fillip Hist; Div. W 18 K25:1m Medical Education An Address delivered before the Harvard Medical Alumni Association, June 26, 1894 BY W. W. KEEN, M.D. Professor of Principles and Practice of Surgery and Professor of Clinical Surgery in the Jefferson Medical College, Philadelphia, etc. Reprinted from the Bulletin of the Harvard Medical Alumni Association, fune, i8q4 MEDICAL EDUCATION Delivered before the Harvard Medical Alumni Association June 26, 1894 BY W. W. 1 KEEN, M.D. PROFESSOR OF PRINCIPLES AND PRACTICE OF SURGERY AND PROFESSOR OF CLINICAL SURGERY IN THE JEFFERSON MEDICAL COLLEGE, PHILADELPHIA, ETC. Reprinted front the Bulletin of the Harvard Medical Alumni Association, June, i8q4 BOSTON Geo. H. Ellis, Primer, 141 Franklin Street 1895 MEDICAL EDUCATION. Mr. President and Gentlemen of the Harvard Med- ical Alumni Association, — I only wish that, in ac- cordance with your President's introduction, I could rise to the height of a great argument ; but I must be satisfied as nature built me. I am very glad, I assure you, to bring to you the greeting of your Philadel- phia brethren. The marble doorsteps of Chestnut Street, so celebrated by Dickens, greet the gilded dome on Beacon Hill, where the descendants of the Pilgrims and the Puritans live and move and have their beans. [Laughter.] It is well known that all of the streets grow grass in profusion ; and Philadel- phia sometimes, by a sepulchral description, is said to be a well "laid out" city. [Laughter.] But I assure you that, when we get together such lively corpses as Mitchell and Wood and Pepper and Hare and Good- ell and Wilson and Montgomery, we have a very good time. Your President was kind enough, in his note ask- ing me to be present on this happy occasion, to pro- pose that I should speak on the subject of Medical Education. It is possibly a well-worn theme, espe- cially before you, who have such elaborate reports, and I am glad to say such encouraging reports, from year to year of the progress of this great School ; but there are still some points of value, it seems to me, which we can consider here. I remember very well indeed, in the days of the elder Gross, hearing ad nauseam of medical education and the progress that we ought to have, — bushels of talk and thimblefuls of action ; but, after all, when you consider it, these discussions, though they led at that time to very meagre action, were not without their results, and great results, too. They were slowly leavening the whole lump of the profession. They gradually made the profession the support of all the progress that we have seen ; and I am sure that the medical schools, even, I believe, Harvard University itself, would never have taken the remarkable steps in advance which have been taken in the last few years, were it not for that very constant talk, that very constant working of the leaven throughout the profession. [Applause.] I trust the profession. I trust them profoundly. They have ever been better in that re- spect than the schools till of late. [Applause.] There has been certainly a remarkable wave of progress passing over this country in the matter of medical education in the last few years. It has been demonstrated, first of all, by the creation of State Boards of Health, and especially by the noble Illinois State Board of Health, a body which has done more for medical education than any other, I believe, in this country [applause], because it fixed an advanced standard. These boards now have been established in almost all the States ; and they have been followed by a still more notable advance, — namely, the estab- lishment of State Boards of Medical Examiners, wholly independent, as they ought to be, of the med- ical schools themselves. Again, another very remark- able indication is that our universities and colleges all over the land are establishing distinct courses leading up to those of the various professional schools, medi- cine among them. And what does this mean but that the medical schools want better men, and that the colleges are groins to furnish them ? In addition to this, another important indication in the same di- rection, which Dr. Langmaid has just alluded to, is the establishment for the first time of a section of Medical Pedagogics in connection with the Pan- American Medical Congress. I hailed with great delight another similar indication in the programme of the American Surgical Association last month in Washington, on seeing that one of the leading papers by the distinguished gentleman who will address you later, our friend Dr. Billings, of Washington, was enti- tled " Methods of Teaching Surgery." It developed what to my mind was one of the most fruitful, and to me personally one of the most useful, debates that was held in that body. Dr. Billings considered in that address three points, — who were to be taught, what was to be taught, and how it was to be taught. The very scope of his paper, perhaps, prevented what is, I think, of as much importance as the methods of teaching; namely, the men who teach. I would like much to see de- livered before all of the boards of trustees of our med- ical schools in this country (and I think the faculties might benefit quite as much) a course of lectures on " How to conduct a Medical School, and who ought to be made Professors in it." [Applause.] Trustees should not select men because they are their friends, nor because they are their family physicians, nor be- cause they are related to them in any way ; but there should be one sole requisite for the position of a teacher, and that is the best and most capable man to teach. [Applause.] Moreover, I should be very sorry indeed to see the day when the practitioner and the professor are to be divorced. I do not know anything that is more enlivening, that renders a man's lectures more juicy, more meaty, than to have the varied experiences, the successes, the failures, the perplexities, and the responsibilities of an active prac- tice. These very men on the benches before him are the men that are to follow him and his colleagues in the actual practice of the profession ; and what they want is, not only science, but the applications of science to every-day practice. I care not what the department is, be it chemistry, be it anatomy, be it pathological anatomy, be it any of even the purely scientific departments (except possibly physiology), if a man wants to teach it in a live way, in a way that will make the knowledge stick, in a way that will make it interesting and attractive instead of a dry statement of facts, he must make the application of almost every fact in his scientific teaching to practice, he must show their practical bearings by cases drawn from his own practice. [Applause.] Along with that, however, I believe that the time will come when the men who are professors in our schools and at the same time practitioners will largely change their methods of practice. A man who is engrossed in a very large private practice often finds it difficult to give that amount of time which the newer education and the newer methods of instruction of classes in small sections require ; and I believe that in the future the professors in our medical schools will be more and more restricted in their practice until, eventually, they will practise in the hospital, give their lectures, and do little or no outside practice. This will require, of course, very much larger salaries than now can be given, where the income of the school is derived from fees ; and,- in order to do this, it is requisite to have large endowments of the med- ical schools. You all know the great need, the crying need, of our medical schools at the present day is larger and more thorough laboratory facilities ; and that means immense sums of money. I do not know anything more striking than the figures given by Professor Welch in a recent address, in which, collecting all the statistics from the medical schools for 1893, he showed that independently of buildings, I believe, the permanent investments yielding revenues to medical schools in this country were but little over $600,000, and the endowments yielding revenues to theological schools were $17,600,000. I believe thoroughly in taking care of the souls of the com- munity ; but I put it to you, and through you to the community, gentlemen, whether there is not a vast disproportion in the discharge of a duty that the public owes to medical education in a country where we cannot depend upon State aid, when they have only given a paltry $600,000 to us as contrasted with the millions for the theological in- struction. [Applause.] Observe that these figures apply only to medical schools, and not to hospitals ; for to them the community has been wonderfully and praiseworthily generous. But, strange to say, though they have given many millions for hospitals, their gifts to create a profession, to educate the men who are to take the care not only of the patients in these hospitals, but of their own wives and children, have been but little over a half million. It is a wonderful lack of perception — perception of the fitness of things, nay, perception of the necessity of things — that the community does not see that it is quite as much their duty to create the facilities to make better doctors as to help the invalid and injured poor. [Applause.] I think another of the most important things in connection with such professors in the medical schools, and one that ought to be a duty, is that of visiting other great medical centres than their own, and seeing other men, surgeons and physicians, and bacteriologists and pathologists, and chemists and clinicians, do their work. I do not know anything that is more inspiring to me. I do not know any- thing that I learn more from than a day in Baltimore, a day in New York, a day in Boston, from time to time, when I see other men at work, and I gain many an idea, many a good point, many a wrinkle that serves me when I am caught in some case of great perplexity. It ought to be a duty, as well as a pleasure, to every teacher to go and see other men teach ; and he will learn one of two things, either how to teach better or, in some cases, how not to teach. [Applause.] There are a number of points that I had noted that I should like to consider at present, but I find that the time is slipping by, and I must confine my- self only to one or two. Allusion was made in Dr. Billings's address, as I said, to the students who are to be taught. I think it is a matter of great impor- tance, in considering the requirements for admission (a subject which has also been alluded to both in the report of your Executive Committee and of the Presi- dent), that the good work at the threshold of medi- cine should be carried further. I am glad to con- IO gratulate you, gentlemen, on the fact that it is being so nobly carried on by Harvard University. I do not know a better indication for the future of the medical profession in this country than the very fact that was alluded to by Dr. Langmaid a moment ago, — of the increased requirements for admission to be exacted in 1896 in this ancient and honorable School. Now, it is perfectly true, as has been urged and as was urged anew in Washington, that we must remember that medical education is for the average medical student, that it is for the medical students who are going to the country cross-roads to settle as well as the men who are going to settle on Beacon Street, or, rather, perhaps I ought to say on Boylston Street. [Laugh- ter.] We must remember, however, that Harvard College can afford, gentlemen, to take an advanced stand. She can afford to do so, because she is Harvard College, because she can set the pace in this matter. You need not fear but that there will be all over the country other schools that will educate the cross-roads doctor, — plenty of them. They will spring up — nay, they have sprung up — almost in every hamlet, and a good many of them have died; and the more that die, the better. As a matter of fact, there will always be enough of those who will educate men for the lower strata; but there ought to be some colleges — and Harvard University should be one of those colleges, and I am glad to say that it is one — that will educate the very best doctors. I believe it II will be only a short time when you will fling your banner to the breeze, and say that A.B. or its equiv- alent shall be the absolute requirement for admission to the Harvard Medical School. [Applause.] I am not one of those who would, at the present time at least, unduly lengthen our course. I alluded a moment ago to the wave of medical improvement that had swept over our methods of education lately. One of the best evidences of this is the large number of colleges within the very last few years — nay, within the last two years — that are urging and insisting upon a four years' medical course. It was but last week, in reading the medical journals, that I found, way off in distant Oregon, that the State Board of Medical Examiners had issued notice that after 1898 no per- son would be admitted to practice in the State of Oregon who had not had four years of medical study. [Applause.] We must look to it that in the East we are not outdone by the West. Not only our medical colleges, but our State Boards, must exact such a large and wise requirement as that, or we will be overrun with the horde of doctors that cannot find a place in the West. Among the methods of study I can only allude to two. One is that we have not in this country at all such service as there is abroad by the Chefs de Clinique. It may possibly exist ; but I am not per- sonally aware of such instruction to practitioners as draws not only students from all parts of our own 12 country, but — as I hope will not be far hence — from Europe as well. Only the other day I was reading a report by Dr. Laurent, of Brussels, on the medical schools of this country. He remarked in the very beginning of it that some people thought there was not very much to be learned from this country ; but he added very significantly, " On marche la-bas a pas de geant." I believe that these giant strides will soon carry us to a position such that men from abroad will be able to come here, and get in our own schools exactly the teaching that many of us have had in Paris or Vienna or Berlin, from the Chefs de Clinique, or men who occupy similar posi- tions here. Its use in training the chefs themselves as clinical teachers would by no means be its least useful function. Second, a great deal has been said of late in reference to the value of recitation as opposed to didactic instruction. Now, I believe thoroughly in recitations. I am glad to see that Harvard has estab- lished them. I believe they ought to be official ; that is to say, compulsory. Every man of the class should go before the examiner from day to day, and not merely before the professor for an examination at the end of his term ; and he should be marked by this official quiz-master, and his standing be determined by his recitations as well as by his final examination. But, gentlemen, I do not believe that the time will ever come when the living voice, when the personality 13 of the speaker, will be discontinued and forgotten. I shall never forget, for instance, one story that was told by dear old Charles D. Meigs, whom you remem- ber, perhaps, as being rather worsted in the fight with Dr. Holmes over the contagiousness of puerperal fever. It was an illustration to emphasize the point which he wished to inculcate in his obstetrical lect- ures, that the child should be put to the breast very early. He gave a description, which I will not at- tempt to rival, — for it is one of the most beautiful pieces of poetry in prose that I ever heard, — of the birth of Cain. He pictured the beautiful bower to which Eve retired and the pains that she suddenly felt, which — for it was rather a novel experience to her — she thought must be due to some grapes that she had eaten the day before that had disagreed with her. Finally, she fainted away for a moment. Then, on waking, she found her slippery little Cain, and, lifting him up in surprise in her arms, he fell into nature's cradle, and immediately took the breast. It was a very simple little story, but it was beautifully told; and to this day, more than thirty years since, it is as fresh to me in its grace and in its lesson as it was then. And, again, I shall never forget the power of Samuel D. Gross. When lecturing on diseases of joints, he began with the question of treatment, look- ing round the amphitheatre very quietly, he said, " The first requisite in the treatment of inflammation of a joint is rest," then after a pause, " rest" ; and 14 then, rising to his full height and folding his arms, he bent majestically forward, and repeated, " In the name of God, Rest." Now you might read that ten times in a book, and forget it the next minute ; but once hear it from the lips of Gross, with his tall form, fine figure, and handsome, earnest face, and I would defy you to forget it. [Applause.] • BIOMED LIB. UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This book is DUE on the last date stamped below. mjJMD P.L- j Form LO-Series 4030 UC SOUTHERN REGIONAL LIBRARY FACILITY AA 001 190 212 9