MEDICAL EDUCATION AND 
LEGISLATION: 
FROM THE 
VALEDICTORY ADDRESS 
To the Class of 92, Missouri Medical College, 
BY 
Geo. J. Engelmann, M. D., 
SAINT LOUIS. 
Professor of Diseases of Women and Operative Midwifery, 
Missouri Medical College; Hon. President First In- 
ternational Congress of Gynecology; Late Pres- 
ident of the Southern Surgical and Gyneco- 
logical Society; of the St. Louis Obstet- 
rical and Gynecological Society. 
Fellow of the American Gynecological Society; of the 
London Obstetrical Society; of the British 
Gynecological Society, Etc., Etc. 
Imprint: THE MEDICAL FORTNIGHTLY, Saint Louis, U. S. A Reprinted from The Medical FORTNIGHTLY, St. Louis; April 15, 1892. 
Medical Education and Legislation. 
From the Valedictory Address to the Class of 1893, Fifty=first Annual Commencement of the 
Missouri Medical College, St. Louis, March 15, 1892. 
Prof. George J. Engelmann, A.M., M. D. 
SAINT LOUIS, 
Ladies and Gentlemen: 
YOU, who grace this occasion with your presence, will bear with me, as 
friends of the young men who graduate here to-night; as friends of 
this institution, as citizens of this state, if I address you upon a 
subject which is neither pleasing nor entertaining, but timely and pertinent to 
the occasion. It is the subject of medical reform—of medical education and 
legislation, important to us all as citizens and as individuals—as living hu- 
man organisms subject to disease, and it is important, above all, to us in this 
grea4-, state of Missouri, which as yet lags behind even her younger sister- 
states, regardless of the efforts of her profession. 
We are well aware that proficiency and success in any branch of the 
arts and sciences—in any form of useful activity in life—demands more or 
less preparation; and that the time which may have been allotted for such 
preparation, fifty and even twenty years ago, can no longer suffice in the 
present state of our civilization, which has advanced with giant stride's, 
seemingly more and more rapid as we near the close of this wonderful nine- 
teenth century. Throughout our great country we see this exemplified in the expanse and development of preparatory and educational institutions of all 
kinds. 
And what, pray, do we see in this our own state of Missouri ? I 
will not direct your attention to the striking progress in our admirable public 
school system—the foundation of all preparation and education ; nor will I 
ask you to consider the preparatory schooling of the student of the Arts and 
Sciences, as it would lead to unnecessary detail. Give but a thought to the 
preparatory training demanded of those who engage in occupations which 
we have been in the habit of looking upon as far more simple, and not requir- 
ing training and study. 
Look upon the Manual Training School, a pioneer institution, and a model 
for its kind, where brain and arm are trained in the use of the tools of trade. 
We have the Nurses’ Training School, where for full two years, the young 
woman, adapted by qualities mental and physical to the occupation of her 
choice, is instructed in the theory, and taught in the practice of nursing. 
Those of us who have the good fortune to have had her aid at the bedside, 
and those of you, to whom she has ministered in disease, with skilled and 
gentle hand—we all cheerfully recognize the blessings of such training. 
It may be a surprise to many of you to know what is taught in the 
School for Garden Pupils—an institution established in connection with the 
Missouri Botanic Garden—the pride of our city—by the forethought and 
munificence of that large-hearted philanthropist, Henry Shaw. 
The garden-pupil who spends his first year with the hoe and the spade, 
in the practice of his art, is only admitted after an examination upon the 
subjects taught in the upper classes of the grammar schools; more is asked 
of him before he is allowed to enter this school than is asked by many of our 
medical colleges of those whom they admit within their portals. He is instruct- 
ed in botany and entomology, in vegetable physiology and forestry, in floral 
culture and in orchard-culture, in vegetable-gardening and landscape-garden- 
ing, in drawing, surveying and book-keeping. 
The curriculum has just been reduced from a term of six years to one 
of four years. 
Four years of theory and practice for the progressive gardener before 
fruit tree or flower are entrusted to his care. 
And what do the laws of Missouri require of him into whose hands 
health and happiness, yea, life and death of her citizens are given ? Two 
terms of study, of six months each! 
It is not so long ago that the young man who had read medicine for a few 
years with some busy preceptor, was allowed, after attendance upon one 
course of lectures in a medical college, to offer his services to the public as a 
practitioner of medicine. Then, as our shifting population became more 
firmly settled, more time was allowed for medical education, and it was 
deemed proper that the physician should have spent at least two years in 
the lecture halls of a medical college before graduating; and such is our con- 
dition still—whilst in our more progressive sister-states, three full courses of 
lectures and four years of medical study are demanded before the degree of 
Doctor of Medicine is granted, or the license to practice within their bound- 
aries is given; and before the close of the present year such will be the law in three-fifths of the states of our Union. Two years of study still admit to 
practice in this state; this will hardly appear to you a desirable condition of 
affairs, and you will naturally inquire why is this so? What are the causes? 
the results? the remedies? 
Ere I answer these questions, let us briefly review the present status 
of medical education in this country. 
In 1891, according to the Report of the Illinois State Board of Health, to 
which I refer for all the following facts, we find in existence in the United 
States 111 institutions in which regular medicine is taught, and which have 
the power to confer degrees in medicine; that is, 111 institutions whose di- 
plomas are recognized by the Boards of Health in the majority of such States 
as have special laws governing the practice of medicine. Including inferior 
and irregular schools, we have a grand total of 135. 
In 1883, these institutions graduated 2,000 Doctors of Medicine; this 
annual harvest, added to the imported medical talent, swelled the number of 
those who practiced the healing art to such numbers, all in all, regulars and 
irregulars, that in these United States we find one practitioner of medicine 
(of some kind) to every six hundred inhabitants. 
It will be of interest to make some comparisons between the number and 
character of our institution's and those of other countries. To the 135 med- 
ical schools of the United States, or if you prefer, to the in in thoroughly 
good standing, recognized by every Board of Health, Canada appears with 
13 institutions in which a medical education can be acquired; Great Britain 
has 13; France only 6; in Germany we find 20, a comparatively large num- 
ber, which is explained by the previous independence of the various smaller 
principalities, each one of which has its university. Spain and Mexico each 
have 9 medical schools, Austria 7, and Turkey 2. 
In the United States we have one practitioner of medicine to every 600 
inhabitants; in Germany we find (me in every 3,000; in Austria one in every 
2,500; in France one in 1,814; in Great Britain one in 1,652, and in Canada 
one in 1,193. 
If we compare the time required for study in our medical schools with 
that demanded by foreign institutions, we will see that the study of medicine 
is, to say the least, greatly facilitated, is indeed underrated, made little of 
in the majority of institutions in this country. In 1891, eighty-five medical 
colleges throughout the various states of the Union made three years of 
study obligatory. The remaining forty-six still adhere to the two-year sys- 
tem. Italy, Spain and most of the South American countries require six 
years of study. In Russia five are necessary, in Germany, in Austria, and 
in England four years. That is to say, the examination for the degree of 
Doctor of Medicine can, at the earliest, be attempted after four full years, or 
eight semesters, of study. Hence, practically, the term of study in all 
European countries is at least five or six years, to the two and three years, 
consisting of one obligatory six months’ course each, in these United States. 
Abroad, no one is admitted to the study of medicine until he has absolved 
a course of study equal to that of the college in this country, whilst the pre- 
liminary examination demanded by the majority of our medical schools is 
merely nominal and scarcely covers perfection in the three R’s. Not alone must sufficient time be given that medicine may be thoroughly taught, but 
the soil must be prepared, if the seed is to develop, and it can be taught only 
to those already trained to study. 
In the number of diploma-granting medical institutions, as in other 
things, we lead the world ; but when we inquire more fully into the charac- 
ter of many of our institutions and into the state of medical teaching in our 
land, our pride must suffer a shock—a rude shock. Let us be candid: The 
medical world knows the facts ; why should not the American doctor ac- 
knowledge them, and the American citizen know them ? 
Highly as the brilliant men of our profession—and we have many of 
them—are honored and esteemed abroad, the American diploma is ignored 
1 am unjust; the diploma of all American nations is honored, but not that of 
the grandest of them all, these United States. It is a sad fact that the 
diploma of but few of our medical schools is recognized. The civilized world 
knows that a medical education cannot be acquired until the solid foundation 
of a thorough general education is first given ; the world knows that thorough 
medical education, such as the welfare of the people demands at the present 
day, cannot be acquired, even by the most gifted, with less than three years’ 
attendance upon lectures and clinics, and the world knows that the majority 
of our medical schools demand neither such preliminary education, nor a cur- 
riculum sufficiently long or thorough. We must know and face these 
humiliating facts; you may say that this is a young country; but so is Can- 
ada and Mexico; so is Cuba, Brazil and poor little Chili. These states 
expect what other countries do of the student and of the graduate in medicine, 
and their diplomas are respected. The diploma of every medical school of 
these United States must acquire for itself the same standing: and if the 
faculty does not arise to the demands of the higher education of the day, the 
people through their legislators must protect their interests at home and their 
standing abroad. Let the people of t!*is country who so proudly claim to 
stand in the very front ranks of modern civilization, thoroughly realize the 
wretched state of many of our medical schools, and they will soon force a 
change; they will no longer be behind-—far behind, though we now be—what 
we are pleased to term the effete monarchies of the East or the semi-civilized 
natives of the West. 
Medical practice and medical instruction must be brought to a certain 
standard, and the highest standard demanded by the law in this country is 
still below that required by any other civilized nation. We have too man)/ 
medical schools; it is evidently not the love for medical science which accounts 
for the superabundance of such institutions in this country; we must look 
to causes less lofty. Might it be the desire for title, for position and prom- 
inence ? Might it be the desire for the “ professorship ” which brings a cer- 
tain amount of publicity, perhaps of notoriety, if not distinction, at times 
remuneration ? A full-fledged medical institution is quickly hatched, when- 
ever the demand for professorships arises ! A charter is easily acquired 
under the lax laws prevailing in many of our states, and trustees with nom- 
inal duties are readily found. 
Students are attracted with ease; a small fee, a short course, and a 
diploma soon granted, will at any time concentrate a number of ambitious youths, and deprive the counter, the work-shop and the plow of worthy fol- 
lowers, We of this country do as we will. 
1 have given you the impression that there is much in our system of 
medical education which is not as it should be. This is true indeed, but 
readily explained by our youth, our independence of action and the extreme 
freedom permitted by our laws. Yet the standard of medical education is 
rapidly advancing, and our best institutions rival the first of any land. Great 
have been the changes wrought of late, and 1 am proud to say that from our 
sister State of Illinois came that great wave of medical reform which is now 
surging over the land. To the impetus given by the action of the State 
Board of Health of Illinois, and its able Secretary, Dr. Rauch, whose name 
must ever be mentioned in connection with medical legislation and education, 
is due the present greatly improved status. 
The leading medical institutions of this country, eighty-five in number, 
demand of their students an attendance upon three full courses of lectures 
for graduation, and a preliminary examination, many of them a preceding 
year of study with a preceptor, making the full term of medical instruction 
four years. We have thirty-two medical examining boards in this country, 
which are independent of teaching, and which aid in guarding their states 
against the influx of ignorant practitioners. All but five of our states have 
enacted practice laws, some of them, indeed, merely demanding registration 
of a diploma ; but the States of Minnesota, of Montana, North Dakota, 
Washington, California, Colorado, New York, Illinois, lowa and Oregon 
issue the license to practice medicine within their limits only to such appli- 
cant cis can certify to attendance upon three full courses of medical lectures— 
who can present the diploma of a three-term medical college. 
This result, gratifying indeed, has been achieved by the combined action 
of independent and advanced medical colleges, and by legislation, as ordained 
by the demands of a progressive profession and an enlightened public. And 
why is this not so in our own State of Missouri ? 
Our State Board of Health is noted in the Illinois Report of 1891 as hav- 
ing under consideration and contemplation the early adoption of the require- 
ments of a three years' graded course, and four years of study for the medical 
colleges of the state, but we now know that the ‘Board has refused us this law, 
as our legislature has denied it to us ! 
What then is our position amid our sister-states who have yielded to the 
demands of progress and of higher medical education ? 
It is mortifying to us> her citizens. Few restrictions are placed upon 
the practice of medicine within the borders of this commonwealth, which 
offers a fair field for those whom the more stringent laws of other states ex- 
clude from the practice of medicine, as dangerous to the community. But 
few of the fourteen medical colleges upon her soil as yet actually demand of 
their students three years of study for graduation. 
Unless a change takes place, the young men who graduate in the col- 
leges of Missouri will be debarred, in other states, from the practice of the 
profession they believe to have entered. They will be debarred from the 
practice of medicine in the State of Illinois ; they cannot exercise the skill 
they have acquired, on yonder side of this Mississippi river. Not in Illinois to the East, not in lowa to the North, not in the younger states of Minnesota, 
of Montana, of Dakota, of Washington, of Colorado, or of California. 
The legislature of Missouri has denied our people the protection they 
sought. The bill prayed for by over fifteen hundred of the most enlightened 
of her profession, urged by the combined action of her medical colleges, de- 
manded by the sentiment of her people, and passed by the House, was 
defeated by the Senate. 
And upon what grounds were the Senators urged to that vote ? It was 
upon the ground of “class legislation ” and “injustice to the poor boy.” 
Such was the argument against the bill before the Senate committee. They 
were told by the representatives of the only medical college in this state 
which opposed the bill, that it was unconstitutional, as an act of class legis- 
lation, “discriminating between colleges,” and that it would be a “hardship 
to the poor boy” were he to be obliged to incur the increased expense of a 
third year of lectures and clinics.* 
In the Senate of this state lay the obstacle to the movement for medical 
reform. Checked and harrassed, halted for the time, the cause of medical 
education does still progress. Regardless of the defeat of this law regulating 
more strictly the practice of medicine in Missouri, the more advanced of her 
medical colleges have pledged allegiance to the cause of higher medical edu- 
cation and will soon adopt the three years’ graded course, as we see it now 
in this institution. ** 
It is now an assured fact that graduation in three-term medical schools 
only can admit the physician to practice in each and every state of this 
Union. Necessity will exact what the demands of the profession have failed 
to attain, as the student will hardly seek a diploma, granted after only two 
terms, which is refused by the laws of numerous states and does not permit 
the practice of medicine within their confines. 
The interests of the people and the interests of the profession, medical 
education and medical legislation go hand in hand, and the laws of the state 
will soon combine with our medical schools in the good cause. Public senti- 
ment and the necessity for self-protection, if not State pride and the spirit of 
progress, will, ere long, force our legislators to retrieve the unfortunate error 
of the past year, and they will enact for the state of Missouri such laws, 
regulating the practice of medicine, as will again place her foremost in the 
rank of progressive states. 
*The facts in the case are tersely and clearly stated by Dr. C, A. Todd in his letter to the Journal of the 
American Medical Association of April u, iSqi, p. 532; and to this 1 refer for a detailed statement of the affair. 
* * The medical journals are calling attention to this fact. Since delivering this address we find in the 
Journal of the American Medical Association of March 19th, a warning to St. Louis medical students, in which 
attention is called to the fact that most of the medical schools of this city demand only two courses of lectures 
and that “unless this is altered their graduates will find more than half of the states jof this Union closed against 
them.”