratories of the School of Medicine, the Laboratoryof Physiological Chemistry, and, on the top floor, thedissecting-room. In 1892 the Laboratory of Hygienewas built, and in 1904 a building was erected toaccommodate the Laboratories of Pathology, Physio-logy, and Pharmacology. The Robert Hare Laboratorywill be shortly vacated, as a new building is underconstruction, attached to the present Laboratories ofPathology, Physiology, and Pharmacology, and thiswill house the Departments of Anatomy and Physio-logical Chemistry. The Wistar Institute of Anatomyand Biology, incorporated in 1892, was the firstAmerican university institute devoted to advancedstudy and research in anatomy and biology.

In 1894 the William Pepper Laboratory of ClinicalMedicine was erected adjoining the UniversityHospital, and provides facilities for the prosecutionof minute clinical studies and original researches.The Henry Phipps Institute for the study, treatment,and prevention of tuberculosis, was established in1903 ; the building, located at Seventh and Lombard-streets, was completed in 1913, and organised andequipped for its university connexion.

In 1909 the University of Pennsylvania originatedthe first graduate courses in Public Health leadingto a degree of Dr.P.H., the Laboratory of Hygienebeing erected for the research work and teaching,while the Department was established in 1920. In 1910the Department of Research Medicine was organised,and in 1916 a "merger" between the Medico-Chirurgical College of Philadelphia and the Universityof Pennsylvania was completed, and the GraduateSchool of the University was organised, while twoyears later the Philadelphia Polyclinic and Collegefor Graduates in Medicine merged with the GraduateSchool to form a Polyclinic Section. The whole story,it will be seen, is one of the pooling of efforts, andalong this policy the future of the Medical School of Ithe University is being designed. i

THE MEDICAL CURRICULUM.

Matriculation and Requirements for Admission.The minimum requirements are a standard four-

year high school course or its equivalent, plus three years in an approved college of arts and science, Iaggregating not less than 45 units, a unit of college

iwork being the same as a semester-namely, theequivalent of one hour of lecture or recitation each week for the full academic year or of two hours of ’’,laboratory work each week for the same period. The candidates must have the following credits or satis-

factory certificates or proof of having passed an

examination in these subjects : chemistry, physics,zoology or general biology, English, and eitherFrench or German. The credits should show that theapplicant has done appropriate laboratory work inthe three science subjects. Students can be admittedto advanced standing, that is to say, can enter in thesecond and third year classes, on proof that they havesatisfactorily completed courses equivalent in kindand amount to those taken by the class to whichadmission is sought. Only 110 students are admittedyearly, though at least eight times that number makeapplication.

SUMMARY OF STUDIES.

The course of medical instruction proper extendsover a period of four years, and the subjects of thefirst two years follow upon each other in logicalsequence.

First Year.-The time is devoted chiefly to anatomy,gross and detailed embryology, normal histology andneurology, physiology, and physiological chemistry.

: FIG. 11.-UNIVERSITY OF PENNSYLVANIA.

Administration Building.

Students are taken in sections, and the instruction inphysiology may be used as an example. It covers workon the circulation and respiration and on metabolism,while laboratory work on frogs and the turtle heartis amplified by experiments on the students them-selves ; so a gradual course is arranged from founda-tion to coping.

S‘econd Year.--The subjects are pathology, bacterio-logy, and pharmacology, under which is implied allinquiry into practical therapeutics conducted by animalresearch. Instruction upon all the subjects of thefirst two years is almost entirely practical, so that thegreater part of the student’s time is spent in thelaboratory ; but a simultaneous introduction is madeto clinical work, for once a week throughout the firstand second years an elementary medical clinic isgiven, while a surgical clinic is given in the last halfof the year to demonstrate to the students the properrelation of the fundamental sciences to the practicalwork of healing. Limitation of the first and secondyear classes to 110 students prevents the possibilityof overcrowding the laboratories and ensures a largeamount of individual instruction. The major partof instruction in pathology is concentrated in thelatter two-thirds of the second vear, courses correlatingthe teaching with ward work extending over theconcluding years of the curriculum. In the second year,general and systemic pathology, including parasito-logy, is lectured upon and demonstrated by teacherst

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care being taken to present aspects of the subjectsnot always contained in text-books and, as far as

possible, connected with recent observation. Theautopsies at the University and Philadelphia GeneralHospitals are attended regularly. I

Third and Fourth Years.-With the beginning of the third year, detailed instruction in the three greatclinical subjects, medicine, surgery, and obstetrics,and in the various specialties, occupies the student’stime; and, just as there is no sharp dividing linebetween the work of the first and the work of the Isecond year, so there is no sharp dividing line betweenthat of the third and that of the fourth year. Whilethe major part of instruction in pathology is con-centrated in the latter two-thirds of the second year,in the third year clinico-pathologic conferences are held; patients presenting unusual points of interest I

FIG. 12.-UNIVERSITY OF PENNSYLVANIA.

Completed block of new hospital.

are presented for debate by the staff, at which groups of students are present.The main work of the students during these years

is in the wards of the hospitals especially connected Iwith the University-namely, the University Hospital,Philadelphia General Hospital (Blockley), and thePennsylvania Hospital. The students are now

separated into ward groups, and as the variousteachers and their assistants are in the wards of oneor other of these institutions practically all of eachmorning, the students are under supervision con-

stantly, and advice is always at their disposal. Inmedicine they take histories of new cases which areallotted to them, and make physical examinations ofeach case as it is assigned to them, and they see anyspecial treatment which is produced in the ward.Each student attends special departments of one ofthe out-patient departments, and in this way getsthree months’ experience, working there three tofive hours a day. Lectures are given throughout thethird year which assist the student in his systematicreading to accompany the more intensive clinical workin the fourth year. Each student of the fourth yearclass works in the clinical laboratory, making routineexaminations of all material from patients assigned tohim in any of the departments during his final year.At small clinics a case-history will be debated by thefellow students of the reporter, in the presence of theprofessor, who examines the class upon the diagnosisarrived at and gives reasons for his own views.The course of instruction in surgery is distributed

over two and a half years, for it starts in the secondyear with an introduction to clinical problems. Thethird year instruction deals with surface lesions and

sions of the extremities, and lesions of the cranial,.oracic, and abdominal cavities are considered ine fourth year. Every patient admitted to the wardsassigned to whoever takes the history, and the

inical clerk or dresser will follow the patient through-it his stay in the hospital, attending the operativeinics on the cases which have been assigned to himr history-taking. In the closing phase, the student,aving mastered the principles of wound repair,isesthesia, asepsis, antisepsis, haemorrhage, andlock, attends special units of the out-patient depart-ents, while he is required to make routine laboratorykaminations. A course of operative surgery is giveni the cadaver. During the fourth year the student,ho has been trained in pelvic diagnosis and obstetricrocedure on the manikin, attends ten labour casest least, as well as lectures on gynaecology andonf erences upon gynaecological cases recently admitted the wards.

Examinations and Promotions.

The personal supervision that is possible by theeachers over small classes of students with whomheir association is so close makes the processes ofeeding-out and of advancement very thorough.he Dean is the last authority in all circumstances,,nd an interesting sidelight on his responsibilities ishrown, in this University, by the assumption thatome of the students may be partly supportinghemselves by paid work in what is called their " spareime." By periodical examination the students are}laced in category, promoted or referred to theirstudies in accordance with their instructors’ opinions,,)r rejected. The student who falls behind throughstress of private circumstances cannot be categorisedas either idle or dull, and wherever possible he isyelped, so that the undue strain may be removed.

HOSPITAL TRAINING.

There are three hospitals in the city of Philadelphia1t which the students may complete their curriculum-namely, the University Hospital, the PhiladelphiaGeneral Hospital, and the Pennsylvania Hospital.

The Hospital of the University of Pennsylvania wasEounded in 1874 and now contains 540 beds. As isthe invariable case in the large general hospitals atthese great medical centres, the alterations of buildingsand the rebuildings have been immense, and to-dayboth the general, and especially the surgical aspects,are represented in large and well-organised depart-ments, while 22 internes are required to cover thegrowing demands, as well as six residents. Thestudents, in accordance with the scheme of the curricu-lum described above, receive clinical instruction insmall groups, while larger sections are taken by theprofessor or his associate over more general ground.The classification of patients treated in the two greatmedical and surgical departments shows that thetraining is fundamental, while the departments ofgynaecology, pediatrics, ophthalmology, neurology,and orthopaedics have adequate facilities. At thelaboratories of clinical medicine and surgical patho-logy bench instruction is given, so that familiarityis obtained with the routine examinations and withthe methods in which the numerous tests required bypractice in the wards are carried out. There is adepartment of physiotherapy, and annexed to thehospital is the fine William Pepper Laboratory.Further developments are contemplated in view ofnew buildings, while the large out-patient departmenthas been recently reorganised, and the dispensaryservice divided into a general diagnostic section, anda number of special clinics.

The Philadelphia General Hospital.-The hospitalstands immediately adjacent to the University build-ings, and can well be designated a hospital of theUniversity, a large proportion of the students beingalways engaged in taking their clinical courses there.The ancestor of the hospital was the " BetteringHouse " or " Almshouse for Relief and Employment

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of the Poor." which from 1707 to 1834 served thepurposes of the English workhouse and its infirmary.This building was superseded by a general hospitaland lunatic asylum, known for local reasons as

"Blocklev," and this in its turn has been largelyreplaced by the enormous modern hospital which isnearing completion. It has 2000 beds, and is con-

be examined. The notes contain a history of thepatient, the signs and symptoms on admission, andthe results of the laboratory tests that may havebeen necessary. H(- is then asked for his diagnosis,when the rest of the class are invited to conin-ientupon their contemporary’s work and to surestalternative diagnoses. All these speeulatiuns are then

FIG. 13.---UNIVERSITY HOSPITAL : THE l-!eRGICAL PAVILION.

structed with complete thoroughness upon the mostmodern design. Clinical instruction to the studentsis indicated by the subjects with which they areto make themselves familiar during the third andfourth years of the curriculum.An example of a morning’s work may be given.

The visiting staff officer attended by an interne, theclinical clerk, to whom the duty of reporting the casehas been assigned, and a small group of students whohave reached the final stage of their course meets theprofessor, who is also a full physician or surgeon tothe hospital. The clinical clerk reads his notes inthe presence of the patient, who may, if necessary,

reviewed by the member of the staff who may, forexample, rule out one theory as being obviouslycontradicted by the history, and a second view asbeing not supported by the symptoms, and so on,until the final diagnosis remains between two or threepossibilities. The professor then indicates to theclass the reason for his own selection, or he may saythat to make any such selection is unsafe withoutfurther infurmatiun. In particular the professormight ask for more assistance from the laboratorythan his clinical clerk could supply. Finally, heindicates to the class what sort of information fromobservation in the wards or findings in the laboratory

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he hopes to obtain, and recommends certain places in medical literature where his hearers can read trust-worthy accounts of the condition in question. The Ismall clinic thus described is typical of many similar I,procedures not only in other departments of this hospital, but throughout all the teaching hospitals inAmerica. That this sort of training, more or lessof it, is going on in all the centres described may betaken for granted.

The Pennsylvania Hospital.-This institution wasfounded in 1751, and to it the same story of progressmay be applied. It has all the departments necessaryfor the student’s curriculum, and especially a notableneuropsychiatric clinic.

The Episcopal Hospital, a general hospital with450 beds, is also at the disposal of University teachersand students.

VII.—THE JEFFERSON MEDICAL COLLEGE.

THE Jefferson Medical College was organised in 1825 and in 1828 received a University Charter from Ithe State making it an independent Corporation with I,the same status as the University of Pennsylvania.The College buildings consist of a medical hall, with lecture rooms, theatres, a museum, a library and ilaboratories, and special class rooms. On the upper- ’.most, or sixth floor, in addition to the museum are Ian animal room and the research laboratory of the Iprofessor of preventive medicine and bacteriology. The library proper contains more than 6000 volumes, i

and another library, the Daniel Baugh Library, contains 1200 further volumes dealing with anatomy , and embryology.

THE MEDICAL CURRICULUM.

Matriculation and Requirements for Admission.Candidates must present evidence of having com-

pleted a four years’ course at an approved high schooland two years at an approved college of art or science,the evidence being held satisfactory by the usualsemester and credit proofs. The two years at collegemust have been spent in acquiring ground work ininorganic and organic chemistry, physics (where itis urged that the course should be preceded bymathematical study including trigonometry), biologyand English, the additional subjects recommendedbeing a modern language, comparative vertebrateanatomy, psychology, and social science.

SUMMARY OF STUDIES.

The medical course of four years is so arrangedthat the student is being trained throughout in thefundamental and practical sides of his future calling.

First and Second Years.-The first two years aredevoted mainly to the fundamental medical sciences,which serve as a basis for the technical and clinicalstudies that follow, the larger part of the time beingspent in practical work in the laboratories. Emphasisis laid upon the laboratory instruction in anatomy,histology, embryology, physiological chemistry,physio-logy, hygiene, bacteriology, pathology, pharmacy andpharmacology. For laboratory instruction each classis divided into three groups, thereby affording greateropportunities for individual instruction. All coursesare obligatory, and satisfactory work and attendanceconstitute a requirement for admission to the writtenexaminations. As the ultimate object of the studyof medicine is practice, the student, during thESecond Year, is instructed in the fundamental prin-ciples of clinical medicine and surgery, in order thatthe correlation between theory and practice may bEestablished in his mind early in the course.

Third and Fourth Years.-The laboratory coursesare correlated with the clinical branches considerec

in the third year. During the fourth year the teach-ing is largely clinical and practical. The fourth-yearclass is divided into sub-groups of 10 or 12 men, whoreceive instruction at the bedside and in the dis-pensaries of the College Hospital and its departments,as well as in other hospitals. Didactic lectures andrecitations are given in the Medical Hall on practiceof medicine, physical diagnosis, surgery, obstetrics,gynaecology, materia medica, therapeutics, neurology,chemistry, physiology, pathology, bacteriology, medi-cal jurisprudence, hygiene, pediatrics, genito-urinarydiseases, orthopaedic surgery, ophthalmology, and

tropical medicine.In the College and Laboratory Building, laboratory

instruction is given in physiology and pharmacology,physiological chemistry, pharmacy, pathology, includ-ing morbid anatomy and pathologic histology, bac-teriology, haematology, bandaging, major and minorI surgery, obstetric manipulations, clinical chemistry,and microscopy. Courses in anatomy, appliedanatomy, dissection, histology, embryology, andI operative surgery are given also, while in the theatrethere are clinics on general medicine, surgery, obste-trics and gynaecology, and all the special subjects.Hospital sections and small ward classes are takento the bedside or to various special dispensaries,I ward-teaching rooms, operating rooms, and mortuary.

The clinical side of obstetrics is taught in theJefferson Maternity and its dispensary, and in theWharton-street Dispensary, and regularly scheduled

I instruction is given in the Jefferson Hospital, Phil-adelplxia General Hospital, the Pennsylvania Hospital,

and the Philadelphia Hospital for Contagious Diseases.i

Examinations and Pronaotions.

No student is admitted at any stage to examina-tion unless his class record is satisfactory ; studentswho fail to pass in not more than two subjects canbe re-examined before the opening of the next session,and if successful will not lose precedence, but failurein both subjects again will mean removal. Failure inone subject will entail removal of this bad mark! by successful examination during the next year, but

. a student may only carry one such condition into histhird year’s work, and no conditions are allowed in

; the fourth year.

;. HOSPITAL TRAINING.

The Jefferson Medical College Hospital is adminis-tered by the same board of trustees as the College,and the staff is composed of members of the Facultyand their assistants. By this arrangement all depart-ments of College teaching, including every detailof clinical instruction and laboratory investigation,may be fully correlated. The present hospital was

opened in 1907.The ground floor is devoted exclusively to out-

e I patient services, which also occupy the larger portionof the first floor, in which there are, in addition,administrative offices and reception rooms. Thesecond, third, and fourth floors and part of the eighth,are devoted to ward patients, and, with the private

wards, afford accommodation for 377 patients.The out-patient department is a very large one,

; the hospital being situated in the centre of the city. ! The department is so arranged as to afford facilitiesfor the examination and treatment of patients, inwhich every detail may be followed by students,assigned in sections to the various departments.

zs Under qualified assistants detailed by the professors;g in charge, students are admitted to wards in whichn I bedside instruction is given. Six’operating rooms areyespecially equipped for section teaching. Under the

supervision of professors and instructors, students1- are required to participate in operations and to

assist in the administration of anaesthetics, and are)e in this way brought into direct contact with themost important details of operative procedures.When the interests of the patient are not thereby

s jeopardised, the student may follow the case fromd admission.