July 3. 1891.J 



SCIENCE. 



75 were rejected for physical disqualiflcations ; and the re- 

 mainder either withdrew *or failed to pass. 



Evidently the standards of the two boards are about the 

 same. The proportion of those rejected for physical defects 

 is noteworthy. In a general way we may say that about 

 one-fourth of the candidates before such boards are approved, 

 and one-fourth fail on the preliminary examination as to 

 general education. Putting aside those rejected for physical 

 causes, and making the necessary corrections for a certain 

 number who came before the boards more than once, we 

 find that of 429 examined, 129, or 30.2 per cent, were success- 

 ful. 



Of those candidates who had a college degree, 34 per cent 

 succeeded, and of those who had no such degree, 28.9 succeed- 

 ed. Of those candidates who had had one year's residence 

 in hospital, 40 per cent passed, while of those who had not 

 been residents, only 21 per cent were successful. The 

 percentage of successful candidates from different schools 

 varies greatly, ranging from 9 to 56 per cent, for those schools 

 from which more than ten candidates presented themselves. 

 I cannot go into details on this point, but may say that 

 taking the medical schools of Harvard, Yale, the College of 

 Physicians and Bellevue Hospital of New York, the Univer- 

 sity of Pennsylvania, and the University of Virginia together, 

 of 141 candidates, 65, or 46.1 per cent, succeeded ; while for 

 all the rest of the schools in a body, of 586 candidates, 64, or 

 22.3 per cent, succeeded. 



The figures from Yale alone are too small to draw accurate 

 conclusions from, but in strict confidence I will tell you that 

 of the five graduates of the Yale Medical School, who came 

 before the army and navy boards during the last ten years, 

 three, or 60 per cent, have passed. The greatest percentage 

 of successful candidates comes from those who were between 

 24 and 25 years of age when they graduated, being 31.7 per 

 cent, as against 27.9 per cent for those who were under 22, 

 and 26.2 per cent for those who were over 25 on gradua- 

 tion. 



Admitting it to be a fact that different schools have differ- 

 ent minimum standards for graduating doctors of medicine, 

 to what extent are these differences necessary or desirable ? 

 There is at present a very general demand that those schools 

 which have the lower standards shall raise them to the ideal 

 of the medical profession just stated. It seems as if the sup- 

 ply of physicians is now, in most parts of the country, in ex- 

 cess of the demand, the number of medical men being from 

 two to thi'ee times as great amongst us, in proportion to the 

 population, as it is in France or Germany, while the annual 

 number of graduates also greatly exceeds the number of 

 places to be filled. 



Under these circumstances, there is necessarily a struggle 

 for existence, in which the men of inferior qualifications 

 usually, though not always, fail. The schools, however, will 

 not shape their course so much with reference to the real or 

 supposed interests of the profession or of the public, as with 

 reference to the demands of their immediate customers, the 

 students, and many of these, as has been said, do not want 

 any more education than is absolutely necessary to enable 

 them to begin practice. The ability and inclination to pay 

 for professional services differs greatly in different localities 

 and among different classes of people. Attempts to enforce 

 a minimum standard of qualifications, by prescribing a mini- 

 mum time for the course, and a minimum for the number of 

 lectures in certain specified branches, will not result in fixing 

 a uniform minimum standard of results obtained, for this 

 can only be assured and maintained by some system of in- 



spection and testing of results which is independent of the 

 schools or, at all events, of each individual school. When, 

 as Professor Sumner says, "A and B put their heads together 

 to see what C ought to be made to do for D," there is small 

 prospect of result so long as C is free to do as he likes. 



In the Russian myth, when the raven brought the water 

 of life and the water of death to the gray wolf, the first thing 

 that the wolf did was to test their powers on the raven him- 

 self, to determine whether his task was properly done. The 

 public do not have an opportunity of seeing the effect of 

 such a test as this upon those who come to them from the 

 schools professing to have obtained the knowledge of healing : 

 if they had, the complaints of overcrowding in the profession 

 would probably cease. 



From the commercial point of view it seems plain that 

 there are too many medical schools in this country, that the 

 education which many of them are giving is a very poor one, 

 and that the students who are attracted to these last by 

 offers of a cheap and short course waste their time and their 

 money. 



The only really efficient remedy for this state of affairs is 

 a system of State examinations, with minimum standards. 

 This also has its evils, since it must lead to cramming; but 

 it is the best we can do at present. It is urged by some that 

 this minimum standard should be uniform throughout the 

 United States, but in that case, it would be unnecessarily low 

 in some parts of the country. The precise nature of the re- 

 quirements in different regions depends on the density of 

 population, and on the ability of the great mass of the people 

 to pay enough to induce highly educated physicians to settle 

 among them. It would be better if it were otherwise, and if 

 every one could have the benefit of the best professional 

 skill; but matters are adjusted in this world largely by con- 

 flict of interests. Certainly no one who intends to practise 

 medicine should be content with the least amount of knowl- 

 edge which will enable him to pass the required examinations, 

 whatever the standard of those examinations may be. 



Putting aside now this matter of a minimum standard, let 

 us consider briefly an ideal of a medical education of a higher 

 type. In addition to the incipient family practitioner of 

 ordinary qualifications, the beginners in the profession, there 

 is need of, and employment for, highly skilled, thoroughly 

 trained physicians and surgeons as family physicians, as con- 

 sultants, as specialists, and as investigators and teachers. 



There are two ways in which these needed men may be 

 educated and developed. The first is by their commencing 

 with the ordinary course of instruction for general practice 

 in the manner just spoken of, and then going on, after 

 graduation and commencing practice, to study and perfect 

 themselves in details, according to individual tastes and op- 

 portunities; and this has been the course pui-sued by a large 

 number of our most distinguished American consultants and 

 specialists. The other is to lay a broad and sound founda- 

 tion of preliminary education before giving any attention to 

 clinical study or practice. This means an education at least 

 equivalent to that required of candidates for the degree of 

 bachelor of arts from our leading universities, including 

 Latin, French, and German, and mathematics to include 

 trigonometry, and the elements of analytics. It should also 

 include one year's work in a physical laboratory, two years' 

 work in chemistry, two years' work in biology, at least one 

 year's work in practical anatomy, and one year's course in 

 materia medica. 



In other words, it requires that the youth of sixteen, having 

 obtained a good high-school education, shall go on to spend 



