V 
 
THE MODERN UNIVERSITY SCHOOL— ITS 
 PURPOSES AND METHODS.* 
 
 JOHN M. DODSON, M.D. 
 
 CHICAGO. 
 
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 The earliest American medical schools were estab- 
 lished in connection with institutions of general learn- 
 ing, as would have been expected from the fact that the 
 physicians who founded them had been educated in 
 Great Britain and France, where the medical colleges 
 were, without exception, departments of universities. 
 Only a few of the American schools, however, were es- 
 tablished with such a relation, the larger majority be- 
 ing quite independent of any university or college con- 
 nection, so that in 1877, twenty-five years ago, less than 
 twenty of the sixty-five medical colleges then in exist- 
 ence were connected in any way with institutions of gen- 
 eral learning. Subsequent to that date, however, such 
 schools have become much more numerous, and of 
 the one hundred and fifty-eight medical schools at 
 present existing in America, between sixty and seventy 
 are connected with a university or college. 
 
 These facts suggest some interesting queries. Why 
 were not all of our medical schools, following the ex- 
 ample of those first founded, established in connection 
 with institutions of general learning ? What motives have 
 prompted the movement which, starting about 1880, lias 
 resulted in the large increase in medical schools so con- 
 nected? What is the nature of the relationship which 
 exists to-day between the medical schools and the uni- 
 versities with which they are connected ? Has this re- 
 
 * Read at the Annual Meeting of the Washington State Medical 
 Society. Tacoma, Wash., June 2C>. 1902. 
 
 p 10592 
 
2 
 
 lationship resulted in the largest possible measure of 
 advantage to either the medical school or the university ? 
 And finally, what should be the nature of this relation- 
 ship in order that the best results may be secured ? 
 
 THE DIFFERENT CONDITIONS IN THE EARLY DAYS. 
 
 In answer to the first query it may be noted' that there 
 were no universities in America in the broad, European 
 sense until comparatively recent years. Our institu- 
 tions of higher learning were, as most of them still re- 
 main, colleges, devoted to purely academic instruction, 
 in the classics, mathematics and philosophy. Such an 
 institution has nothing in common with the professional 
 school, and there can be little advantage or propriety 
 in any connection between them. Then, too, it was 
 hardly possible to establish the medical school on such 
 a basis as to make it a fit member of a university organ- 
 ization. The rapidly-growing country demanded phy- 
 sicians in large numbers, trained as best they might be 
 for practical life, but with requirements and the ex- 
 pense of the college course such as not to place it beyond 
 the reach of all but a few students. Until the middle 
 of the last century the majority of students entered the 
 practice of medicine through an apprenticeship with a 
 preceptor. The chief problem was how to induce these 
 students to spend any time at all in the medical school, 
 and to have exacted high requirements for admission, 
 and a prolonged and expensive course would have been 
 to defeat the very purpose for which the school* was es- 
 tablished. But a college with such standards, little or 
 no restriction as to preliminary education, graduating 
 after attendance on two, four or five months’ sessions 
 of repetitional lecture courses, could not fittingly have 
 been made a department of a true university. 
 
 Thus medical colleges came to be established by med- 
 ical men as independent institutions, sometimes, it is 
 true, with other than the highest motives, but, on the 
 whole, with an honest purpose to meet a real need. In 
 passing judgment on these colleges and their founders 
 due regard must be taken of the conditions which ob- 
 tained at the time they were organized. In the absence 
 of endowment or financial aid from the state the college 
 had no resources excepting from the fees of students, 
 which were of necessity low. It was imperative that 
 
3 
 
 the standards of the school should be such as to insure 
 a sufficient number of students to maintain it on a work- 
 ing basis. For the past twenty-five years there has been 
 no real demand for more medical colleges, and the judg- 
 ment if not the motives of those who have 
 instituted most of the colleges established within 
 this period may well be questioned, but previous 
 to that time the physicians who established the 
 medical colleges of the old type were, with few excep- 
 tions, animated by an honest purpose, and possessed a 
 logical and discriminating judgment in adjusting the 
 standards of education very closely to the needs and 
 conditions of the times. These institutions, sometimes 
 styled commercial, never, so far as I have knowledge, 
 yielded a direct money profit, though the indirect return 
 to the occupants of the clinical chairs was in many cases 
 large. Fortunately, the demand for physicians is no 
 longer such as to compel the maintenance of schools 
 with low standards. 
 
 THE TRUE UNIVERSITY. 
 
 The true university dates its inception in America 
 from the founding of the Johns Hopkins University, 
 which within a few months has celebrated its twenty- 
 fifth anniversary. From this institution, with its em- 
 phatic pronouncement that the extension of knowledge 
 by original investigation must constitute the very es- 
 sence of the true university, can be directly traced the 
 origin of the university idea in this country. Soon 
 Harvard. Yale, Columbia and Pennsylvania caught the 
 new spirit, and the founding of the Clark University in 
 the early ’80s, with the growth of Cornell and some of 
 the state universities, gave evidence of the fact that the 
 university idea had taken deep and abiding root in 
 American soil. Unfortunately, however, many other col- 
 leges, entirely lacking the means, the men or the equip- 
 ment essential for true university work, stimulated by a 
 feeling of rivalry, became ambitious to pose under the 
 larger name. Mistaking mere multiplicity of departments 
 and a large enrolment of students as the essential feat- 
 ures of the university, they promptly became, by a mere 
 process of rechristening, nominal universities. Natur- 
 ally the next step was to institute professional depart- 
 ments, and, as in many cases, colleges of law, medicine, 
 
4 
 
 dentistry, pharmacy and the like, already established and 
 prosperous, were located in more or less close proximity, 
 the ambitious university found it much easier to expand 
 along these lines by a process of amalgamation than 
 by the creation of wholly new departments. The pro- 
 fessional schools were, in most cases, more than willing 
 to enter into such an alliance, for they, too, had caught 
 the university idea in the same superficial way, and 
 had come to feel that a university connection of some 
 sort was the order# of the day, and that the medical 
 school must be so connected to be in vogue. Yet an- 
 other motive was found in many cases in the rapidly- 
 increasing cost of maintenance. The introduction of 
 laboratory methods, the necessity for salaried teachers in 
 the fundamental branches, and for the maintenance of 
 hospitals and dispensaries to provide adequate clinical 
 material had increased the cost of the medical course be- 
 yond the students ability to pay for it even when the 
 fees were increased to twice those formerly charged. It 
 was obvious that governmental aid or private endow- 
 ment must be had and that this could seldom be secured 
 by the medical college as an independent institution. 
 
 THE NOMINAL CONNECTION WITH A UNIVERSITY. 
 
 The character of the relationship, however, which 
 exists between the college or university and the medical 
 school has been in the large majority of cases purely 
 nominal, as evidence of which a specific case will 
 serve. I have in mind an institution which blos- 
 somed forth in a few months from a college with less 
 than four hundred students into a university with an 
 enrolment of nearly twenty-five hundred. An analysis 
 of the student list, however, discovers the fact that about 
 eight hundred of these students were in the medical 
 college, which had added to its title “The Medical De- 
 partment University/' over four hundred were 
 
 in a dental college, similarly allied, some two hun- 
 dred in a law school, and a large number in a school of 
 pharmacy. The number of students in the actual col- 
 legiate departments had not increased nor had the num- 
 ber of members in the faculty, while the courses offered 
 and the character of the work done had not been ma- 
 terially altered. And what was the nature of the union 
 between this “university” and its constituent professional 
 
5 
 
 schools? Purely nominal. They had not surrendered 
 one iota of their autonomy. The separate board of 
 trustees and faculty were in each case retained intact, 
 having entire and unrestricted control over the finances 
 of the professional school, of appointments to its faculty, 
 of the standards of admission and graduation, and of 
 all its other affairs. These departments were located 
 several miles from the university, and the only visible 
 evidence of their connection with it, aside from the 
 printed line on the announcements and letter heads, was 
 the appearance of the president of the university to con- 
 fer the degrees at the annual commencement. 
 
 While this example represents the extreme degree of 
 looseness, in such a connection, it differs only in a de- 
 gree from that of the large majority of the medical 
 schools now connected with universities in this country. 
 May not the real value of such an alliance, to either the 
 university or the professional school, be fairly ques- 
 tioned? There has been a disposition to attribute to 
 these university connections the rapid progress which 
 has taken place in medical education in recent years, 
 but it is difficult to conceive how such a purelv nominal 
 relation can have had much influence in this regard. 
 This progress, comprising the elevation of the stand- 
 ards of admission and graduation, the lengthening and 
 grading of the curriculum, the introduction of new 
 branches and of improved methods of instruction, has 
 come about as the inevitable result of the advancement 
 which has been going on in all lines of education. The 
 development of the true university and of the university 
 spirit in America has had much, indeed most, to do with 
 it, but not through any such nominal relationship 
 as in the case above cited. It is a singular fact that 
 even in the older medical schools, which were from their 
 inception university departments, the relation of the 
 medical with the general faculty has had so little of 
 unity or intimacy about it. The medical department is 
 usually removed by some distance from the university 
 proper, the faculties never meet together, and in almost 
 every respect the jnedical school is conducted as an inde- 
 pendent institution. 
 
 THE PROPER RELATIONSHIP TO THE UNIVERSITY. 
 
 The largest service can never be accomplished by the 
 
6 
 
 medical school nor can the fullest measure of advantage 
 result to it or to the university from such a purely 
 nominal relationship. What, then, should be the nature 
 of the union between the medical school and the uni- 
 versity of which it is a part ? 
 
 It must be made an intimate, integral part of the uni- 
 versity. Its financial management must be given over 
 wholly to the board of university trustees, a body of 
 laymen with large business experience, deriving no pe- 
 cuniary advantage from this position and commanding 
 the fullest confidence of the community. Only by such 
 an arrangement, and the assurance of wise and disin- 
 terested management which it affords, can private en- 
 dowment be successfully invited. It would be of distinct 
 advantage to the university to have at least one medical 
 man on this board of trustees. The medical teachers 
 must be members of the university faculty, sitting in 
 its councils and having a voice in the educational policy 
 of the whole institution, while, on the other hand, the 
 conduct of the medical work should be subject to the ad- 
 vice and approval of the general faculty. 
 
 THE FUNDAMENTAL BRANCHES. 
 
 The teaching of the fundamental medical branches 
 which constitute the first two years of the curriculum, as 
 now arranged, should be conducted in the corresponding 
 university departments of physics, chemistry, anatomy, 
 zoology, physiology and bacteriology. Even pharmacology 
 and fundamental pathology should be so taught, for in 
 the widest and best sense these sciences are branches of 
 general learning and should be provided for in the uni- 
 versity quite apart from their medical significance. The 
 advantages of such an arrangement are many and im- 
 portant. It will obviate the expensive duplication of 
 departments as they exist now under the prevailing sys- 
 tem. Most of these branches are at present taught in 
 the university proper, in well-appointed laboratories, by 
 men who are devoting their lives to research and teach- 
 ing in their respective lines, yet at the medical school 
 of the same institution this expensive equipment is 
 duplicated and another corps of teachers employed, 
 either on a similar basis, or more often as men who are 
 primarily practitioners of medicine, only incidentally 
 teaching these subjects in a perfunctory way while wait- 
 
ing for some incumbent of a clinical chair to vacate by 
 death, resignation or otherwise, and thus make possible 
 the fulfilment of their real ambition. Of more im- 
 portance is the fact that these subjects can only be 
 taught in the right way in the university proper, for 
 only there can they be so pursued as to lay a broad, 
 thorough foundation for their subsequent application 
 to clinical medicine. 
 
 MEDICINE AS APPLTED SCIENCE. 
 
 Medicine is applied science. Its practice consists in 
 the application of the principles, facts and methods of 
 chemistry, anatomy, etc., to the study and treatment of 
 the diseases and accidents of the living body. In the 
 pursuit of any applied science it is surely the logical 
 method to master the general principles and methods 
 first and to proceed therefrom to a study of their appli- 
 cation in any specific direction. Fundamentally the 
 chemistry which the physician needs to know is quite 
 the same as that required by the metallurgist, the man- 
 ufacturing chemist, the pharmacist, or one in any other 
 vocation where chemistry is concerned. It is only in the 
 application of chemistry along these special lines that 
 the methods differ. 
 
 The medical school has for years been attempting to 
 teach its students the fundamentals of chemistry and 
 their specific application at the same time. In the short 
 course of two five months* sessions there seemed to be no 
 escape from this. But what was the result? The stu- 
 dent, crowded for time and jealous of every minute, 
 sought to learn, as his professor sought to teach him, 
 those isolated facts of chemistry which seemed, at the 
 time, to have most direct bearing on medicine. Yet no 
 teacher, however wise, much less any student, could pos- 
 sibly anticipate the chemical knowledge which might 
 be of medical import a few years in the future, in the 
 rapidly-progressing art and science of medicine. The 
 result was a half knowledge mostly soon forgotten. If 
 the medical man is to have a groundwork in chemistry 
 which will enable .him to keep abreast with his pro- 
 fession, he must be so trained in the fundamental facts 
 and principles as to enable him to keep in touch with the 
 advances in that science, to read its literature intelli- 
 gently and to apply the frequent new discoveries to his 
 
8 
 
 daily work. To illustrate: ten years ago the remark- 
 able facts of physical chemistry relative lo the behavior 
 of mineral salts in very dilute solution — the so-called 
 ionic condition of matter— would have been pronounced 
 by any chemist as among the most theoretical and im- 
 practical facts of that science, yet already the investiga- 
 tions of Loeb and his pupils have demonstrated these 
 facts to have a most important bearing on physiology, 
 pathology and pharmacology. Indeed, it is not too 
 much to say that these facts of physical chemistry, 
 which we owe to Arrhenius and van PHoff, offer an ap- 
 parent promise of a solution of more problems in the 
 fundamental and practical medical sciences than any 
 others no ; w known to us. Few physicians trained by the 
 older methods of the medical school, have been able to 
 keep pace with these developments or even to read them 
 understanding^, but to the medical man who received 
 an adequate training in chemistry in a college or univer- 
 sity, they present little difficulty. 
 
 What has been said in reference to chemistry is equally 
 true of anatomy, both gross and microscopic, of neu- 
 rology, embryology, physiology and physiologic chem- 
 istry, of bacteriology and pathology. Studied primarily 
 in the atmosphere and by the methods of the univer- 
 sity the ground-work of these sciences is laid in a broad 
 and comprehensive manner wdiich enables the student 
 to follow their progress in later years and their specific 
 application to medicine and surgery is easily acquired. 
 Pursued in the illogical, unsystematic manner of former 
 years, they are never mastered and too often the physi- 
 cian soon awakes to the unpleasant consciousness that 
 the facts acquired at such a laborious expenditure of 
 time and energy have most of them flown from his mem- 
 ory. Not only has he failed to keep abreast with the 
 newer knowledge — he has forgotten the old. Life is 
 too short and time too precious to be wasted in memo- 
 rizing facts that must soon be forgotten. 
 
 THE BENEFITS OF THE UNIVERSITY ATMOSPHERE. 
 
 Great benefit will come to the student from two or 
 three years spent in the atmosphere of the university 
 in the daily companionship of men who are masters in 
 their several departments and who, as investigators, are 
 seeking to add new knowledge by their own discoveries. 
 
9 
 
 The spirit and method of the research worker is exactly 
 that of the successful practitioner of medicine whose 
 every case is a problem, never exactly like any other 
 that has been met before. Such problems are never 
 satisfactorily solved by routine rules of diagnosis and 
 treatment, but only by the exact painstaking examina- 
 tion of the facts in the particular case and the applica- 
 tion thereto of the principles of anatomy, physiology 
 and pathology. The successful practitioner is he who 
 is most completely a master of this “investigative” 
 ability, and who avoids most effectually the pressing 
 temptation to become a “routine” doctor. 
 
 Of the influence on the student of the social and 
 intellectual life of the university it is hardly neces- 
 sary to speak. No environment is more conducive to 
 the development of a strong, broad-minded influential 
 man and citizen, and that is what we would wish every 
 physician to be. The transfer of the teaching of the 
 fundamental branches to the halls and laboratories of 
 the university proper, will do more toward the creation 
 of a strong and influential profession than any other 
 plan that has yet been tried. For this reason, and be- 
 cause it is adaptable to so many medical schools, it 
 seems to me to be the most progressive and far-reaching 
 movement which has yet been made in medical education. 
 
 THE PURPOSES OF THE UNIVERSITY MEDICAL SCHOOL. 
 
 The purposes of the university medical school, organ- 
 ized on the lines indicated, will be broader and more 
 comprehensive than those of the existing medical 
 schools because of its larger facilities and possibilities. 
 They may be briefly summarized : 1. The preparation 
 
 of men for the practice of medicine — undergraduate 
 instruction; 2, the training of selected students for 
 teaching and research work ; 3, to offer opportunities 
 for practitioners to keep pace with the advance of medi- 
 cine — such as are now afforded by the policlinic 
 schools; 4, the preparation of men for public health 
 service; 5, to extend the bounds of medical knowledge 
 by affording opportunity and encouragement for re- 
 search work ; 6, to investigate and pronounce authorita- 
 tively on alleged new discoveries bearing on medicine, 
 and 7, to educate the public along medical lines by the 
 methods of university extension. 
 
10 
 
 THE UNDERGRADUATE STUDENT. 
 
 The preparation of young men for the practice of 
 medicine in the usual sense of the term, must always 
 constitute the largest and most important function of 
 the university medical school. And by this is meant the 
 education of students for the humblest as well as the 
 most exalted walks of the profession. Time was when 
 the college or university was an exclusive institution, 
 whose members were disposed to feel themselves re- 
 moved from the world at large, set apart for certain spe- 
 cial and exalted duties. Happily that time is past and 
 the modern university seeks above all things to keep in 
 touch with and to supply the needs of the world of 
 affairs, wherever and whenever it can do so. Witness 
 the rapid growth of the university extension, of corres- 
 pondence courses, of short courses in agriculture, peda- 
 gogy and the like, and of the establishment of depart- 
 ments of agriculture, economics, banking and com- 
 merce, journalism and other ultra-practical branches. 
 
 TIIE STANDARDS OF ADMISSION. 
 
 The attitude which the university medical school as- 
 sumes in regard to this matter will largely determine 
 its standards of admission and graduation. While the 
 university must stand always for the highest practicable 
 requirements, it seeks not to cut itself off from the 
 education of men who are needed for the work of the 
 world by placing these standards beyond the reach of all 
 but a few. Its requirements must be adjusted to the 
 conditions of the times and be gradually raised as the 
 community is educated up to their endorsement and to 
 the adequate appreciation and support of the men whom 
 the university has trained. It would be a great mis- 
 fortune if the university medical school were to confine 
 itself to the instruction of the select few who would 
 find adequate recompense for their expensive training 
 only in the higher walks of professional life. Such a 
 policy would inevitably result in a wide and ever widen- 
 ing breach between the few schools of this class, and 
 the great number of medical colleges with low stan- 
 dards to whom would fall the teaching of the rank and 
 file of the profession. 
 
 We hear much of an ideal standard of admission to 
 the medical school. And what may that be? Surely 
 
11 
 
 not the bachelor's degree, for as conferred in this coun- 
 try by the thousand or more institutions empowered 
 to grant it, it is no standard at all, its significance rang- 
 ing from less than many high school diplomas to that 
 conferred by the highest grade universities. One insti- 
 tution, to my knowledge, admits students from the 
 grammar school, confers a bachelor's degree after two 
 sessions of fifty weeks each, allowing the student during 
 the same period to complete the course for the degree 
 of Ph.G. If knowledge of certain specific branches 
 be demanded in addition to the bachelor's degree, may it 
 not well be asked why, if these are the essential things, 
 the degree should be made a prerequisite at all? 
 
 The degree which affords the nearest approach to an 
 ideal is that of Ph.D. This degree has been guarded 
 with much more care in America than any other. It 
 certifies, when from any standard institution, that the 
 student has not only pursued a seven years' course of 
 collegiate instruction, but that he has given evidence of 
 capacity as an investigator — of the very qualities of 
 mind, indeed, which are most demanded in the study 
 and practice of medicine. But would any one contend 
 that such a requirement could reasonably be exacted 
 of all candidates for admission to the medical college 
 under the conditions and emoluments of private prac- 
 tice at present in vogue? Such a demand would be 
 “ideal" under ideal conditions and an ideal apprecia- 
 tion bv the public, of the physician's merit and the com- 
 pensation due him. but the truly “ideal" standard, in 
 the most useful sense of the word, is that which best 
 fits the graduate in medicine for the conditions of his 
 time, and this must be, for a long time to come, not a 
 fixed but a gradually increasing standard. 
 
 THE TRULY IDEAL STANDARD. 
 
 And what may be fairly demanded under existing 
 conditions? Bearing in mind the readiness with which 
 the medical schools have met the rapidly increasing de- 
 mands of the last decade — demands, in large part cre- 
 ated by the schools themselves — there can reasonably 
 be exacted in the near future, by every medical school, 
 a four-year high-school education, and, in addition, two 
 years of college work, insisting that this be partly in 
 chemistry, physics, biology, mathematics, English, Ger- 
 
12 
 
 man and French — branches which are especially need- 
 ful as a preparation for medical work. And with such 
 a preparatory course the student can procure the 
 bachelor’s degree in the university medical school by 
 applying his credits for the first two years of his purely 
 medical work on the course for that decree, without 
 in any degree doing violence to existing university pro- 
 cedure. The fundamental medical branches, if taught 
 in the university itself, by university teachers and 
 university methods, have quite the same culture value 
 as have geology, astronomy or any of the other sciences, 
 and credits for work in these branches should count 
 on the scientific or arts course in exactly the same way. 
 Under such an arrangement the average student is able 
 to secure the degrees of B.S. and M.D. in from six to 
 six and a half years from the date of his entrance to 
 college, should begin his medical work at the age of 
 21 or 22, and be launched into practical life, with a year 
 of hospital training, at 26 or 27. The problem of 
 launching young men into professional life with an 
 adequate training at an earlier age than has been pos- 
 sible under the existing methods, has been much dis- 
 cussed by leading educators. In some of our best uni- 
 versities the course for the bachelor’s degree has been 
 shortened to three years. The plan here outlined, of 
 telescoping the literary or scientific with the profes- 
 sional course, where they so nearly correspond, seems 
 to offer a much more logical and satisfactory solution. 
 The advantage to many students of a complete colle- 
 giate course of four years, as precedent to the medical 
 school, is clearly recognized, and every inducement 
 should be offered such students to prolong their course 
 of preparation. The right of any school to insist on a 
 four years’ college course as a standard of admission 
 may not be gainsaid. It is only meant to contend that 
 it would be unfortunate for the community if all of the 
 high-grade schools were to adopt such a policy. 
 
 Should any special medical degree be conferred on 
 the student who has presented a bachelor’s degree for 
 admission? Not unless he gives evidence in his medi- 
 cal course of the superior capacity and attainments, 
 which he should have derived from his longer course of 
 preparation. And, if he does this, if he manifests the in- 
 vestigative ability, and accomplishes research work in 
 
13 
 
 the medical branches similar to that wmch is demanded 
 for a master’s degree or the degree of doctor of philoso- 
 phy, one of these degrees should be conferred. 
 
 THE PREPARATION OE TIIE TEACHER AND INVESTIGATOR. 
 
 Recent changes in the methods of medical education 
 have greatly increased the demand for men who have 
 been especially trained for the work of teaching and 
 investigation and who prepare themselves with the in- 
 tention of devoting their lives to such work. Not the 
 least, therefore, of the functions of the university med- 
 ical school will be the education of this class of stu- 
 dents. And how shall these students be selected ? Shall 
 the entrance requirements for these pupils be different 
 from those exacted of the larger group who are prepar- 
 ing for the practice of medicine? I believe not, for no 
 plan of examination can ever enable a faculty to select 
 such men so wisely as will the observation of their 
 daily work in the regular course of instruction. One 
 of the most capable and successful investigators and 
 teachers whom I have known possessed only a high 
 school diploma when he entered the medical school, yet 
 in his sophomore year he accomplished a piece of re- 
 search work which would have done credit to a doctor 
 of philosophy, and immediately after his graduation he 
 was appointed to a responsible university position, 
 which he fills with distinction. It is not at all certain 
 that this young man has done an unwise thing in fore- 
 going a collegiate career. True, his case is somewhat 
 of an exception to the general rule, but provision must 
 be made for such exceptions. Furthermore, it is of 
 mutual advantage to the research worker and to the or- 
 dinary student, that they be educated in the same insti- 
 tution and in daily contact with each other — to the 
 ordinary student because it is of the greatest advantage 
 to him that he should be in the atmosphere and should 
 catch the investigation spirit; from the standpoint of 
 the research worker because the selection of such men 
 can best be made from large groups of students who are 
 revealing their special abilities and characteristics to 
 their teachers in their daily work. 
 
 THE UNIVERSITY POLICLINIC. 
 
 In every progressive occupation, reports of progress 
 from all over the world find their way most quickly to 
 
14 
 
 the large centers and men who are themselves engaged 
 in teaching and investigation are most likely to keep 
 informed as to the new discoveries which are being 
 made. The physician engaged in a busy practice, far 
 removed from snch a center, finds it difficult, even with 
 the abundant current literature and the aid of a good 
 library and laboratory, to keep thoroughly abreast of 
 the times. He finds it of advantage, therefore, to seek 
 such a center from time to time, to spend a few weeks 
 in special postgraduate study. The necessity for this 
 sort of review on the part of the general practitioner 
 has been especially pressing during the last few years, 
 owing to the enormous and rapid advance of the medical 
 sciences. How great has been the demand for facilities 
 in this direction is evidenced by the large number of 
 policlinic and postgraduate schools which have come 
 into existence since 1882. These institutions have met 
 a real need and have been of great service, but it is not 
 too much to say that they have not been organized 
 on the best possible basis nor do they offer facilities for 
 the highest kind of work. A great varietv of work is 
 demanded by these policlinic students; some need 
 courses even more fundamental than the ordinary 
 undergraduate, for whole new sciences, like bacteriology, 
 have been created since these gentlemen took their med- 
 ical degrees; some few are really competent to enter 
 on the study of and preparation for a specialty, while 
 a few have the necessary equipment and qualities of 
 mind demanded by research work of a high order. To 
 adequately supply these various demands, needs an in- 
 stitution of large resources, a large faculty, and very 
 large hospital facilities. Only the university medical 
 school has anything like the equipment necessary for 
 this work, and the instruction of practitioners, in the 
 broadest, most complete manner, will constitute one of 
 its important functions. The university policlinic will 
 not be conducted on the “Make-a-specialist-of-vou-while- 
 you-wait” policy that has too often prevailed, but for the 
 sound and legitimate purpose of enabling the practi- 
 tioner to continue his student-life, and to keep in touch 
 with the new knowledge and improved methods so that 
 he may utilize them in his daily work. Its laboratories 
 and libraries will be at all times open to the physicians 
 in proximity to the university that they may the more 
 
15 
 
 thoroughly and exhaustively study their cases by the 
 methods and apparatus and the literature not otherwise 
 at their command. 
 
 THE EDUCATION 0 F THE SANITARIAN. 
 
 Courses in state medicine and sanitary science are a 
 pressing need of the time. Preventive medicine has 
 profited far more than curative medicine by the dis- 
 coveries of recent years, especially in bacteriology. Our 
 hope for the future lies in the education of the public 
 in regard to matters already well known to the profes- 
 sion, in the enactment of suitable laws, and in the effi- 
 ciency of properly trained health officers, city, state and 
 national. State medicine constitutes a distinct specialty 
 and its successful pursuit demands a particular course 
 of study which should extend over at least two years. 
 Nowhere can the facilities for such a course of post- 
 graduate instruction be adequately afforded excepting 
 in the university, with its many departments, its large 
 corps of trained investigators and teachers, and its well- 
 appointed laboratories. In the department of geology, 
 there may be studied the character of rocks and soils and 
 of physiography in their relation to water supply, 
 drainage, sewage disposal, and the like; in the depart- 
 ment of chemistry, instruction in water analysis, toxi- 
 cology and the chemistry of food and drug adulteration, 
 will be offered ; in the department of zoology, a knowl- 
 edge may be acquired of animal parasites and of the 
 microscopic examination of animal foodstuffs for their 
 detection; the department of bacteriology will occupy 
 a conspicuous position in this course in state medicine 
 for the study of the bacteriologic examination of water, 
 of milk, and other foods, and the detection of the vari- 
 ous pathogenic organisms; the theories and methods of 
 disinfection should be fundamentally studied; in 
 the department of pathology, connected as it must be 
 with a large hospital, there will be taught the methods 
 of conducting a postmortem examination, especially in 
 connection with medicolegal cases. And, finally, prac- 
 tical instruction must be afforded, in the health depart- 
 ment of the city itself, in such matters as house inspec- 
 tion, the testing of sewer traps and other plumbing, 
 public vaccination, the detection of cases of infectious 
 diseases, the institution and maintenance of quarantine, 
 
16 
 
 the registration of vital statistics, the best methods of 
 educating the community by the circulation of pamph- 
 lets, through the public press, and otherwise. There are 
 few health officers who would not heartily cooperate 
 with the university in offering such facilities as this, 
 as these students can be of great service to the health 
 department in the conduct of its daily work, and they 
 would thus make abundant return for the instruction 
 received. 
 
 THE PROMOTION OF RESEARCH WORK. 
 
 The obligation of the university and of everyone 
 connected with it. to extend the bounds of knowledge by 
 independent research, is now universally recognized. 
 Investigation of the unknown as distinguished from 
 mere appreciative study of the work of others, consti- 
 tutes the keynote of the modern university, and this will 
 be no less emphatically a feature of the medical than 
 of its other departments. Investigation is essential, 
 however, not simply that the bounds of knowledge may 
 be extended, but that the spirit and method of research 
 may be inculcated in every student. It is important 
 that this fact be kept in mind for a thorough apprecia- 
 tion of this purpose will affect most decidedly the atti- 
 tude of the teacher toward his pupils. He is not dis- 
 charging his full duty nor doing the largest service 
 when he confines his attention and devotes his best 
 energies to the few selected students who demonstrate 
 special capacity for such work and give promise of de- 
 veloping into competent investigators. Naturally, his 
 interest will be especially aroused in this group of pu- 
 pils. but he has no less an obligation to inculcate the 
 same spirit and to train in the same methods of work 
 the less capable individuals who are preparing for the 
 ordinary practice of medicine. 
 
 RESEARCH IN THE CLINICAL BRANCHES. 
 
 In several American universities superior opportuni- 
 ties for investigation in the fundamental medical 
 sciences of anatomy, physiology, chemistry, bacteri- 
 ology, pharmacology, embryology, physiological chem- 
 istry, and pathology, are now afforded, and research work 
 of a high order is being conducted in these branches. 
 Quite as important, however, are the clinical branches 
 of medicine and it remains for the university medical 
 
17 
 
 school to provide the men and the facilities to take 
 up research work along these lines. This means, in the 
 first place, the provision of a corps of teachers in each 
 of the clinical branches who, divorced entirely from 
 the labor and distractions of active practice, may de- 
 vote themselves unreservedly to teaching and investiga- 
 tion in their several departments. This does not by 
 any means imply that there will be no place in the 
 faculty of such a school for the teacher who is at the 
 same time a practitioner of medicine. Medicine, as has 
 been said before, is an applied science and in its teach- 
 ing force there will always be need of men who are 
 daily engaged in the application — the regular practice — 
 of their vocation. A large part of the necessary instruc- 
 tion of the student can only be accomplished by such 
 teachers. Nor will the active practitioner be excluded 
 from the privileges and obligations of research. Most 
 of the advances in medicine which have been made up 
 to the present time have been accomplished by physi- 
 cians in active practice. Doubtless some of these men 
 might have accomplished more in the way of discovery 
 had they been freed from the exacting duties of practice, 
 but we may not say this of them all. Some of these dis- 
 coverers doubtless found in the conditions of their daily 
 work the very incentive and environment which was 
 essential to their investigations. Certainly this has 
 been true in the other applied sciences, as, for example, 
 in electrical, mechanical and chemical engineering, 
 some of the most important discoveries in which, not 
 only in methods of application, but in fundamental 
 principles have been made by men who were practicing 
 engineers. 
 
 In the second place, investigation in the clinical 
 branches demands the provision of special hospitals, ab- 
 solutely under the control of the university, perfectly 
 equipped and adequately supported, where patients may 
 be studied under conditions which have not vet ob- 
 tained in full measure in any hospitals with which I am 
 acquainted. It will be of advantage, if there can be 
 brought together in such a hospital, from time to time, 
 groups of cases of the same or allied disorders. What 
 might not be discovered, for example, from an exhaus- 
 tive study of a group of forty or fifty cases of diabetes 
 mellitus, gathered in one building for a few months. 
 
18 
 
 where the condition could be absolutely controlled? 
 That every such hospital must have abundant labora- 
 tory facilities and a corps of trained assistants goes with- 
 out saying. 
 
 THE INVESTIGATION OF ALLEGED DISCOVERIES. 
 
 From time to time there arise in medicine fads and 
 Asms and Apathies, loudly heralded by their promul- 
 gators as the only and long-awaited panacea for all the 
 ills that flesh is heir to, and such has been the history 
 of the world since time began. Many such claimants 
 for popular credence carry their own refutation and are 
 no more worthy of investigation by the university than 
 would be the claims of the newspaper weather-prophet 
 or the street-corner astrologer and horologist. Some of 
 these passing fancies, however, take a strong hold on the 
 public mind, and much harm results, before the utter 
 falsity of the fad is demonstrated, or. possibly, the small 
 kernel of truth winnowed from the mass of chaff. Often 
 it would seem as if the credulity of the public were 
 in direct ratio to the absurdity of the claims of the 
 system. The fancied division in the public mind of 
 scientific medicine into so-called “schools,” and the 
 supposed animosity of the adherents of these schools to- 
 ward each other, has precluded the possibility of any 
 investigation and pronouncement from the independent 
 medical college having any considerable weight or au- 
 thority. May not the university with its large faculty, 
 representing many phases of thought, and free from the 
 suspicion of prejudice, perform an important service 
 to the community by the impartial investigation of 
 such claimants as seem at all worthy of serious con- 
 sideration, and a candid statement of the facts? In the 
 broad open spirit of liberality and desire for the truth, 
 which should characterize the university, the advocates 
 of any new system or Apathy might properly be invited 
 to present their claims before the faculty or a commis- 
 sion to be selected for that purpose. Such an investi- 
 gation as that conducted under the auspices of the uni- 
 versity of Pennsylvania a few years ago — the Seybert 
 Commission for the investigation of spiritualism — 
 occurs as an illustration of the thought here presented. 
 
 UNIVERSITY EXTENSION AS RELATED TO MEDICINE. 
 
 If the beneficent results to the recent enormous ad- 
 
19 
 
 vance in our knowledge of preventive medicine are 
 to be realized in any large measure, this can only be by 
 means of the education of the public in matters of per- 
 sonal and community hygiene. The medical profession 
 has been remiss in this direction, but this has been in 
 large part owing to the difficulty of addressing the pub- 
 lic without violating the established ethics of the pro- 
 fession. The practitioner, competent to give instruc- 
 tion, has hesitated to do so because of the certain im- 
 putation of ulterior motives, the charge that he was 
 seeking to exploit his knowledge and so secure his own 
 aggrandizement. A great work awaits the university 
 medical school which it can accomplish by adapting to 
 this purpose the university extension methods, which 
 have been so successful in other branches of learning. 
 Especially available for this service as lecturers and 
 writers will be those members of the medical faculty 
 who are not engaged in active practice, and to whom, 
 therefore, no suspicion of improper motives can attach. 
 The vital and well-established facts in reference to in- 
 fectious diseases, etc., advice in reference to personal 
 hygiene, clothing, food ; the abuse of intoxicants, the 
 need of legislation in reference to sanitary matters 
 and the enormous possibilities of wise enactments — 
 these are but some of the items which may be effectively 
 presented to the public by means of the university ex- 
 tension and correspondence courses, articles in the 
 newspapers and popular magazines, and through other 
 avenues of instruction. Existing organizations like 
 the social clubs for either sex, university extension cen- 
 ters, churches, and the like, may be readily utilized in 
 this work. 
 
 THE METHODS OF THE UNIVERSITY MEDICAL SCHOOL. 
 
 The methods of the university medical school will 
 differ in some respects radically from those which have 
 heretofore obtained. While didactic and so-called clini- 
 cal instruction to classes of 200 or 300 students may 
 continue to have place, that place will be a very limited 
 one. Students must be taught singly or in small groups 
 in the laboratory, at the bedside, and in the dispensary, 
 where they may train their faculties and acquire knowl- 
 edge at first hand by seeing, hearing and handling 
 things, instead of at second-hand by merely reading or 
 
20 
 
 hearing what some one else has had to say about them. 
 Then, too, education and not the imparting of informa- 
 tion will be the prime subject of instruction. In the 
 ten months formerly available there seemed so much 
 knowledge to impart that there appeared to be time for 
 little else, but with the thirty to thirty-six months now 
 occupied by the medical course, and with the obvious 
 impossibility of imparting any considerable fraction of 
 our medical store in thrice that time, it- has come to be 
 realized that the actual facts selected for the students 
 acquisition are of minor importance, but that it is a vital 
 matter that he acquire the ability to observe accurately, 
 record clearly and concisely and to think logically along 
 medical lines. This means that the scheduled work of 
 the curriculum must consume fewer hours of the day — 
 never to exceed six — that the remainder of his working 
 day may be spent in the library, or in his room learning 
 to use medical literature properly, to write clearly and 
 to think ! to think ! to think ! It is surprising how ab- 
 surdly overcrowded, and how utterly unbalanced the 
 curricula of most of our medical schools have grown. 
 In not a few of them, eight and even nine hours of 
 scheduled work being daily demanded. 
 
 THE ELECTIVE SYSTEM. 
 
 Nothing offers a more ready and satisfactory solution 
 of this difficulty than the elective system — so long and 
 successfully in vogue in some institutions of general 
 learning and recently adopted, in whole or in part, by 
 some medical schools. It may be defined as that plan 
 by which a student, pursuing a course for a degree, 
 is allowed some choice in the studies he shall pursue, 
 in his methods of study and of the teachers who shall 
 instruct him ; to adapt, in a word, his course of study to 
 his tastes, his ability and his needs. It finds its raison 
 d'etre in two fundamental and obvious facts : the vast- 
 ness of knowledge and the variability of individuals. 
 If it were possible to encompass all medical knowledge 
 within the limits of a four years* course of study, or if 
 it were possible to select for all students alike those 
 facts which are most essential for every one of them to 
 know, then the question of curriculum would present 
 little difficulty. Neither of these things is possible and 
 therefore the items of information which are acquired 
 
21 
 
 by each student, exclusive of a few of the fundamental 
 and important truths in each branch, are not of neces- 
 sity nor with advantage, the same for each student. 
 On the other hand, students differ very widely in mental 
 make-up, and no plan of education can be successful 
 in developing the best there is in each man which fails 
 to take cognizance of this fact and adapt its course of 
 preparation to each individual, or, rather, to permit the 
 student to so adapt it by the election of his work with 
 the advice and approval of his instructors. 
 
 It will be no purpose of the elective system to make 
 specialists of the undergraduate student, and any ten- 
 dency in this direction may be readily avoided. It is 
 unfortunate that the term “elective” should have been 
 used in such a restricted sense by some writers a s apply- 
 ing only to a system where the student is allowed ab- 
 solute freedom of choice as between major branches. 
 All of the advantages of election may be secured in full 
 measure by requiring a specified minimum of work in 
 each branch, as in anatomy, physiology, medicine, sur- 
 gery, obstetrics, and the like, but permitting choice as to 
 topics, methods of study and of teachers. Such a de- 
 mand together with the requirement of the approval 
 of a dean or other officer of the registration card, and 
 the subjection of the student to a thorough practical 
 examination in each of the major subjects, previous to 
 graduation, affords a perfect safeguard against this 
 abuse. Moreover, the good sense and judgment of the 
 student himself, which teachers are prone to under- 
 estimate, are, in themselves, a sufficient safeguard. 
 
 I have elsewhere discussed the merits of the elective 
 system as applied to medicine , 1 and the limits of this 
 address preclude a fuller presentation of this important 
 topic at this time. It will suffice to say that in the med- 
 ical schools where it has been adopted on the most lib- 
 eral lines, it has proven eminently satisfactory and has 
 been demonstrated to be quite as decided an advance 
 in the medical as in other departments of education. 
 
 THE CONTINUOUS SESSION. 
 
 The continuous session, in one form or another, will 
 be a conspicuous feature of the university medical 
 school; that is to say, the school will be in session, with 
 
 1. Bulletin of the Am. Acad, of Med.. July. 1900. 
 
perhaps slight intermission throughout the year in 
 northern climates where work in the summer months 
 is feasible. A board of trustees composed of business 
 men will be little likely to allow an expensive plant 
 to lie idle three or four months of the year, any more 
 than they would close a manufacturing plant, represent- 
 ing an investment of several millions of dollars, for a 
 like period. And this does not mean that only special 
 or supplemental courses for teachers, physicians or stu- 
 dents will be offered during vacation period, but that 
 full work will be done throughout the year, exactly the 
 same during the summer months as at other periods. 
 Such a plan is scarcely feasible except under the elective 
 system, for reasons sufficiently obvious. The continu- 
 ous session is especially advantageous to the self-sup- 
 porting student, who may often find it more convenient 
 to devote the winter months to some bread-winning oc- 
 cupation. It is, moreover, of assistance in subdividing 
 the classes, especially for clinical work, which can only 
 be done satisfactorily in small groups. Many diseases, 
 too, are to be seen and studied in the summer which are 
 peculiar to that season. The continuous session will 
 enable the ambitious, progressive student to shorten 
 the period between his matriculation and graduation, 
 and this ought to be made possible. It is true that this 
 is in contravention of the present medical practice acts 
 and of the rulings of the several state boards of medical 
 examiners — rulings which seemed necessary to correct 
 a serious evil at the time they were passed, but there is 
 no logical defense for the present chain and halter 
 method of hitching students together and compelling all 
 to go at an unvarying pace. A certain minimum 
 amount of accomplishment should be demanded, but 
 while. one student might require five full years to com- 
 plete such a course, another may do it equally well in 
 three, and he should be permitted to do so. Alexander 
 Hamilton completed a law course, ordinarily requiring 
 three vears, in four months — an extreme exception, to 
 be sure, but illustrative of the great difference in power 
 of accomplishment between individuals. 
 
 The same laboratory methods which have been so suc- 
 cessfully applied to the fundamental branches must be 
 utilized in the teaching of the clinical branches, and 
 this means that the medical school must have hospitals 
 
23 
 
 — not necessarily large — under its absolute control and 
 available for research work in the clinical branches by 
 all modern methods. It means, too, that some of the 
 clinical teachers will be wholly engaged in teaching and 
 research work to'the exclusion of practice, and an ade- 
 quate corps of trained assistants, both in laboratory and 
 clinical lines. The clinical faculty will, therefore, 
 comprise two classes — those who are exclusively devoted 
 to teaching, research work and hospital practice, and 
 who are adequately compensated therefor, and those who 
 are in active practice — both hospital and private, but 
 who devote a portion of their time to teaching and in- 
 vestigation. 
 
 THE EXTRAMURAL CLINIC. 
 
 While the university must have research hospitals 
 under its own control, the amount of clinical material 
 which is required for the large number of students is 
 so enormous, and the expense of maintaining large hos- 
 pitals so stupendous, that it seems unlikely that the 
 millions of money which such a plant would require will 
 be within the control of the university in the near fu- 
 ture. But even with unlimited means, it would be poor 
 business policy to neglect the large amount of clinical 
 material already available in existing hospitals, but 
 unutilized for teaching purposes, and especially would 
 this be unwise in view of the fact that the use of these 
 patients for teaching purposes is certain to be of great 
 advantage to the patients themselves. No patients are 
 so exhaustively examined, so carefully studied and so 
 well treated as those who are the subjects of clinical 
 teaching. 
 
 In almost every large city are hospitals in which the 
 members of the attending staff are anxious to teach ; and 
 students are sorely in need of clinical material. All of 
 this difficulty may be adjusted by a system of extramu- 
 ral clinics. Needless to say that the members of the 
 several staffs who are appointed to extramural positions 
 should be selected with due reference to their capacity 
 as teachers and investigators, and never should one be 
 given such an appointment merely because he can com- 
 mand a large amount of clinical material. By judicious 
 effort in many cases the appointment of competent men 
 can be secured to hospital staffs to the betterment of the 
 
24 
 
 clinic and the advantage of the patients, as well as for 
 the extension of the extramnral work. The removal of 
 these hospitals by some distance from the college is not 
 an insurmountable objection, for students will cheer- 
 fully go a considerable distance to receive such opportu- 
 nities if the courses are only so arranged that the time 
 spent in going and coming be not too great in propor- 
 tion to the hours occupied by the course. It is usually 
 best to arrange these courses so they will occupy a half- 
 day. In the very large cities the establishment of two 
 or three clinical centers, where students may remain 
 in residence for the whole or part of the year, will en- 
 able all of the hospitals to be easily reached. Extra- 
 mural teaching is only possible under the elective sys- 
 tem, where credit is given for the work on the course 
 for the degree, for the student’s time is too fully occu- 
 pied to permit of his giving much time to work which 
 carries no credit. The control of very large charity hos- 
 pitals by political appointment should be no discourage- 
 ment, for by the combined and persistent efforts of the 
 faculty, aided by the influential men of the board of 
 trustees, even these obtuse politicians can sooner or later 
 be convinced of the enormous advantage to the institu- 
 tion and its inmates of this kind of service. 
 
 The necessity for great care in the courteous and 
 careful handling of patients needs to be strongly empha- 
 sized, for nothing will be more certain to prejudice the 
 public against clinical work of this kind than a harsh, 
 discourteous manner on the part of the clinician, the 
 undue and unnecessary exposure of the body sometimes 
 resorted to, or the granting of too great liberty to the 
 thoughtless student. An undergraduate should rarely 
 be allowed to examine a patient except in the presence 
 of an instructor. Properly conducted, extramural clin- 
 ical teaching is of advantage to the patient, the student, 
 the attending physician, the hospital; indeed, to all 
 concerned, and it offers a ready and practical solution of 
 a serious difficulty which just now presents itself to the 
 medical school. 
 
 THE MIGRATION OF STUDENTS. 
 
 The migration of students from one school to an- 
 other, such as is common in the German universities, is 
 a plan which ought to be encouraged. Such a custom 
 
25 
 
 enlarges the student's latitude of election, broadens his 
 mental outlook, and the constant interchange of stu- 
 dents strengthens and stimulates the several colleges 
 and the individual teachers. 
 
 PRACTICAL EXAMINATIONS. 
 
 The question of thorough, practical examinations as 
 the final test of the student's ability to enter safely on 
 the practice of his profession, has been much neglected 
 in America. It is a matter of great importance and 
 must be satisfactorily solved by the university medical 
 school, but time does not permit a fuller discussion of 
 the matter in this address. 
 
 THE NEED OF ENDOWMENT. 
 
 The expense of carrying out the scheme which I have 
 briefly outlined for a modern medical school is enor- 
 mous. With the largest classes, and even prohibitory 
 fees, the income from tuition must fall far, far short 
 of meeting that cost. In a word, the cost of a modern 
 medical education has grown to be greatly in excess 
 of the student's ability to pay for it. State aid or pri- 
 vate endowment must be had if these plans are to be 
 realized. With our present outlook private benefi- 
 cence holds out much the larger promise, and in the 
 hope of such assistance there is every reason to feel 
 the greatest encouragement. The recent gifts to medi- 
 cal institutions and for the promotion of medical re- 
 search on a princely scale, furnish conclusive evidence 
 of the fact that men of Affairs and of large capital, 
 whose chief desire is to find a use for their means 
 which shall be of the largest service to the world, have 
 come to realize that, in these medical channels, large 
 gifts are more likely to yield a certain, speedy and 
 bountiful return in good to the world than in almost 
 any other. And so, in conclusion, let me assure you 
 that the outlook is most hopeful. The modern univer- 
 sity school is already in existence in three or four cities, 
 and while it has not yet come to its full glory and use- 
 fulness, we may rest assured that the signs are most 
 encouraging, and that in the near future we shall have 
 in operation in America medical schools in advance of 
 any which the world has yet seen. 
 

 

 
 

 
UNIVERSITY OF ILLINOI9-URBANA