It is rare that from so slight a cause, apparently, such extensive lesions in all parts of the body should follow, and especially that septicemia should set in so early and violently. Only twelve hours after the injury was received pain existed in the entire leg, presumably from early invasion by the lymphatics; within thirty-six hours after the injury, the left shoulder joint was involved, the temperature rose to 104.5°, and was followed speedily by a chill, the involvement of other joints, and, after a comparatively long illness, by death. The infectious endocarditis of the right side was a typical lesion. Associated with this were infarcts in the brain, heart, lungs, spleen, kidneys and intestines.

This case may teach us two most important lessons: 1. The danger of delay even in slight wounds. Three hours elapsed between the receipt of the injury and any surgical attention, and that of the most superficial character. Within that time doubtless the mischief began. The local trouble, however, was at no time serious in external appearance. When I first examined the foot on the fifteenth day and found the joint entirely destroyed, with the exception of a small almost uninflamed opening caused by the splinter, and a drop or two of pus, the toe looked perfectly normal. Yet even in so casual and apparently unimportant a wound with so little local trouble the infective process ran an extraordinarily rapid course.

2. It teaches us the absolute importance of careful, thorough and antiseptic surgery. The proper course to pursue would have been to etherize the patient (or cocaine might have been used), and to make a free incision at the site of the wound, so as to be sure that the entire splinter was removed immediately; and, as the wound was so near a superficial joint, to determine the fact whether this joint was involved or not.

Next, and equally important, the wound should have been most carefully disinfected, and an antiseptic dressing applied. Had the patient sought surgical advice at once, and had thorough surgery and careful antisepsis

been used, it is probable that he would have recovered without any serious trouble.

That he was personally a blonde, with a suppurative tendency; that his father had suffered for eighteen months with suppuration following an injury near the knee from a tack, and that his sister had suffered for six weeks from a palmar abscess, make it possible that suppuration, and even death, might have occurred in spite of the utmost precaution. But the existence of this tendency, personally, and in the family, would be the very strongest possible reason for extra precautions to prevent any septic trouble.

Until surgery becomes an exact science (a consummation in the far distant future, I fear), we cannot say that a different result would certainly have followed had antiseptic methods been used; but we can say, that without them he was certainly doomed to trouble, and even, as the result showed, to death; and that with them his chances would at least have been extremely good.

Alumni Address.

(Concluded.)

THE AMERICAN MEDICAL STUDENT. BY PROF. AUSTIN FLINT, M. D.,.

Of Bellevue Hospital Medical College, New York. An Address delivered before the Alumni Association of Jefferson Medical College, April 2d, 1888.

Preliminary Education. Before beginning the study of medicine, a student should have received a good English education, including a fair knowledge of mathematics, and should know something of the Latin language. To exact, in addition, a knowledge of a modern foreign language, would be to assume that English medical literature does not meet the needs of English-speaking medical students, which is certainly untrue.

It seems to me that the desirability of a proper preliminary education is too evident to admit of discussion; but questions that very properly and profitably may be discussed are, whether a good English education and a fair knowledge of Latin are indispen

sable as preliminaries to the study of medicine, and whether the conditions which obtain in this country render it possible to exact these requirements of all students.

It is a fact, not only that some unpromising students, sadly deficient in early advantages and education, do well in their medical studies, but a few have attained professional distinction. Such instances, however, are infrequent, and occur only in those who begin the study of medicine young. As a rule, a man of twenty-five, ignorant, uncultured, and without habits of serious thought and study, can never learn enough medicine to pass his final examinations. In former years, when some colleges accepted "five years of practice as equivalent to a course of lectures," some of these "practitioners," after hard and honest work during an entire session, have developed, on their final examinations, a depth of ignorance truly marvelous. Those who attain success in the face of serious deficiency in early mental training are exceptions, and to them the labor involved in acquiring a professional education is enormous. A student with absolutely no knowledge of Latin may acquire the nomenclature of medicine without serious difficulty, as a child learns the words in a foreign language, but he is at a considerable disadvantage.

On the whole, I think it may be fairly said that, while proper mental training and a "liberal" education are very desirable as preparations to the study of medicine, there are certain men lacking these advantages, but, having youth, ability, enthusiasm and industry, who cannot be repressed. These, however, are the exceptional men, who seem destined to succeed under any and all cir

cumstances.

In this country the only grade of medical men, as regards their pretensions to the position of practitioners of medicine, is determined by the degree of M.D. Licentiates form a very small proportion of the class of general practitioners. The professional income and social position of many physicians, even when actually overburdened with practice, are rewards so small as inevitably to

exclude a high order of talent and acquirements. Such a grade of practitioners must, however, exist both in rural districts and in large cities, although the income of many is less than the average earnings of ordinary mechanics.

It is difficult to suggest a practicable way in which those who receive the degree of M.D. from our colleges may be divided into classes, and it is to be feared that whatever division is made must continue for many years to depend upon the public. The only feasible method of making any distinction between graduates would be for certain colleges to issue special diplomas to those who have passed a preliminary examination and have studied for the full three years at such colleges. In other countries, under a more or less paternal form of government, and where the practice of medicine is strictly regulated by law, the necessity of at least two grades of physicians has long been practically recognized. The relative position of the officiers de santé in France, and of the apothecaries and general practitioners in Great Britain, is an illustration of this.

There is much that can be done by the faculties of medical colleges to improve the opportunities of medical students, to render teaching more efficient, and to make it easier for students to acquire a knowledge of medicine. That efforts in these directions have been made with considerable success is sufficiently evident; but that more can be done, and easily done, is unquestionable.

Perhaps the most important change to make in college requirements would be the abolition of the private preceptor. Most students learn so little, as a rule, from their preceptors, so called, that the certificates of three years' study, as a general rule, actually represent nothing. A busy practitioner has no time to devote to his students, and rarely gives them any systematic instruction. In the great majority of instances, the country practitioner who takes students into his "office" exacts of them little services not always of a professional kind, puts into their hands old editions of medical works and tells

them to read, this being the beginning and the end of the functions of the "preceptor." Certainly there are exceptions to the rule in regard to private preceptors; but what is desirable is to remedy defects which exist in the great majority of instances. If the term of study of medicine be fixed at three years, the instruction which students receive during these three years should be thorough, systematic, and continued, with reasonable vacations, throughout the year. Such instruction is now provided at well-organized medical colleges, and it should be made obligatory. The following statistics point to the importance of this reform:

Of one hundred candidates for graduation, sixty studied with private preceptors, and forty spent one or more full years, including recitation terms, at medical colleges. The average of the marks of the former on final examination was 68 per cent., the highest being 884, and the lowest 524 per cent. The average of the latter was 784 per cent., the highest being 974, and the lowest 574 per

cent.

The shortcomings and errors of judgment in teachers frequently present serious obstacles to the acqusition by students of the knowledge to be reasonably expected of them after three years of study. Who is there among us who has taught for a number of years who cannot now recognize great defects in his earlier efforts? These defects, however, have generally been incident to lack of experience and to efforts to accomplish too much in a single course of lectures. Having had a not inconsiderable experience in medical teaching, and an extensive and varied field of observation, I may, perhaps, be pardoned if I venture to give my own ideas of how American medical students should be taught. Instruction by lectures is an ideal form of teaching. It is emphatic, it makes learning easy for students and removes many difficulties usually experienced by those who attempt to learn exclusively from books; provided, always, that the lecturer be a competent and conscientious teacher. Lecturers are popular in proportion as they impart instruc

tion positively and clearly. Subjects of lectures are attractive to students in proportion as they seem to be practical and useful, and are easily learned.

Many young lecturers, with industry, enthusiasm and an aptitude for teaching, greatly impair the efficiency of their instruction by endeavoring to cover the entire ground embraced in the subject which is assigned to them. Many older and experienced teachers err in giving to parts of their subject, in which they are especially interested, undue time and prominence. Many fail to teach their subject thoroughly from lack of system and proper

arrangement.

An ideal teacher in any department of medicine is one who knows his subject thoroughly; who appreciates those parts of his subject that present peculiar difficulties to students; who is systematic and consecutive, and so clear in his statements as to be never misunderstood; who has no undue pride of opinion and makes no attempt at personal display; who teaches emphatically and thoroughly what is essential, treading lightly and judiciously upon disputed questions; who remembers the processes by which he has learned his subject and the difficulties which he has himself surmounted; who keeps constantly in mind the possibility that the shortcomings of his class may be in a measure due to errors in his methods of teaching. A good teacher is never dull. A dull and uninteresting lecturer is never a good teacher.

A public teacher should never relax his efforts to improve his methods. He should himself examine his class upon the subjects of his lectures, the most important advantage of this being in the fact that these examinations often reveal to him defects in his teaching. An ideal medical teacher is rare indeed. “La critique est aisée et l'art est difficile." Still, there may be those whose reminiscences of our Alma Mater date back as far as mine; and can we not vividly recall more than one grand figure in the history of American medicine, filling the ideal of what a public teacher should be?

In two courses of lectures, with two courses

of systematic instruction by books and recitations, it is not difficult for a student to learn his chemistry, anatomy, physiology and materia medica, and to acquire the necessary technique of medical chemistry, microscopy and dissections. Anatomy and physiology constitute the groundwork of medicine; and the materia medica furnishes a considerable part of the means used in the treatment of diseases. It is most important that these subjects be taught so thoroughly and efficiently that students shall know them as they know a familiar language. This can best be done by lectures with frequent repetitions and reviews, reinforced by recitations from books. The serious work of the first two years of study does not seem to involve much more than the acquisition of certain established facts taught dogmatically and impressed on the memory by repetition and thorough drilling. A student learns and forgets his anatomy, for example, once or twice before he becomes even a fair anatomist. It is evident enough that youth is the time for this. Anatomy and physiology give the grammar and a great part of the vocabulary of medicine; for the classification and nomenclature of diseases have, or should have, essentially an anatomical basis. I venture to assert that a well-educated boy of nineteen can learn anatomy, physiology and materia medica more easily and thoroughly in two years than can a ripe scholar of thirty in three. Learning by efforts of memory is not unattractive to the young, while it is often mere drudgery to those of more maturity of mind.

In my opinion, students, while learning the so-called elementary subjects, should listen to lectures on the practical branches and should attend clinics. It should be borne constantly in mind by teachers that the final object of the course of instruction of medical students is to qualify them for the practice of their profession. Medical students should begin early to observe the aspect and treatment of disease, and to witness surgical operations. They cannot be too familiar with the practical duties of their profession. The notion that young students cannot comprehend lectures

on practice, surgery and obstetrics is not well founded. While students are devoting their best efforts to the study of the elementary subjects, it is of immense use to them to hear lectures on medicine, and thus to learn from the first the practical value and importance of a thorough knowledge of anatomy, physiology and materia medica. I make this statement after much reflection, observation and inquiry among intelligent students at different periods in the course of study.

After a student has devoted two years faithfully to the elementary subjects, if found qualified on examination, he may safely leave these branches and devote the remainder of his term of study exclusively to the practical departments. While he is studying practice of medicine, surgery and obstetrics, it is not possible for him to forget his materia medica, physiology and anatomy. His memory is being constantly refreshed by the applications of the primary branches to the study of actual disease. Now is the time to gather up what he has seen and heard on practical subjects in lectures and clinics during his first two years of study; and now he can become prac tically familiar with the methods and technique of physical diagnosis, surgical dressings, operations, etc.

Can a faithful student become qualified to begin the practice of his profession within a period of study extending over three years? Undoubtedly he can; but he must certainly not confine himself for one only, of these three years, to the study of the so-called practical subjects. He should be required to attend lectures and clinics on these subjects for at least two years. It seems to me absurd to exclude even a first-course student from everything that relates to the actual practice of our profession. I venture to assert that a firstcourse student cannot occupy two or three hours of his day better than by attending clinics and listening to lectures on practice of medicine, surgery and obstetrics, and that a student, pursuing such a course, will, in the end, be better qualified as a practitioner than if he had ignored these subjects during his first year of study.

No amount of what is called instruction can fully qualify a man to practice medicine. The conscientious study of a single case, of which he has the sole care and responsibility, is often of more practical value than the observation of a score of similar cases in a clinic. A recent graduate should be qualified to begin practice; but no preparatory training can equal the lessons of actual experience.

Neither the professor nor the student should expect to accomplish too much during the collegiate course. A mature practitioner who is an accomplished physician, skilled in all methods of diagnosis, a competent surgeon, an expert oculist, aurist, gynæcologist, laryngologist, dermatologist, chemist, microscopist, bacteriologist, etc., is unknown. No length or amount of study will produce a physician of such varied accomplishment and learning, and the schools should not attempt impossibilities. A well-educated physician should have some knowledge of all departments of medicine and should be equal to any emergency; but the science of medicine has become too large for the grasp of any single intellect and the technique too multifarious for any one hand. It is an error to attempt to teach, thoroughly and exhaustively, even the legitimate specialties, such as ophthalmology and otology, in the ordinary curriculum of a medical college. Nevertheless, students should receive such an amount of instruction in the so-called special subjects as will enable them to recognize the diseases of all organs of the body and make no blunders in diagnosis and treatment. A legitimate specialty involves special dexterity, acquired by long practice as well as special study. A specialist who has an imperfect knowledge of general medicine is a dangerous practitioner. After graduation, a student may study any restricted subject exhaustively; but his special acquirements and skill should always have as a foundation a comprehensive knowledge of the science of medicine. Without this no one can be a good practitioner, either as a surgeon or as a specialist of any kind.

There is one serious defect in medical teaching in this country which has been due

to the rapid extension of the boundaries of medical science within the last quarter of a century. The actual knowledge at the present time is so extensive that lectures are necessarily confined to existing facts and opinions. It is not possible for each professor to enter to any considerable extent into the early history of his subject. It seems to me that a chair devoted to the history of medicine is now a desideratum. Students are now graduated with little or no knowledge of the history of the great discoveries and advances in medical science; and this defect could be met without materially increasing the labors of a medical class. It is also desirable that students should have some idea of the proper ethics of intercourse with fellow-practitioners. There are points of strictly professional etiquette which are as important to the medical practitioner as are the polite usages recognized by gentlemen; and it is certainly proper and desirable that medical students should be told something of the proprieties and amenities of professional life.

I fear I have wandered from the direct question of what can be done to improve the condition of the American medical student. When I say, what can be done, I mean what is practicable in the near future, securing the greatest benefit to the greatest number. It may be well, however, to begin by considering what cannot be done.

It is impracticable to bring all the medical schools of the different States under the control or supervision of the general Government. Our political organization does not admit of this, which can exist only under a centralized power, and would involve a considerable expenditure of public moneys. In my opinion, absolutely uniform medical legislation in all the States is equally impracticable.

State medical boards, appointed to deter mine by actual examination the qualifications of applicants for license to practice medicine, can never be of any great practical benefit so long as it is deemed necessary to recognize, in their organization, certain so-called systems of practice, such as homoeopathy and eclecticism.