430 



NATURE 



[February 28, 1901 



is thrust upon them. The obstetrician and the ophthalmologist 

 still receive the same instruction. It is obvious, however, thai 

 this indiscriminate gorge will be soon an unpleasant memory. 

 The wonderful growth of medicine is breaking bonds already 

 centuries old. All minds in one mould is ceasing to be the 

 ruling axiom in medical teaching, not because it is a terrible 

 delusion which by retarding discovery has cost the lives of 

 countless thousands, but because it is no longer practical. 

 Success demands some acquaintance with all subjects and an 

 intimate knowledge of one. Day by day the walls rise higher 

 between one speciality and another. The parting of the ways 

 begins at the threshold. In anatomy, physiology and pathology 

 the student should spend his time on those portions which are 

 directly associated with his future work as practitioner or 

 investigator. 



This early election will be strenuously resisted by partisans of 

 the tradition. They will contend that the present instruction 

 embracing the entire field is known to give a very inadequate 

 acquaintance with the subjects taught ; therefore, instruction 

 covering only a part of the ground will give still less. The 

 argument is beside the mark. The present method of instruc- 

 tion would be inadequate in any event. The medical degree is 

 granted for superficial information in twenty-five or thirty 

 subjects. The sign of the scholar and man of science, namely, 

 thorough knowledge of some one field, is wanting. Yet this 

 training of the man of science is more and more necessary for 

 success. Moreover, a thorough training in at least one subject 

 increases the power of acquiring the fundamental data of related 

 subjects while it protects the mind against superficiality. A 

 further necessity for election is seen in the fact that the great 

 medical schools are university departments. They are attended 

 by an increasing number of men who will never practise 

 medicine but will become investigators in some branch of 

 biological science. 



Following the idea of concentration, sequence and election, 

 I have proposed that the student's undivided attention be given 

 to one principal subject at a time. The principal subjects in 

 medicine are anatomy, physiology, pathology and clinical 

 medicine including surgery. The four years' course in medicine 

 is divided into eight terms or semesters, which usually comprise 

 sixteen weeks of instruction. The first of the eight terms may 

 be given to the primary course in anatomy, including histology ; 

 the second to the primary course in physiology, including 

 physiological chemistry ; the third to the primary course in 

 pathology, including bacteriology ; the fourth to pharmacology, 

 clinical chemistry and physical diagnosis ; and the four remain- 

 ing terms to clinical medicine and surgery. The primary courses 

 just mentioned provide the instruction in anatomy, physiology 

 and pathology which every student is advised to take. Advanced 

 instruction in these subjects may be offered in subsequent elective 

 courses. 



To meet the needs of the several classes of students found in 

 universities the department of physiology must provide : (l) The 

 primary course already mentioned, suitable for every student of 

 biological science, including medicine ; (2) An advanced course, 

 intermediate between the , primary course and research ; this 

 advanced course will be taken by candidates for the degree of 

 Doctor of Philosophy who have selected physiology either as 

 their principal subject or as one of the two or three subordinate 

 subjects required of such candidates ; (3) Opportunities for 

 physiological research. 



The primary course in physiology is held from 9 a.m. to I 

 p.m. daily during the second term of four months in the first 

 year of the medical curriculum. The afternoons of these four 

 months are devoted to physiological chemistry. The primary 

 instruction in physiology is divided into three parts. Part i. ,. of 

 five weeks' duration, provides thorough experimental work in 

 some limited field. In this, the student should acquire the point 

 of view, the general physiological method, training in technique, 

 and a complete knowledge of one or more tissues to serve as an 

 introduction to the physiology of the remaining tissues. There 

 can be little doubt that the physiology of muscle and nerve 

 should be chosen for this purpose. It is the most fully developed 

 chapter in physiology, and is well adapted to train the mind in 

 habits of exact experimentation and close reasoning. Moreover, 

 the physiology of muscle and nerve is in large measure the phy- 

 siology of all living tissues, so that a man learned in this one 

 field is in effect already acquainted with the general principles of 

 physiology. Part ii., of about seven weeks' duration, comprises 

 carefully arranged fundamental experiments, giving in turn the 



NO. 1635. VOL. 63] 



elements of each field in physiology except that of nerve and 

 muscle, which has just been studied. In part iii., covering the 

 remainder of the term of sixteen weeks, the instruction is divided 

 into special courses on the physiology of the eye, ear, larynx, 

 digestion, the spinal cord, the innervation of the heart, &c. 

 Each course is long enough to include all the practicable experi- 

 ments that should find a place in a systematic, thorough study 

 of the subject. The number of such experiments, and hence 

 the length of the special courses, is naturally different in the 

 various instances ; thus the experimental physiology of the 

 eye occupies more time than the physiology of the larynx. 

 The student may elect the subjects that most interest him, but 

 must choose a sufficient number to occupy him during the 

 entire four weeks of instruction. In planning these courses the 

 aid of distinguished specialists is sought. 



Each student is required to present one written discussion of 

 some small and sufificently isolated thesis, giving the work of 

 the original investigators. The way of dealing with the sources 

 at first hand is thus learned. Many of these essays are read and 

 discussed before the class. The discussions begin with the 

 sixth week of the course and are held daily during nine weeks. 

 None is held during the last two weeks. The literature of each 

 subject is divided into two portions and each is assigned to one 

 man. The fifty-four subjects, therefore, are presented in one 

 hundred and eight essays. The men chosen for this purpose are 

 the best in the class ; their choice is determined at first by the 

 results of their examinations in anatomy, and, so soon as prac- 

 ticable, by the results of their work in physiology. In addition 

 to the two men who read theses, one or more of the investi- 

 gations on each subject are studied by four men, who are thus 

 specially qualified for the discussion. The four are selected 

 in turn from the whole class. To illustrate, let us take as an 

 example " The Transmission of the Cardiac Excitation Wave." 

 One student defends the theory that the cardiac excitation wave 

 is transmitted through muscular tissue ; a second defends trans- 

 mission through nerve tissue. Each presents a carefully written 

 account of the evidence pro and con. The four men, each of 

 whom has read at least one of the investigations on this subject, 

 lead the discussion, which is held by the entire class and the 

 departmental staff. The subjects chosen for discussion are, as a 

 rule, such as cannot be fully studied in the laboratory. Thus the 

 discussions complement the remaining instruction. The subjects 

 to be discussed are bulletined before the appointed day so that 

 the class may come to the discussion somewhat prepared. 



In the last two weeks of the course, students who have per- 

 formed their experimental work especially well may elect instruc- 

 tion in physiological research. The subject chosen must 

 necessarily be very narrow, and, where possible, should be one 

 the literature of which has been already examined in the 

 preparation of the student's thesis. Experience has shown that 

 after fourteen weeks of strenuous labour in experimental 

 physiology, the student of average ability learns to work rapidly 

 and carefully, so that much can be accomplished in two weeks 

 of experimentation in one small subject. Even a very brief 

 experience of investigation is of the greatest value and interest. 

 Examples of subjects suitable for training in investigation are : 

 "The Compensatory Pause ; " "The Tetanus Curve;" "The 

 Action of Calcium and Sodium Ions on Rhythmic Con- 

 tractility." 



Beginning with the second week of the course, a daily written 

 examination, twenty minutes in length, is held. One or, at 

 most, two questions are asked. They concern the student's own 

 experiments. The purpose of the examination is to cultivate 

 precision in statement. The emphasis which the question gives 

 imparts a correct perspective. Further, the examination reveals 

 men whose indolence or incapacity marks them for special 

 care. The following questions are some of those asked in such 

 examinations : ." Give experimental evidence to show where 

 stimulation begins on the closure of the galvanic current. 

 Explain the difference between the stimulating electrodes and 

 the physiological anode and kathode in the stimulation of human 

 nerves. Give the experimental basis for an explanation of the 

 auric ulo- ventricular interval." 



The didactic instruction consists of a ten-minute talk in the 

 laboratory, commenting on the examination of the previous day 

 and explaining any special difficulties in the experiments, and of 

 a daily lecture. In every instance this lecture is intended to 

 discuss experiments. Wherever possible the experiments are to 

 be performed by the students themselves before coming to the 

 lecture. Experiments which the students cannot do for themselves 



