July 8, 1910] 



SCIENCE 



43 



possess substantial resources ; universities 

 of limited means can retire without loss of 

 prestige — on the contrary, the respect in 

 which they are held must be heightened by 

 any action dictated by conscientious re- 

 fusal to continue a work that they are in 

 no position to do well. 



(4) A reconstruction of medical educa- 

 tion can not ignore the patent fact that stu- 

 dents tend to study medicine in their own 

 states, certainly in their own sections. In 

 general, therefore, arrangements ought to 

 be made, as far as conditions heretofore 

 mentioned permit, to provide the requisite 

 facilities within each of the characteristic 

 state groups. There is the added advan- 

 tage that local conditions are thus heeded 

 and that the general profession is at a va- 

 riety of points penetrated by educative in- 

 fluences. New Orleans, for example, would 

 cultivate tropical medicine; Pittsburgh, 

 the occupational diseases common in its 

 environment. In respect to output, we may 

 once more fairly take existing conditions 

 into account. We are not called on to 

 provide schools enough to keep up the 

 present ratio. As we should in any case 

 hardly be embarrassed for almost a genera- 

 tion in the matter of supply, we shall do 

 well to produce no doctors who do not rep- 

 resent an improvement upon the present 

 average. 



The principles above stated have been 

 entirely disregarded in America. Medical 

 schools have been established regardless of 

 need, regardless of the proximity of com- 

 petent universities, regardless of favoring 

 local conditions. An expression of surprise 

 at finding an irrelevant and superfluous 

 school usually elicits the reply that the 

 town, being a "gateway" or a "center," 

 must of course harbor a "medical college." 

 It is not always easy to distinguish "gate- 

 way" and "center" ; a center appears to be 

 a town possessing, or within easy reach of, 



say 50,000 persons; a gateway is a town 

 with at least two railway stations. The 

 same place may be both — in which event 

 the argument is presumably irrefragable. 

 Augusta, Georgia, Charlotte, N. C, and 

 Topeka, Kans., are "centers," and as 

 such are logical abodes of medical instruc- 

 tion. Little Rock, St. Joseph, Memphis, 

 Toledo, Buffalo, are "gateways." The ar- 

 gument, so dear to local pride, can best be 

 refuted by being pursued to its logical 

 conclusion. For there are still forty-eight 

 towns in the United States with over 50,- 

 000 population each, and no medical 

 schools : we are threatened with forty-eight 

 new schools at once, if the contention is cor- 

 rect. The truth is that the fundamental, 

 though of course not sole, consideration is 

 the university, provided its resources are 

 adequate ; and we have fortunately enough 

 strong universities, properly distributed, 

 to satisfy every present need without seri- 

 ous sacrifice of sound principle. The Ger- 

 man Empire contains eighty-four cities 

 whose population exceeds 50,000 each. Of 

 its twenty-two medical schools, only eleven 

 are to be found in them: that is, it pos- 

 sesses seventy-three gateways and centers 

 without universities or medical schools. 

 The remaining eleven schools are located in 

 towns of less than 50,000 inhabitants, a 

 university town of 30,000 being a fitter 

 abode for medical study than a non-uni- 

 versity town of half a million, in the judg- 

 ment of those who have best succeeded 

 with it. 



That the existing system came about 

 without reference to what the country 

 needed or what was best for it may be 

 easily demonstrated. Between 1904 and 

 1909 the country gained certainly upwards 

 of 5,000,000 in population; during the 

 same period the number of medical stu- 

 dents actually decreased' from 28,142 to 

 22,145, i. e., over 20 per cent. The average 



