SCIENCE. 



[Vol. XVIII. No. 439 



orders, — when it comes to the parting of the ways. Most 

 travellers on an Atlantic steamer accept without murmuring 

 the edict that " passengers are not allowed on the bridge." 



The information which those who propose to earn their 

 living by the general practice of medicine stand most in need 

 of is that which will enable them to recognize the ordinary 

 emergencies and to deal with them in the ordinary way. 

 As students, their time, money, and zeal for study and in- 

 vestigation, are all usually more or less limited, and there 

 are many things in a course which is called the " higher 

 medical education" which are of comparatively little use to 

 them. The clinical instruction which they can get at a 

 school in the region of country in which they intend to 

 practise will often be more valuable to them than that which 

 they could get at a distant school of greater repute, simply 

 from the difference in the class of cases presenting them- 

 selves for treatment. Good local pilots are in demand, al- 

 though we have a superintendent of the coast survey. In 

 some respects the old-fashioned system of medical appren- 

 ticeships, in which the student spent from one to three years 

 in the office of a physician in general practice before he 

 went to a medical school to hear lectures, was a good one 

 for producing these general practitioners. 



To learn to do such work easily and propei'ly, one must 

 live among the sick, learn how they look, how they talk, 

 how they are to be talked to and handled ; and must do this 

 at close quarters, and not by looking on from the top bench 

 of an amphitheatre, or from the outer ring of a group of 

 thirty or forty men standing around a bed. Moreover, it is 

 the common every-day ailments and their effects and treat- 

 ment that the student wants to become familiar with at first, 

 rather than the rare cases. Cases of colic, of effects of over- 

 eating or drinking, of sore throats, croup or diphtheria, or 

 scarlet-fever or mumps, of the ordinary fevers, of simple 

 fractures and dislocations, of bad cuts of the palm of the 

 hand, are far more important to him from a business point 

 of view than brain tumors or ligations of the innominate 

 artery. 



And these comparatively simple, every-day cases are just 

 what the young man reading in the office of his preceptor 

 may become familiar with. How many of the men without 

 such experience, who graduate this year at our great medi- 

 cal schools, have ever seen closely a case of measles, or scar- 

 let-fever, or incipient small-pox; or have actually looked 

 into the throat of a child suffering from diphtheria, or have 

 ever assisted in adjusting and dressing a fractured thigh- 

 bone, or in getting the clothing off from a case of extensive 

 burn or scald? I have no doubt most of them could repeat 

 the description of these things which they have heard or 

 read, but they are not as well prepared to deal with such 

 cases in that unhesitating way which commands confidence, 

 as is the man who has seen and touched one or two such 

 cases in his preceptor's office, and has observed what that 

 preceptor said and did. 



On the other hand, the number of practising physicians 

 who are qualified to act as preceptors, and who are willing 

 to give the requisite time and attention to students, is very 

 limited ; and with any other kind of preceptor the student 

 wastes much time, is apt to lose interest, and become idle 

 and unfit for continuous mental interest. If the student 

 spent his apiirentice year or two years in a preceptor's office, 

 either at the end of his first or second year's medical lec- 

 tures, or after obtaining his degree, it would be much better 

 for him ; but the latter course is open to the objection that 

 he would probably think that he knew more than his pre- 



ceptor. The Scotch medical schools prefer that the year 

 spent as an articled pupil shall come after the first two years 

 of education in a medical school. The decision of the British 

 Medical Council has been that a five years' course of study 

 shall be compulsory, and that the last year shall be spent in 

 practical work. 



Theoretically there is still a considerable amount of pre- 

 liminary reading with a preceptor done in this country, but 

 practically this method of beginning the study of medicine 

 is fast disappearing. Through the kindness of the officers of 

 some of our large medical schools I have obtained some data 

 on this point, from which I infer that in the Eastern schools 

 the proportion of students who claim to have read with a 

 preceptor for one year before commencing lectures is from 

 1.5 to 30 per cent, and in Western and Southern schools from 

 25 to 60 per cent; but no doubt such reading in the majority 

 of cases was merely nominal, and the student had seen little 

 or nothing of practice. In most schools the certificate of the 

 preceptor is not required. 



The ideal of the average student who is in a hurry to begin 

 practice needs no special decription. What he wants is to 

 pass the examinations with the least possible labor, — the 

 less he is compelled to take for his money the better he is 

 pleased. The ideal of the majority of the medical profession 

 as to what should be the minimum course of study for the 

 degree of doctor of medicine appears to be that the student 

 should first obtain at least such preliminary education as is 

 furnished by our ordinary high schools, and then should 

 study medicine four years, the first of which may be with a 

 preceptor, and three of which are to be occupied in attending 

 a graded course of lectures, the last two years being largely 

 devoted to clinical and hospital instruction. About one-third 

 of our medical schools have expressed their intention of car- 

 rying out this programme. As regards the time, it is not 

 sufficient, according to European standards, but it is perhaps 

 the best general standard which can be fixed at present for 

 the education of the general practitioner for this country. 

 Its success depends upon whether the student has had the 

 needed preliminary education. It is the want of this last 

 which is the chief deficiency. 



The ideal of the army and navy examining boards is that 

 a surgeon in the government service should have received 

 either the literary, classical, and mathematical training of 

 the ordinary college course for the degree of bachelor of arts, 

 or the training leading to a degree in scientific studies ; and 

 that, after that, he should have spent five years in medical 

 studies, the last year as resident in a hospital. 



This ideal cannot yet be enforced in either service, for the 

 reason that they could not get enough men who come up to 

 this standard to fill the vacancies, so that the actual standard 

 is somewhat lower than this, although it is higher than the 

 minimum standard of any medical school or of any State 

 board of examiners. Through tlie courtesy of the surgeon- 

 generals of the army and navy, I am able to give you the 

 following results of the work of their examining boards for 

 the last ten years : — 



Before the army boards, 348 candidates presented them- 

 selves during this period, of whom 76, or 22.3 per cent, were 

 approved and passed ; 31 were rejected for physical disquali- 

 fications; 90 failed to pass the preliminary examination; 

 and the remainder failed to pass the medical examination. 

 The rejections for physical defects are for the last three years 

 only. 



Before the navy boards, 237 candidates presented them- 

 selves, of whom 55, or 23.1 per cent, were approved and passed ; 



