EDITORIAL ARTICLES.

TIME PRODUCES CHANGE.

The rapid growth of medical and surgical science and practice is compelling great changes in the methods of medical education. Formerly the student "read" several years with a preceptor, who would hear him recite, and would take him to see his patients, who generously submitted to any examination which the physician directed his student to make. The young man thus acquired considerable familiarity with the symptoms and treatment of disease before he ever entered the medical college. Every physician of any prominence in the profession had one or more students. The doctor prescribed their own medicines and the student became familiar with the physical and therapeutic properties of drugs and their preparations. People now object to students being brought to the sick-room, and to their presence in the consulting room of physician's office. Instead of being of service, the student is now an incumbrance to the practitioner. This change makes one of the chief arguments for the extension of the time of the lecture course, and the result is that students spend their three years of study in the medical college. The course of study is graded, and while the student is unquestionably better drilled in the elementary medical branches, he loses much that was of the most useful practical nature. Two years are spent in the lecture room and in the laboratories. It is only during the senior year that the student is permitted to see anything of a practical character of disease.

These great changes in medical education have been made in the last few years, and each additional year the demands for greater modifications become more urgent. Extension of the course provides more time for study, but it does not supply the bed-side experience, which is now the greatest deficiency in the present method of medical instruction. The student who enjoyed the advantages and privileges of a preceptor's office and practice never felt and cannot appreciate the helplessness and the utter lack of confidence in his ability to combat disease that is experienced by the medical student who graduates to-day from a college that has not the command of large hospitals and extensive clinical facilities. These students have learned disease in the abstract. They have memorized the symptoms of an

ideal typical case, and know the names of the medicines to be administered in its treatment, but they have never had any practical experience with the actual thing in its various stages and modifications. He has never inspected the tongue, the countenance, the general appearance, or felt the pulse, or seen the excreta of a typhoid fever patient, or of the little victim of cholera infantum.

We make no mistake when we state that Dr. Nagle, whose communication we publish in this number, did not gain all the practical knowledge of disease which he possessed at graduation in the hospital at Ann Arbor, and we will further state that if all the graduates of his much loved alma mater, had, when they graduated and entered practice, learned all they knew of disease in that hospital, the number of the laity would be less "who believe that a physician who has the seal of the great University of Michigan on his diploma is entitled to the confidence of the people as one well qualified to treat their ailments." The students, with a few possible exceptions, who now graduate, do not have that confidence in themselves, and it is not natural that they can inspire it in others. An example of this has recently come to our notice. One of the most brilliant young men in the last graduating class applied for an army appointment. His shortcomings are seen in the following quotation taken from a letter from a member of the Army Medical Examining Board to the Medical Faculty: "Dr., who was before the board this week, passed a very creditable examination in most branches; but his entire want of experience in practice makes it inexpedient for us to accept him. It would be unkind to him, as well as unfair to the service, to thrust the responsibility of practice upon him at present. I have advised him to get a hospital appointment for six months, or better for a year.”

We do not and have no desire to cast unfavorable reflections on the high character of those "credentials for public confidence," but we do wish to increase the fame and reputation of the college from which those "hard earned diplomas" were issued. The doctor has been so long away from his alma mater that he does not understand the situation. If he did we are sure he would forget all about his diploma and would join hands with those who are working to make the medical department of the great University of Michigan more honored.

Accepting the doctor's estimate of the wealth of clinical material offered the student, the extension of the term permits abundance of time for parading all the cases who come for treat

ment, and as often as they present themselves for inspection. We will again notice a few changes. Formerly, and at the time Dr. Nagle was a student, six hours a week were devoted to clinics. They were on Wednesdays and Saturdays, from 9 to 12 A. M. Then the sènior students were compelled to give their afternoon hours to laboratory work. The present graded course permits all laboratory work to be finished before the senior year, and clinics are held daily, each branch having the entire morning or afternoon. The clinic on "practice" is not compelled to be completed in one hour, to give opportunity (?) for twenty or thirty eye cases to be presented during the next sixty minutes, so that the surgical drama might occupy the "boards." Yes, the entertainment was wearisome, because the student comprehended little, and learned less. The benefit which the student derives now is not proportionate with the increase of hours. Patients cannot conveniently be passed around the amphitheatre when they are being examined or operated upon. The clinical amphitheatre is a good place to exhibit patients, but a very poor place to study disease. How vividly we recall the oft repeated scene of our venerable and now revered professor of practice adjusting his stethescope, placing it over the heart or lungs of a patient, requesting the class to be quiet, that he might hear, and, then gravely turning about with instrument dangling from his ear, to inform us of a blowing sound heard at the apex of the heart, or of a deminished respiratory murmur at the base of the right lung. The prescription would be written on the board, and the patient instructed to call in a week or two. It did grow wearisome toward the close of the hour. Would an hour be wearisome in the hospital ward, filled with heart and lung patients, where the student could listen to the sounds himself after they had been explained by his teacher?

The value of the diplomas of the alumni of the medical school of the University of Michigan, will not be diminished if the claims be made: that the student of to-day has not proper facilities to obtain the best knowledge of disease; that hospital advantage cannot be so great as to prove a detriment to the school of which they are adjuncts; and, that Detroit possesses more of these advantages than ever can be given in Ann Arbor.

To represent to the public and to the profession and those entering it, that the facilities for imparting knowledge of practical medicine and surgery, and especially obstetrics, are all that could be desired, or more than are needed, would be

unjust and not consistant with truth. We admire the honesty of the Faculty of Medicine of the University of Oxford. The students' number of the Lancet in commenting on this institution says: "Medical education in the present day is so essentially practical that the establishment of a proper course of medical education requires a great deal more than mere willingness or fitness on the part of individuals to instruct." The many advantages of the Oxford school are set forth, but the following statement shows a self-acknowledged defect: "Although the Faculty of Medicine advises the student to finish his medical education away from Oxford [italics ours], it is nevertheless highly advisable that he should have some insight into practical work while in residence at the University." To supply this mere insight there is provided an infirmary in which, "during the past year there were over fifteen hundred in-patients. and seven thousand out-patients relieved. There were eightythree deaths, with sixty-six post-mortems, and asæsthetics were administered five hundred and two times." In this eminent institution with as many thousands patients as Ann Arbor has hundreds, the Faculty advises "the student to finish his medical education away from Oxford.

In a recent address delivered at Yale University, by Dr. Welch, Professor of Pathology in Johns Hopkins University, the speaker said: "The development of scientific and of prac tical medicine during the last half century has been so immense that the number and the extent of subjects to be mastered by the medical student are far greater than formerly, and are constantly increasing. It is a matter for serious consideration how to distribute these objects in a medical course, so that each shall receive its proper share of attention. * I would say

that in my judgment, the last two years of a medical course should be given mainly to the study of the practical branches of medicine. This study I would have more practical and demonstrative than it is with us at present. Systematic lectures on the theory and practice of medicine and surgery, would be in large part and with advantage replaced by clinical instruction. If a young man choose the medical profession, he should devote at least four years to medical studies, including the preliminary sciences. One who has had a liberal education will probably supplement this with a year and a half in hospital experience, the value of which cannot be over-estimated."

When Dr. Nagle was a medical student, the medical department had just advanced its term of lectures to nine months. It

was claimed that two years of lectures of six months were not sufficient to qualify the student to practice. Were the diplomas that were issued prior to this change reduced in value as purchasers of public confidence? Three years' lectures are now required. When this change was made several years ago, did Dr. Nagle's diploma suffer? Three years permitted a graded course of study. The time spent in the laboratory work was increased and the courses made more thorough. Many subjects are taught that formerly were incidentally referred to as the evidence of the growth of medical science. Did this advance in the amount of work, made on the claim that two years were not adequate time to gain sufficient knowledge to treat disease, cause those "only credentials for públic confidence" to drop in the market?

If past advancement did not deteriorate the standard of these credentials, why should the supplement of a recognized necessity create a fear. The production of doctors is greater than the demand. The quality is below a fair standard. The demand for higher qualification for graduation comes from all quarters. Four years, two spent in recitation and the laboratory work of fundamental sciences, and two for the practical study of the practical branches, are strongly advocated by all medical educators. To attempt two years of study in the hospital at Ann Arbor, would be in the strongest sense of the word absurd. Yet, if the medical department of the University of Michigan, means to maintain the high standard, facilities for practical study must be provided. Since the hospital at Ann Arbor cannot furnish them, they must be supplied away from the seat of the University.

MEDICAL SOCIETIES.

The medical societies are at this season of the year holding their annual meetings, electing their officers, and otherwise preparing for their winter's campaign. In the cities and counties, we might almost say in the towns and villages, the same activity prevails, so general has the medical society now become.

The rapid rise, development and multiplication of the medical society, is phenomenal. Nowhere has that epocical ware of co-operative enterprise, which has so completely revolutionized the commercial world, produced more striking changes than in the body medical. The medical career was singularly fitted to develope individuality at the expense of these altruistic forces