Strictly Confidential I. H. C. D. R. 79 INTERNATIONAL HEALTH COMMISSION REPORT OF THE MEDICAL COMMISSION TO BRAZIL NEW YORK THE ROCKEFELLER FOUNDATION 1916 Strictly Confidential I. H. C. D. R. 79 INTERNATIONAL HEALTH COMMISSION REPORT OF THE MEDICAL COMMISSION TO BRAZIL Richard M. Pearce, Chairman John A. Ferrell Bailey K. Ashford William D. Garvey, Secretary NEW YORK THE ROCKEFELLER FOUNDATION 1916 CONTENTS I. Education in Brazil Introduction Classification of Schools Elementary Schools Secondary Education-the Gymnasium . Normal Schools Vocational and Industrial Schools . Professional Schools (i) Law (2) Engineering (3) Theology (4) Medical (5) Dentistry and Pharmacy . (6) Midwifery (7) Veterinary Medicine .... Teachers' Pensions Libraries II. The Hospitals and Dispensaries . III. The Medical Profession and the Practice of Medicine (1) General Impressions of Medicine in Brazil (2) Number and Distribution of Physicians . (3) Requirements for Licensure . (4) Miscellaneous Information IV. Final Comment and Suggestions . (1) Medical Education (2) Research in Medicine .... (3) Hospitals and Dispensaries PART I PART II Details of Medical Schools 3 PART I I. EDUCATION IN BRAZIL Introduction Education in Brazil theoretically is free, secular, and compulsory. As, however, the supplying of elementary and secondary schools by the govern- ment has not kept pace with the increase of children of school age education is in many communities largely in the hands of the private school, and as many of these are controlled by religious organiza- tions it is, therefore, not entirely secular. It must be admitted, however, that there is little effort in such schools at religious teaching. As for compul- sory education, some states, as Sao Paulo in 1893, established penalties for parents who neglected to send their children to school but it is difficult to en- force such laws for the state cannot afford to abolish private schools until the number of its public schools is adequate, and, moreover, it is not easy where private schools exist, to determine, without expensive supervision, whether all children attend school and receive a proper primary education. Moreover, in many instances-and this applies to Brazil generally -where public schools are insufficient and parents cannot afford private schools, the law as to com- pulsory education cannot be enforced. The diffi- culties in this regard are largely financial and there 5 cannot be the slightest doubt that Brazil, certainly since the founding of the republic, has made every effort to establish primary and secondary education on a proper basis. This ideal of popular education is reflected in the federal constitution, which pro- vides that no illiterate can exercise the franchise. The fact remains, however, that the facilities for primary education, except in the few large centers, are most unsatisfactory. TABLE I Illiteracy in Brazil as Shown (?) by Proportion of Voters to Population in Ten Cities Selected at Random (Figures from "Almanack Laemmert," 1915) State City Population Voters Pernambuco Belmonte 12,000 592 Bahia Bahia 300,000 7,805 Sao Paulo Campinas 100,000 14,500 4,408 Parana Castro 522 Rio Grande do Sul Rio Grande 75,000 5,762 Santa Catharina Joinville 32,000 12,000 2,842 Rio Grande do .Norte Santa Cruz 893 Rio de Janeiro Cantagallo 29,865 2,425 Minas Geraes Juiz de Fora 145,000 6,000 Alagoas Penedo 18,000 718 If the voting population of Brazil (Table I) is to be regarded as an index of the number of educated men Brazil is certainly in a bad way. The propor- tion of voters to population averages about i to 25, thus differing widely from the ratio of 1 to 5, con- sidered as normal for the United States. Factors other than illiteracy may be concerned in this matter of electorate but we have been told that while there is some indifference concerning the vote in Brazil 6 illiteracy is the chief factor in keeping the electorate at a low figure. If these figures and the conclusion drawn from them are correct, they explain the ex- treme liberalism of the Brazilian government to- wards private education. The government, either federal or of the states, cannot hope to bear at present the cost of educating the whole people and, therefore, they permit the establishment of private schools even when controlled by foreign influences, and even favor and indirectly aid them. This is particularly true in Sao Paulo, where one sees and hears of Anglo-Brazilian, Italian, and other private schools.1 The same liberal attitude exists towards secondary education, and although each state is supposed to have one-some have more-schools termed "gym- nasium" (or as in the federal district "Collegio"), supported and controlled by the government, these are considered merely as official or model schools for private schools to copy. The hold of the government on professional schools, or superior schools as they are called, is stronger. The most important of these have been established and are financed and absolutely con- trolled by the federal government. Thus the schools of medicine and engineering at Rio de Janeiro, of law at Sao Paulo, and mining at Ouro Preto, medicine at Bahia, and law at Recife, are federal institutions. Other professional faculties are affiliated with the federal government, inasmuch as by receiving federal subventions, they become 1 Almanack Laemmert states that in the city of Sao Paulo alone are 95 Italian schools. 7 amenable to federal supervision, even to the details of courses and the approval of professorial appoint- ments. This federal control, as we will see later, is strengthened by the fact that licensure to practice a profession is an affair of the union government. Sometimes a state with lax laws, as those of Rio Grande do Sul for medicine, encourages independent professional schools of inferior grade, but this, on account of close federal supervision, does not occur elsewhere in Brazil. On the other hand, foreign schools under wise management, as Mackenzie College of Sao Paulo, which has a school of civil engineering, and the Granbery College at Juiz de Fora (Minas Geraes), which has departments of dentistry and pharmacy, have developed as valuable adjuvants to the govern- ment systems of general and professional education. Finally the fact must be emphasized that Brazil has no universities of the type characteristic of the educational system of the United States. Groups of professional schools are sometimes referred to as universities, but these are merely affiliated pro- fessional schools. Moreover, the Brazilian system, which is based on the principle of a boy going di- rectly from the six-year's gymnasium course to the professional school, does not provide for what cor- responds to the four-year college course of the United States. Brazil's educational system sacrifices "cul- ture" for the immediately practical needs of the professions. It is doubtless the absence of oppor- tunity for general university education that en- hances the social prestige of a degree in law, medi- cine, or engineering. The latter become the equiva- 8 lent in Brazil of the degrees which, in other coun- tries, are considered indicative of a liberal education. With this general introduction we may present, before going into the details of the system, a synop- sis of the different types of Brazilian educational in- stitutions : i. Elementary Schools: (a) Supported by and controlled by state 1 or municipal government. (b) Private, but supposed to adhere to govern- ment standards. 2. Secondary Schools: (a) Official (model) gymnasium or collegio.1 (b) Private schools. 3. Normal Schools: Supported and controlled by states or municipalities. 4. To this classification must be added, although they are not a recognized part of the offi- cial educational system: (a) Commercial or business colleges. (b) Industrial or vocational schools. 5. Professional Schools: (a) Federal control and support. (b) Federal supervision but supported otherwise. (c) Independent. (For most part schools of pharmacy and dentistry.) 1 Those of federal district supported in part or entirely by the Union. 9 Elementary Schools We have found it impossible to obtain detailed information concerning elementary education in all the states of Brazil and have been forced to con- tent ourselves with a study of conditions in Sao Paulo and Rio de Janeiro. Some general figures for the entire country, more or less incomplete, are, how- ever, presented in Table IL1 The figures given for both schools and pupils in North Brazil are too incomplete to be of much value for purposes of comparison with South Brazil. It is noteworthy, however, that the average per cent of income spent on education in North Brazil is 11.3, while in South- ern Brazil it is 17.2. Only one state (Para) of northern Brazil passes the average of the southern states and only one of the southern states (Espirito Santo) falls below the average of the northern group. It is evident, therefore, that popular educa- tion in southern Brazil receives much greater sup- port than in the northern part of the country. If total expenditures are taken it is seen that the federal district and the state of Sao Paulo lead in the amount of money devoted to educational develop- ment. As a matter of fact, it is in these two political divisions, and Minas Geraes, that the greatest edu- cational progress has been made. In close relation to these, however, comes Rio Grande do Sul. In- deed, reference to Table II shows that Sao Paulo, 1 The figures of Table II are based on Buley's calculations collected from the Annuaire Brazil Economique for 1913 and represent statistics as of the year 1911; as no editions of the "Annuaire" have appeared since 1913 we have been unable to add to the figures. 10 Minas Geraes, and Rio Grande do Sul have more than half of all the primary schools in the republic. According to area, however, the highest proportion Illustrating Elementary Education in Brazil TABLE II State Population Schools Scholars Percentage of Revenue Spent on Education Actual Expense (J) in Pounds Sterling (2) North Brazil: Alagoas 1,500,000 12 19 200 Amazonas 300,000 12.25 147'000 Bahia 2,500,000 577 8.3 49 800 Ceara 1'200,000 344 15,000 14 3 34 320 Goyaz 350'000 11. 4 400 Maranhao 560,000 230 11. 17 600 Matto Grosso 180'000 4 691 6 7 16 080 Para 660,000 18 000 21 0 260 400 Parahyba 600,000 84 4,668 12. '24 000 Pernambuco 1,310'000 4 5 34 200 Piauhy 400'000 10 3 8 240 Rio Grande do Norte 360,000 13.75 ll'oOO Sergipe 480,000 15 6 18 720 Territory of Acre.. . 70,000 South Brazil: Espirito Santo 297,000 271 7,340 8. 24,000 Minas Geraes 4,000,000 1724 140,645 15 277 530 Parana 700'000 19. 65 500 Rio de Janeiro (St.). 1,000'000 877 58,233 17. 101,400 Rio de Janeiro (Fed. The figures for District) l,305,481| | 28 588 800 includ ed in St. Rio Grande do Sul.. 1,700,000 1197 85,000 21. 180,000 Sao Paulo 3,500,000 1445 157 791 15 688 000 Santa Catharina.... 500,000 213 6,866 15. 23',785 1 Calculated, for northern states, on basis of total revenue and per cent, spent for education. 2 Of all moneys spent on elementary education, 20 per cent, is repaid to states by federal government. 11 of elementary schools is doubtless in the federal district of Rio de Janeiro, but as it is impossible to determine how many of the total number for state and district are actually in the federal district it is impossible to affirm this statement. If, however, the federal district is excluded, Sao Paulo undoubtedly leads all states in the value of its schools and in the amount of money expended upon them.1 Its efforts are, however, dedicated chiefly to primary education, although it has three state gymnasia and has recently subsidized its new school of medicine and has an excellent polytechnic institute. In Appendix VI, Nos. 2 and 3, may be found the manuscript record of statistics concerning public and private schools of elementary, secondary and normal grades compiled from Almanack Laemmert. These are incomplete in that all cities and towns are not given but we believe that when information is given it may be considered as essentially correct. Because it is not complete for states we have made no effort to put this data into tabular form. It offers, however, much evidence indicating the prev- alence of schools in various cities in relation to. population and also indicates the relative propor- tion in the cities listed of private and public schools. The names of public schools are so various that con- fusion arises unless the value of these names is clearly understood. As we understand them, the names may be interpreted somewhat as follows: 1 See Appendix IV, No. 27, for (1) digest (1912) of laws re- lating to elementary education, and (2) report of department of education for state of Sao Paulo; also for school of this state see Appendix IV, No. 71, Vol. II. 12 (i) "Primeiro grupo escolar" refers to primary schools maintained by the government. (2) "Segundo grupo" and "escolar complementar" are of somewhat higher grade of the same system and equivalent to some grades of our grammar school. (3) "Gymnasio" represents secondary school sys- tem preparing for superior schools, with courses planned by the government. (4) "Institutio" is usually of indefinite secondary grade, but with emphasis on literary side and not official. (5) "Collegio" is indefinite and usually not offi- cial except in the case of the federal school, the Collegio Dom Pedro II, where it is equivalent to a gymnasium of arts and sciences. It is used com- monly by the Catholic schools and may also apply to schools covering a field anywhere between that of the elementary schools and the superior schools. (6) "Lyceo de Artes e Officios" refers to schools combining vocational and educational training; not official and are frequently night schools. (7) "Externato" and "Internato" refer to day and boarding pupils respectively. Every effort is being made in Brazil, particularly in the southern part of the country, to complete the system of elementary education, and although we were unable to obtain definite figures during our visit to Sao Paulo, we were assured that at the pres- ent time it was practically possible to provide schools for all children of the primary grade. This may be true of the city of Sao Paulo, but there is no evidence that it is true of the rest of Brazil. Nevertheless 13 all statistics show a healthy increase in the number of public schools, as may be seen by comparing figures in Table II with the following abstract from the Statesman's Year Book for 1910: "There existed in 1907 in the various states 7,089 public schools, of which 1,363 were in Minas Geraes, 1,144 in Rio Grande do Sul, and 1,112 in Sao Paulo." (Details concerning government regula- tion of primary schools, the curriculum, equipment, and duties of teachers, etc., may be found in Ap- pendix IV, No. 1, and for Minas Geraes, with table of schools, in Appendix IV, No. 138, Report of the Department of Education, "Relatorio," pages 149 to 476.) Secondary Education We have shown in the previous section how diffi- cult it is to gather exact statistics concerning elemen- tary schools but in connection with secondary and professional schools we find ourselves face to face with a more serious difficulty-the reorganization now going on of the higher schools under govern- ment control. The laws covering the proposed changes were passed under date of March 18, 1915, but the changes are so numerous and revolutionary that many institutions considered it unnecessary to publish catalogues for last year and have not yet been able to print new matter. Indeed, they have destroyed, or have refused to distribute, old material and we have found it exceedingly difficult to get the data descriptive of new conditions. We have, how- ever, been able to procure copies of the law of 1915 as well as of the old law of 1911, indicating the 14 changes in the system of secondary and superior edu- cation, and these are filed in Appendix IV, No. 29. It is impossible, however, without the old and new catalogues before us, to state definitely how impor- tant some of the changes are. Reorganization of Brazilian schools, as a result of new laws, is one of the difficulties that the schools are continually facing, for changes in the laws occur, as a rule, when a new ministry comes into office. As the theory of States Rights is quite strong in many parts of Brazil and as some states have a great dis- like of federal control, those changes are always accompanied by considerable disturbance. We have been told that in connection with the recent change some schools have refused to recognize the new laws, and that several institutions have sued the federal government for losses entailed by following the changes demanded. We have not become sufficiently familiar with the entire situation to hazard an opin- ion, but as most writers on education in Brazil have deplored the lack of central control we are inclined to regard the changes as tending to greater educa- tional stability and as destined eventually to benefit education in Brazil. Thus Speer1 states: "There are notable defects to be overcome in Brazil's edu- cational scheme. The country is immense and with- out any common and central educational organiza- tion." He also quotes Marrion 2 as follows: "In Brazil education is backward, due, in large measure, to the fact that it is one of the interests that is in 1 Speer, Robert E., "South American Problems," New York, 1913. 2 Marrion, Wilcox, "International Co-operation in South Amer- ican Education," the Student World, January, 1909. 15 the control of the states rather than in the hands of the federal authorities. In great centers like the capital, there is real interest in arts and letters but the doctrine of States Rights held in those outlying districts where the people themselves are not edu- cated imposes, from their point of view, practical obstacles to educational progress." As a result of our observations we are inclined to agree with the point of view expressed by these two students of the Brazilian system of education. There seems to be no doubt that recent and pres- ent disturbances are due to a gradual attempt on the part of the federal government to unify educational procedures. Definite reforms began during the presidency (1909) of Dr. Pecanha and were con- tinued by his successor, Marshal Hermes Da Fon- seca, an education expert, especially on the technical side. Moreover, it is not long since (1908) the Union passed laws authorizing the federal govern- ment to open and to subsidize schools on state terri- tory. This law, however, became inoperative, as the senate failed to vote the necessary budget, but it indicates the general tendency of the federal gov- ernment, as does also the law of 1911, which pre- vented the indiscriminate conferring, without ade- quate training or examination, of the degree of "Doctor." 1 This privilege was formerly enjoyed by many irresponsible schools all over the country. 1 This is the old problem of the social and political value of the degree "Doctor" discussed in a later section (see page ). Oakenfull (Brazil in 1913) estimates that under the old condi- tions not 20 per cent of the students graduating from professional schools went into the practice of their profession but looked in- stead for government employment. 16 The recent changes under the law of 1915 we will indicate whenever possible but in some instances, on account of the impossibility of obtaining new cata- logues, the conditions of previous years must be recorded instead. The Gymnasium-The Collegio It is with the gymnasium that the Brazilian edu- cational system articulates from below and above. Speer states: "The strongest section of the educa- tional system in Brazil is the gymnasium. There are 20 such state institutions and some of them con- tain efficient and well equipped teachers, and accord- ing to Latin-American standards do good work." On the other hand, foreign-trained teachers, especi- ally English and American, criticize the gymnasium, saying that instruction is mainly on paper, is not practical, and that the examinations are often farcical. The truth probably lies somewhere between these extremes. The secondary school system is based on the estab- lishment, by the federal government and each state, of one gymnasium, sometimes more, known as the official or state gymnasium. This is financed and controlled by the government and is supposed to serve as a model to other private schools. The lat- ter, if they conform to government requirements, are officially recognized by the state and at one time graduates of such, as also of official schools, were admitted to professional schools without examina- tion, but the educational reform of 1911 abolished this privilege for both private and government gym- nasia. All graduates must now take an examination 17 for entrance into professional schools-an examina- tion, however, that is said to be, in many instances, merely perfunctory. As a matter of fact, every state does not appear to have an official gymnasium, and, on the other hand, at least one state, Sao Paulo, has three. As a rule they are overcrowded but to this Sao Paulo again offers an exception, for the one in its capital city is not well attended on account of the competition of the excellent private schools of that city. The other Sao Paulo gymnasia at Campinas and Ribeirao Preto are greatly favored. The private gymnasia, which are variously estimated at from 40 to 50, not only conform to government requirements but sometimes (and this is especially true of those under foreign control) go beyond such requirements. It is difficult to classify these schools, either private or public, by their name or curriculum. The term "coliegio" appears to be equivalent, in some in- stances, to "gymnasium," as, for example, in the case of the official school of the federal district, the Collegio Pedro II. Again, some of the official gymnasia combine both primary and secondary edu- cation and the catalogues are indefinite about the dividing line between these two courses. Also some private schools, especially those under foreign con- trol, are known as "colleges" but give elementary as well as secondary, and sometimes even professional, training. Thus MacKenzie College, of which this is true, gives work leading to degrees in letters and in civil engineering. Colleges in the American sense, that is institutions giving four years devoted to gen- eral cultural education without relation to vocational 17 or professional requirements, do not, as far as we have been able to determine, exist in Brazil. As to attendance in the schools of secondary educa- tion we can give few figures as Brazilian schools of all grades do not, as a rule, publish a list of students in their catalogues and general statistics, apparently, have not been collected. The figures for the fed- eral school (Coliegio Pedro II) are, however, doubtless representative. The session of this school for 1914 was attended by 275 students, including both day and boarding pupils. For the same school the faculty includes 21 professors, 4 masters, and 2 auxiliary teachers. The list of administrative offi- cers is twice as large as that of the teaching staff.1 The following regulations taken from the 1915 catalogue of Collegio Pedro II may be considered as characteristic of all gymnasia: Admission: Pupils must: (1) Be at least 11 and not more than 14 years of age; (2) Present certificate of vaccination; and (3) Certificate of freedom from infectious dis- eases. They must show fitness for the work of the school by tests in the reading and writing of Portuguese, in simple arithmetic, in geometric figures, in geography, and the history of Brazil. Preference in matricula- tion is given to sons of college professors, adminis- 1 In all our visitations to educational institutions, of whatever grade, we have been impressed by what appears to be an unneces- sarily large administrative staff independent of the teaching staff. 19 trative and institutional officers, public officials, and orphans in the order named. The number of board- ing pupils is limited to 200, of whom 50 pay no fees, and of day pupils to 400, of whom 100 pay no fees. Fees for boarding pupils are 18 milreis1 for matriculation and 900 milreis for a year's instruction; for day pupils the figures are 18 and 48. The salaries of professors are 9,600 milreis ($2,400) and of instructors of lower grades, 2,400 and 1,600 milreis. The gymnasium term usually runs from April 1st to November 15th. Below are given (1) the usual six-year course in vogue in most gymnasiums under the law of 1904, and (2) in Table III, the five-year course at Col- legio Pedro II on basis of law of March 8, 1915 : Six-year Course of Study in Official Gymnasium (From "Regulamento" approved 1904, pub- lished 1905) I. Languages- (a) Portuguese-language and literature-6 years-including literature of Brazil-| year. (b) French-5 years. (c) English-5 years. (d) German-3 years. (e) Latin-4 years. (f) Greek-3 years. 1 At present rate of exchange a milreis is about the equivalent of 25 cents U. S. money. 20 Five-Year Course in Federal School, Collegio Pedro II TABLE III Study 1st Year 2nd Year 3rd Year 4th Year 5th Year Portuguese 3 hours1 3 hours 3 hours French 80 lessons2 80 lessons 80 lessons English 3 hours 3 hours 3 hours German 3 " 3 " 3 " Latin 3 hours 3 hours 3 " Geography 80 lessons 80 lessons History (General) 3 hours History of Brazil 3 hours Arithmetic 3 hours Algebra and Geometry 3 hours Geometry and Trigonometry. 3 hours Physics 40 lessons 60 lessons Chemistry 40 " 20 " Natural History. 3 hours Philosophy, logic, psychology, etc 80 lessons Drawing 3 hours 3 hours 3 hours 3 hours 1 Per week. 2 Per term. II. Sciences- (a) Mathematics. (i) Arithmetic-2 years. (2) Algebra-3 years. (3) Geometry-2 years. (4) Trigonometry (part of one year.) (b) Mechanics and astronomy, 1 year. (c) Physics and chemistry, 2 years. (d) Natural history (including Zoology, Botany, Mineralogy and Geology, 2 years). III. Geography-3 years. 21 IV. History-Ancient civilization, Greece, Rome, Mediaeval and Modern History, 3 years. V. Logic-1 year. VI. Drawing-4 years. The schedule as given is all obligatory work except that the student has a choice between English and German. (For other details see pamphlets of Col- legio Pedro II, fded herewith in Appendix IV, No. 2. "Annuario" for 1914 contains a general history and digest of educational laws affecting secondary education while the "Regimento" and "Programma" include changes demanded by the law of March 18, 1915. See also catalogue of MacKenzie College of Sao Paulo, Appendix IV, No. 3. This latter school is organized under the laws of the State of New York and maintained, in part by the Presbyte- rian Board of Foreign Missions, which is affiliated with the University of the State of New York, the degrees being conferred by the Board of Regents in New York. See also Commission's notes, Appendix II, No. 21.) The Normal Schools These schools, which give instruction leading to the teacher's diploma, offer a four-year course. In all Brazil there are about 30 supported by the gov- ernment and about 15 more or less independent. The curriculum as given at the Escola Normal for the Federal District of Rio Janeiro for the year 1915 follows: 22 Portuguese-3 years (1st, 2d and 3d). French-2 years (1st and 2d). Literature of Brazil-1 year (2d). Arithmetic-1 year (1st). Algebra and geometry-1 year (2d). Penmanship-1 year (1st). Gymnastics-1 year (1st). Sewing (needle work)-2 years (3d and 4th). Manual training-2 years (3d and 4th). Music-2 years (1st and 2d). Geography-1 year (1st). History-2 years. 2d year-general. 3d year-Brazilian and civil. Drawing-3 years (2d, 3d and 4th). Physics and chemistry-1 year (3d). Natural history-1 year (4th). Pedagogy-1 year (4th). Hygiene and emergency aid-1 year (4th). In other schools some slight variations are found in order of studies or amount of time given to each, but all are essentially as given. The term is usually from March or April to November or December. Professors in this school receive salaries ranging from 4,800 milreis to 7,200 milreis, and the Direc- tor 12,000 milreis. (For other details see cata- logues of Escola Normal of Rio de Janeiro, filed in Appendix IV, No. 4.) VOCATIONAL AND INDUSTRIAL SCHOOLS These include all types of schools from the agri- cultural school to the most commercial of business col- 23 leges.1 Some, as agricultural and occasionally voca- tional schools, receive subventions from the govern- ment but for the most part their object is private gain. The agricultural schools fall so far outside the scope of a medical survey that we have investi- gated only such as advertise courses in veterinary medicine (see page 76). We have given little at- tention to vocational schools of this group, but one visited in the city of Sao Paulo, in that it presents so many points of interest and is so typical of a desir- able phase of effort, we feel obliged to describe in some detail. This is the "Lyceo de Artes e Officios," controlled by a society of the same name, an institu- tion for the training of artisans and essentially an arts and crafts school. It has had some little aid from the state and a few small private gifts but is essentially self-supporting. It consists of two buildings, one of which has a foundry and woodworking shop where iron work, mainly decorative, is made and also an abundance of the better type of furniture. In both lines handwork is encouraged and machine work reduced to a minimum. The second building is used as a night school for elementary instruction and also for instruction in drawing, painting, modeling, sculpturing, bookbind- ing, etc. In both, the boys are under the direction of older men. In the foundry and furniture shop the boys receive small wages and, in addition to this practical instruction, are given instruction also in the night school. The latter, however, includes 1 The "Statesman's Year Book" for 1907 says that Brazil has "28 industrial schools, 11 agricultural, and 9 commercial institu- tions for tuition." We have been unable to find later reports. 24 boys who do not work in the shops. All instruction is free. Profits in the shops pay the wages of the day boys and the expenses of the shop as well as the expenses of the night school. It is an excellent in- stitution, both as regards its function as a school and its function as a means of training artisans. All products turned out are of the highest quality and workmanship, and are in great demand. The ele- ment of charity is removed in the day school and its method of support makes it almost unique as an educational institution. Furthermore, it is for the community an important source of trained workers. Its moving spirit is F. P. Ramos de Azevedo, the most prominent architect of Sao Paulo and also pro- fessor of architecture in the polytechnic school. It appears to be largely his influence and ideals that have made the schools so distinctive. This school has been one of the most interesting educational experiments we have seen in Brazil and its methods suggest the possibility of their successful application to other communities, provided always they do not arouse the opposition of organized labor. It may be added here, parenthetically, that labor unions do not exist in Brazil except among stevedores of certain port cities. No description of this school has been published recently, but we file herewith printed mat- ter for the years 1903 to 1910 (see Appendix IV, No. 5), and a series of large photographs, for which we are indebted to Dr. Ramos de Azevedo, illustrat- ing some of the departments of the school and some of its products (Appendix V, No. 1). As an example of another school of this general type receiving state support, we present a brief state- 25 ment concerning the School of Liberal Arts and In- dustrial School of Parana: Course begins on the first day of July. The sub- jects taught are: Drawing, Painting, Sculpturing, Architecture, Music. fhe faculty is composed of: Professor of piano, Professor of painting (Directoress), Professor of artistic drawing, Professor of lineal and architectural drawing, Professor of vocal music. Number of students-both sexes: 302. Of these 191 received gratuitous tuition. The state gives an- nually ten contos; 1 the expenses per month being 956 milreis. The expenses: House rent 250 milreis Light (average) 80 milreis Professor of painting - milreis Professor of drawing 200 milreis Professor of lineal drawing. .100 milreis 2 professors of music 100 milreis Servants 90 milreis Gardener 20 milreis Piano rent 25 milreis Material for painting, etc.... 50 milreis XA conto is 1,000 milreis, about $250. 26 Professional Schools The only professional schools 1 which we have felt competent to investigate are those of medicine. For the sake, however, of completing this sketch a few notes concerning schools of law, engineering, the- ology, dentistry and pharmacy, have been included.2 Law schools: Law schools are maintained by the federal government at Sao Paulo and Recife (Per- nambuco), and more or less closely affiliated facul- ties of law are located in the cities of Rio de Janeiro and Bello Horizonte (Minas Geraes), Bahia, Ceara, Goyaz, Para, and Porto Alegre. Of these, that of Sao Paulo is very famous as a training school for both jurists and statesmen. Its classes are said to contain every year 5,000 students. The student enters the law school, as he does all professional schools, on the completion of his course in the gymnasium. The course in law covers five years and includes according to law of 1915 : 1 In Appendix VI, No. 4, may be found a list arranged by states of professional schools compiled from Almanack Laemmert, which includes also some information concerning faculty organization. Also in Appendix VI, No. 5, are given some of the schools of the Federal District. Neither list is complete. 2 Other schools which we must mention but which we feel are entirely outside the scope of our work are (1) the military and naval schools; (2) the schools for the blind, the deaf and dumb; (3) the School of Arts and the Institute of Music, and (4) the School of Applied and Social Science, all maintained by the Federal Government in the city of Rio de Janeiro. Academies of music are to be found also in the States of Maranhao, Para, Sao Paulo, Rio de Janeiro, Minas Geraes, and schools of fine arts in Manaos, Bahia, Curityba and Parana. 27 I st year-Philosophy of law : public, constitutional and Roman law; 2d year-International law, political economy, science of finance, and civil law; 3d year-Commercial and penal law and civil law continued; 4th year-The work of the 3d year is continued and in addition theory of civil and commercial process; 5th year-Practice of civil and commercial process, theory and practice of criminal process, legal medi- cine (Medico Publica '), law of administration, and private international law. (For further details concerning the law schools see pamphlets of the law school of Sao Paulo filed herewith, Appendix IV, No. 6.) Engineering Schools: These include also poly- technic schools and the School of Mines in Minas Geraes. The schools of Rio de Janeiro and Ouro Preto (Minas Geraes) are under federal control. Other schools of this class are at Recife (Pernam- buco), Bahia, Sao Paulo, and Porto Alegre (Rio Grande do Sul). The course in some schools, as the Escola Polytechnica at Rio, is four or five years, ac- cording to the phase of engineering the student de- sires to follow, while in others, as that of Sao Paulo, it is six years. In all schools the courses are ar- ranged so that general instruction is followed by special courses in (a) civil engineering; (b) mechani- cal and electrical engineering, and (c) industrial engi- 1 These are direct translations and may not correspond to the proper legal terms. 28 neering. The School of Mines in Minas Geraes, Brazil's great mining state, very naturally offers special training in mining engineering; on the other hand, that of Sao Paulo has special advanced courses in architecture. This last school was visited by the commission. It has about 230 students who pay a moderate fee of 200 milreis per year. The first three years of instruction are given to general train- ing and the last three to special lines of engineering effort. The school is housed in three buildings of modern construction and well equipped. The labora- tories of chemistry, four in number, have an abun- dance of apparatus and supplies, and each gives ample desk space for about 20 students. The equipment for physics, electrical work, microscopy, photography, and mineralogy, all seemed adequate and we were especially impressed with the testing rooms and prac- tical workshops. Models of all kinds were abun- dant and a great amount of space was set aside for drawing and also for a library said to contain 5,000 to 6,000 volumes. This school is especially fortu- nate in having on its faculty a number of foreign engineers who are interested in the various large tech- nical plants and construction schemes of Sao Paulo, thus bringing foreign training to the education of its students. (For further details of this school see pamphlets filed herewith, Appendix IV, No. 7. These include (1) publications of research work; (2) an historical account of the school, with many illustrations; and (3) an account of the municipal theatre built under the direction of professors in this school.) It may be added here that we have made many 29 inquiries concerning special training in sanitary en- gineering as a part of the curriculum of schools of engineering but have found no evidence that such instruction exists as definite courses. Lectures are given as in the Rio de Janeiro school on hygiene of buildings and sanitation of cities, but these are more from the practical architectural point of view than from that of sanitary engineering. Apparently no opportunity for training sanitary engineers exists in Brazil. Schools of Theology: The separation of church and state in Brazil naturally precludes the support or recognition of theological training by either fed- eral or state government, and the antagonistic atti- tude of the great mass of Brazilians to all religions has not encouraged the establishment of theological schools. Such schools as exist are maintained by religious organizations-Roman Catholic, Presbyte- rian, Baptist, Methodist, and Episcopal. We have visited none of these but are told that the Presbyte- rian School at Campinas (Sao Paulo) and the Meth- odist School at Juiz de Fora (Minas Geraes) are the most important. The Campinas School has been in existence about 40 years and is now under the direction of Dr. J. Rockwell Smith. The course is a two-year course and the classes average about 15 each. The faculty consists of 6 professors, two of whom are Americans. (For details see catalogue of this school and a statement by its Director filed herewith, Appendix IV, No. 8.) 30 MEDICAL SCHOOLS1 The medical schools of Brazil are: (i) Faculdade de Medicina de Rio de Janeiro, Federal District. (2) Faculdade de Medicina de Bahia, State of Bahia. (3) Faculdade de Medicina de Porto Alegre, State of Rio Grande do Sul. (4) Faculdade de Medicina e Cirurgia de Sao Paulo, State of Sao Paulo. (5) Faculdade de Medicina de Universidade do Parana, at Curityba, State of Parana. (6) Faculdade de Medicina de Bello Horizonte, State of Minas Geraes. (7) Escola de Medicina e Cirurgia de Uni- versidade de Sao Paulo. (8) Escola Medico Chirurgica de Porto Alegre. (9) Faculdade de Medicina Homeopathica do Rio Grande do Sul, located at Porto Alegre. (10) Faculdade de Medicina homeopathica de Rio de Janeiro, located in the Federal District. The faculties of Rio de Janeiro and Bahia are the oldest in Brazil, having been established under the Empire in 1808 and always controlled and financed by the central government, both under em- pire and republic. The faculty of Porto Alegre was established in 1899, is recognized by the federal government and is supported by students' fees and 1 For summary of important data concerning these schools see Tables IV and V. 31 TABLE IV 1 Medical Schools of Brazil Name State Q W i o Years in Course Annual No. of Students9 No. OF Professors' Teachers of | Other Grades4 Supported by " Faculdade": 1 Bahia Bahia 1808 6 600'0 55 45 Fed. Government 2 Rio de Janeiro Fed. Dist. 1808 6 1492 52 37 Fed. Government 3 Porto Alegre Rio Grande do Sul 1899 6 250 39 40 Students' fees5 4 Sao Paulo Sao Paulo 1912 6 165 22 17 State Government8 5 Bello Horizonte... Minas Ger- aes 1911 6 1202 38s 0 Students' fees5 6 Univ, of Parana at Curityba Parana 1913 6 292 22 0 Students' fees5 "Escola": 7 Porto Alegre Rio Grande do Sul 1915 4 902 18 0 Students' fees7 8 Univ. Sao Paulo... Sao Paulo 1912 5 160 26 0 Students' fees ''Homeopathic" : Students' fees Rio de Janeiro Fed. Dist. 1912 6 125 22 0 Porto Alegre Rio Grande do Sul 1914 4 402 16 0 Students' fees 1 Date of founding does not always correspond to admission of first class; this was usually a year later. 2 New schools not yet giving full course. 3 Includes Ordinaria and Extraordinaria ("cathedraticos" and "substitutes"). 4 Not always possible to determine how many of these are student assistants. 5 Also subventions from state or city or both. 6 Also students' fees which, however, are only 200 milreis ($50) a year. 7 Claims also contributions for dispensary from the charitably inclined. 8 Figures furnished by Director to cover full and assistant professors; catalogue (1915) gives only 19 professors. 9 Based on 1915 reports. 10 For 1916 matriculation is only 394. subventions from the state government (Rio Grande do Sul). All the other schools have been estab- lished during the past few years and none has yet graduated a class. The "Escola" 1 of Sao Paulo graduates its first class this year. 1 As both Porto Alegre and Sao Paulo have each two schools of entirely different type, to avoid confusion we will refer here- after to the better type of school by the designation of "Faculdade" and the poorer type by that of "Escola." 32 TABLE V Finances (l) of Medical Schools Name | Students' Fees j Professors' Salary2 Value of Plant 1915 Annual Budget8 Assistants' Salary' "Faculdade": 1 Bahia Jpg 1,053,000s 6,000to 9,600 per year 1-5,400 per year 2 Rio de Janeiro.. o £ 1,326,683s 3 Porto Alegre 250 10 per lecture 547,654 205,256 None 4 Sao Paulo 200 6,000 to9,800 per year7 420,000s 4,800 per year 5 Bello Horizonte... 400 3,000 350,000 65,000 6 Univ, of Parana at Curityba 400 5 per lecture 545,862' 325,006® None "Escola": 7 Porto Alegre. .. 400 3 per lecture 8 Univ.of Sao Paulo "Homeopathic": 9 Rio de Janeiro... 370 None 200,000 50,00010 10 Porto Alegre.... 200 23,000" 1 Figures are given in milreis of Brazilian currency; at present rate of exchange milreis equals 25 cents. 2 Includes professors " Cathedraticos " and "substitutes," but not contract professors. a Includes "assistentes" and "preparadores." 4 Figures for entire university in which medical school is housed. 5 Federal subvention. 6 Includes many items'of original equipment of laboratories and is for entire university. 7 One contract professor (anatomy and histology) receives 3,000 milreis a month, and contract professors of Pathology and Bacteriology each, 1,000 milreis a month. 8 Exclusive of students fees. ' State support. 10 Estimated and including students' fees. With an annual enrollment of about 1,500 stu- dents at Rio de Janeiro, of 600 at Bahia, and 250 at Porto Alegre, it is obvious that Brazilian physi- cians are largely the product of the faculties of Rio de Janeiro and Bahia. As a matter of fact, these have been heretofore the important schools of the country and graduation from either is looked upon with more or less pride. In recent years, however, Porto Alegre has done a good work in bringing 33 about an increase in the number of physicians in Rio Grande do Sul. Of the new schools the most important are the "Faculdade" of Sao Paulo, Bello Horizonte, and Curityba. All aim at fulfilling the functions of a state school and depend upon state subventions and students' fees for support. These three schools are recognized (?)* by the Federal government, but, except at the time of their inauguration, when the last two named received small subventions from the federal government, the latter gives them no finan- cial aid. The school at Sao Paulo is rather distinc- tive in that it is supported almost entirely by the State of Sao Paulo, and is, therefore, essentially a state medical school. The "Escola" at Sao Paulo and that at Porto Alegre are inferior schools without Federal recog- nition and without definite means of support other than students' fees. The Sao Paulo "Escola" is not even recognized by the state government, and it is problematical what is to become of its students when the first class graduates next fall. The "Escola" of Porto Alegre is an obvious attempt to take advan- tage of the lax laws of medical licensure in the state of Rio Grande do Sul. These laws will doubtless bring about a flooding of the state by poorly trained men, coming not only from the Escola of its own city but also from the poorer school of Sao Paulo. The two homeopathic schools at Porto Alegre and Rio de Janeiro, respectively, are poor schools 1 A school must be in existence for five years before the govern- ment grants recognition. It is said that these schools will be recognized as soon as this law will permit. 34 of the same type as the "escola" described above. Neither has yet received government recognition. With this brief statement of the status of the ten schools of medicine this discussion of medical educa- tion will be continued in: (i) a general statement concerning various phases of organization, equip- ment, and instruction, to be followed by (2) detailed descriptions of the schools as grouped by states.1 Buildings: The medical schools of Brazil are housed, as a rule, in a single building, a two-story structure with large central court. A large part of the space is given over to administrative offices and elaborate faculty rooms, with usually a spacious as- sembly chamber, which is used not for teaching, but for graduation exercises and other formal functions. These rooms are usually the most impressive part of the medical plant and have always been shown to us with great eclat, and it may be added that these features, with also the large number of, usually idle, administrative officers, have never failed to excite our amazement and wonder as a useless waste of good space and money. The lecture rooms, always abun- 1 Concerning defunct schools we have been unable to obtain much information. We have heard of schools established formerly at Ceara, Para, and the City of Rio de Janeiro, but these, as a rule poor schools, were forced out of existence by the promulga- tion of more stringent laws governing medical education and licensure. Unfortunately, Brazil has apparently no medical his- torian and it is impossible, therefore, to preface this account of medical education with the proper historical background. (Since this footnote was written we have come into possession of a pub- lication by the Academia Nacional de Medicina (See Appendix IV, No. 28) commemorating 100 years of medical education in Brazil and giving much important historical information. Un- fortunately, it was received too late for translation and incor- poration into this provisional report but can be utilized later. 35 dant, and sometimes with one for each laboratory department, vary from the most ornate, with indi- vidual chairs, to simple rooms with wooden benches. The details concerning laboratories we will present later, but here it may be stated that the dissecting room is always on the first floor, always more or less spacious, and is, as a rule, the best equipped of all departments for individual work by the student. Other laboratories are small and apparently in- tended merely for demonstrations in small groups rather than for individual work by the student. The school at Curityba shares the single building of the University of Parana with other departments, as engineering, law, commerce, and agriculture, and in this respect differs from all other schools of the country. The Faculdade at Porto Alegre teaches in three widely separated buildings, as does also the Escola of Sao Paulo. The Faculdade at Sao Paulo has two buildings only a few minutes' walk apart, with, in connection with the main building, a separate struc- ture for anatomy. The extra buildings at Porto Alegre are one for general laboratory work and one for dissection. The same arrangement holds for the Escola at Sao Paulo, except that the so-called laboratory building is given over almost entirely to medical and dental dispensaries, and the anatomical building is of interest in that it is a building in the corner of a cemetery, on the outskirts of the city. The second building of the Faculdade at Sao Paulo is devoted to histology, pathology, and bacteriology. The Escola at Porto Alegre occupies a remodelled dwelling house, a large part of which is given over 36 to a dispensary. The homeopathic school at Porto Alegre occupies one floor of an office building, as does also that of Rio de Janeiro. None of the schools of Brazil maintains its own general hospitals. The school at Curityba, however, maintains a ma- ternity hospital as does also that at Bahia. With the exception of the school at Rio de Janeiro, which is next door to the Santa Casa,1 and that at Bello Hori- zonte, which is about a block away from the hospital, all schools are more or less widely separated from hos- pitals. In the case of the Faculdade at Porto Alegre, which is removed only a few blocks, this is not, how- ever, a serious matter. The Escola of Porto Alegre and that of Sao Paulo have no hospital affiliations, but the Sao Paulo school states that it is about to build one. The homeopathic school of Rio has a ward in the Santa Casa and in the Military Hospital. The similar school of Porto Alegre is without hospital facilities. With the exception of the Faculdade of Sao Paulo, all the medical schools of Brazil offer allied courses in dentistry and pharmacy, and some of them courses also in midwifery. Such schools, there- fore, have a dental clinic and an elaborate pharmacy, both located usually in rooms adjacent to the main entrance of the school building. Other dispensary facilities are secured in the affiliated hospitals, but some schools, as the Escola of Porto Alegre and Sao Paulo, and the homeopathic schools of Porto Alegre and Rio de Janeiro, doubtless in an effort to make up for the absence of hospital facilities, 1 The usual name of a public charity hospital. 37 have established dispensaries of their own. A notable exception to the general rule concerning dis- pensaries is that found in Rio de Janeiro, where the Faculdade controls the Polyclinic, a large, well- equipped dispensary built largely at the expense of the federal government and supported by the chari- tably inclined. Three of the medical schools of Brazil are now planning new buildings, while a fourth has a new building under construction, and a fifth is remodel- ling an old building. The Faculdade of Porto Alegre has a new building partially erected, but work has stopped for the present on account of the financial stringency due to the European war. (For pictures of building see Appendix V, No. 2.) The Faculdade of Rio, as also that of Sao Paulo, has complete plans prepared and will start building as soon as the financial situation improves. (For pic- ture of proposed building of Sao Paulo see Appen- dix V, No. 3.) The Bello Horizonte school is en- larging its building and the homeopathic school of Rio de Janeiro is now moving into a remodelled building, which will be used as medical school, hos- pital, and dispensary. We have visited the new quarters of the homeopathic school at Rio and have examined the plans of the new buildings of the other schools, and while it is evident that the schools will gain space and be able to install modern equip- ment, there is no evidence that laboratory space sufficient for individual student work has been pro- vided. Administrative and Faculty Organization: All medical schools of Brazil are administered by a 38 director. In the case of federal schools, as those of Bahia and Rio de Janeiro, he is appointed by the president of the republic; elsewhere, as in Sao Paulo, by the governor of the state, or, as at Porto Alegre, is elected by vote of the faculty. This director may not necessarily be, but usually is, a member of the teaching staff. His duties are, in general, the administrative functions of the dean in American schools, and he is responsible for finances. He acts also as the go-between for government and Faculty and makes reports to the government through the medium of the Superior Council of Education; nominates to the government teachers of professional rank, and appoints, subject to the approval of the faculty, teachers of lower grade. With the director are associated in the administra- tive work of the school several other officials, as secretaries, treasurers, librarians, clerks, etc. (See Table VI, which gives a list of salaries of adminis- trative and instructorial staffs of federal schools, in- cluding law, medicine, engineering, and Coliegio Dom Pedro II.) According to the law of March 18, 1915, the teaching staffs of Brazilian professional schools in- clude, in the order of their rank: Professores cathedraticos, Professores substitutes, Professores honorarios, Professores simplementes, Livres docentes. In medical schools only the first and second are found, and the fifth are mentioned only in the cata- 39 Cargos Faculdades de Direito (Law) Faculdades de Medicina Escola Polytechnica Collegio D. Pedro II Ordenado Grati- ficacao Total Ordenado Grati- ficacao Total Ordenado Grati- ficacao Total Ordenado Grati- ficacao Total Director 6:0008000 6:0008000 9:2008000 6:0008000 6:0003000 6:0008000 6:0008000 6:0008000 6:0008000 6:0008000 Professor Cathedratico Professor Substituto 6:4008000 4:0008000 3:2008000 2:0008000 6:4008000 4:0008000 3:2008000 2:0008000 9:6008000 6:0008000 6:4008000 4:0008000 4:0008000 3:2008009 2:0008000 6:2008000 6:0008000 6:4008000 3:2008000 9:6008000 Professor 2:0008000 6:0008000 2:4008000 1:0008000 3:6008000 Assistente... 3:6008000 3:6008000 1:8008000 1:8008000 5:4008000 5:4008000 Preparador 3:6008000 1:8008000 5:4008000 1:6008000 8008000 2:4008000 Secretario 4:0008000 2:0008000 6:0008000 4:8008000 4:8008000 3:6008000 7:2008000 4:8008000 3:2008000 4:0008000 3:2008000 4:8008000 2:4008000 1:6008000 2:0008000 1:6008000 2:4003000 7:2008000 4:8008000 2:4008000 7:2008000 4:8008000 2:4008000 7:2008000 Sub-secretario 3:2008000 3:2008000 2:4008000 4:8008000 1:6008000 1:6008000 1:2008000 2:4008000 4:8008000 6:0008000 4:8008000 7:2008000 Bibliothecario . 4:0008000 3:2008000 4:8008000 2:0008000 1:6008000 2:4008000 6:0008000 Sub-bibliothecario Thesoureiro 4:8008000 7:2008000 4:8008000 2:4008000 7:2008000 Amanuense 2:4008000 1:2008000 3:6008000 2:4008000 1:2008000 3:6008000 2:4008000 1:2008000 3:8008000 Inspector de alumnos 1:6008000 8008000 2:4008000 Porteiro 1:8008000 9008000 2:7008000 1:8008000 9008000 2:7008000 2:2008000 1:1008000 3:3008000 1:6008000 8008000 2:4008000 Bedel 1:3338000 6668000 2:0008000 1:3338000 6668000 2:0008000 1:3338000 6668000 2:0008000 2:4008000 1:2008000 3:6008000 Conservador 1:6008000 8008000 2:4008000 1:6008000 800S000 2:4008000 Enfermeiro 1:6008000 8008000 2:4008000 Roupeiro.. . 1:6008000 8008000 2:4008000 TABLE VI-SALARIES IN FEDERAL SCHOOLS Instituto de Ensino Superior E Secundario 40 logues of the Faculdades of Rio de Janeiro and Bello Horizonte. The first type of professor named has the duties, privileges, and responsibilities of a full professor and appoints his own assistants and auxiliary staff; the second officiates in the absence of the full professor, assists the latter, and gives such other courses as may be approved by the faculty. These two correspond to the professor ordinarius and professor extraordinarius of the German sys- tem, and professor and assistant professor of the American system. The graded, salaried staff char- acteristic of the United States does not exist and, as a rule, so-called assistants are advanced students who serve as aides to the professor. In connection with this absence of a definitely graded system it must be remembered that, with few exceptions, the teachers of laboratory subjects in Brazil are not specialists in the various medical sciences, but clini- cians who lecture on physiology, pathology, or chem- istry, as the case may be, much as in the old days of the proprietory schools in the United States. Furthermore, as detailed individual instruction in the laboratory subjects is not given and research is not in vogue, there is no call for a graded staff of assistants. In the clinical subjects there is naturally no dearth of voluntary assistants who assist in teach- ing and devote the bulk of their time to practice. The livres docentes, who correspond practically to the p rival docent of the German system, are, in a sense, assistants in that they are appointed, after examination, on a basis which allows them to give special courses and to receive a certain percentage of the fees paid for such courses, and may be called 41 upon for more or less routine work in the depart- ment with which they are associated. The organization at the Bahia school consists of 30 professors of the first type and 25 of the second.1 Other instructors are listed as "preparadores" 20 and assistants 25. The former assist in the labora- tory work and the latter in clinical teaching. At the Rio school the two classes of professors number re- spectively 32 and 20; "preparadores" 10 and as- sistants 11, with a list of 16 livres docentes.2 The Faculdade of Porto Alegre gives in its 1915 cata- logue a list of 39 full professors, with no second grade, and with 40 auxiliary teachers (auxiliares de ensino), of whom three are classed as "chefe," two as "preparadores," three as "assistente," thirteen as "interno," thirteen as "ajudante," and six as "auxiliar practico." Of these terms "chefe," "pre- paradore," "ajudante," and "auxiliar practico" refer to the laboratory, and "interno" and "assistente" to clinical subjects. As only eight of the names have the prefix "Doctor," it is evident how freely students are used as assistants in this school. Figures as to the total number of teachers in other schools are im- possible, as they are all new schools and have not entirely completed their faculties. The by-laws of the Faculdade of Sao Paulo, however, provide for the usual professor and assistant professor and an 1 Taken from Almanack Laemmert for 1915. A catalogue of this school was not obtainable at the time of our visit, but answers to a questionnaire received since our return to the United States give a faculty of 48 professors and assistant professors. 2 Some other schools, as Bello Horizonte, speak of livres docentes in their regulations but the Rio school is the only school which gives a list of such. 42 assistant for each clinical chair, and a "preparador" for each of the other chairs.1 This school also pro- vides for contract professors, who represent a means of getting around the government regulation that only native Brazilians may hold chairs in schools controlled by the government. A contract pro- fessor is, therefore, a foreigner procured by special agreement for a period of years and usually at a higher salary than that received by other professors. Moreover, he is not appointed for life, as is the case when native Brazilians are selected. Contract professors, as might be expected, are to be found, as a rule, only in the laboratory chairs, although Bello Horizonte has one in ophthalmology. We have heard of them in medicine only at the Facul- dade of Sao Paulo, which has three contract pro- fessors-French, German, and Italian, respectively -in the departments of anatomy, pathology, and bacteriology, and of the Faculdade of Bello Hori- zonte, which has a German as professor of chem- istry. The Bello Horizonte school provides for two types of professors and livres docentes and for teachers of grade of "preparadores" and "assis- tentes." The University of Parana names only the two types of professors and states that as many auxiliary teachers may be appointed as may be necessary. From this account it is evident that the grouping of instructors is quite similar to that of the German 1 In a written communication from the secretary of this school the following terms are used: professor, associate professor, dem- onstrator, and assistant. 43 universities and when it is added that the subordi- nate teachers receive little or no compensation the analogy becomes more striking. But, practically, the result, especially in the laboratory branches, is quite different from that of the German system for the professors are not full-time teachers and research, which can be developed to its fullest extent only in departments manned by full-time teachers, is absent. This situation naturally fails to encourage the de- velopment of men devoting their entire time to the medical sciences and the career of a teacher and in- vestigator. Clinical medicine is the goal of all, and as a chair in any one of the sciences of medicine can be won by the clinician these branches of medicine suffer, and, therefore, medicine generally does not progress rapidly. The large number of professors in Brazilian medi- cal schools is due to several factors. One is the in- clusion of chairs in physics, chemistry, and natural history, subjects to which the first year of the six- year course is devoted. Another factor is subdivision of subjects, as pathology, into general pathology, medical pathology, surgical pathology, and patholog- ical anatomy and physiology.1 Also descriptive anatomy, taught in two different years, may have a different professor for each year with other pro- fessors for histology and applied anatomy, respec- 1 It should be explained, however, that much of what is taught in the American school, as principles and practice of medicine and surgery, is taught in Brazilian schools by the chairs of medical pathology and surgical pathology, which apparently are equiva- lent to our chairs of the principles and practice of medicine and surgery, respectively. 44 tively. Again, medicine and surgery usually have two or three chairs each, and, finally, schools offering courses in dentistry and pharmacy, as do all except the Faculdade of Sao Paulo, include in their faculty list several dental specialists, who supplement the teaching given by the regular medical faculty. It must be admitted, however, that the new schools show, at present, a tendency to smaller faculties; thus Bello Horizonte presents a list of 19 professors and the Parana school of 22, but these schools have not yet completed their organization and the graduation of first classes in the next few years may coincide with an announcement of the customary large Brazi- lian faculty. Finances: A general idea of the finances of the Brazilian medical schools may be obtained by con- sulting Tables IV, V, and VI. Table V is some- what incomplete in that exact figures on value of plants, etc., are not always available. Catalogues of Brazilian schools do not always give a financial statement, and sometimes when it is present the finances of the medical school are not separated, as in the case of the University of Parana, from those of other schools. Moreover, we have found a reti- cence on the part of the smaller and newer schools to give exact figures. The federal schools of Bahia and Rio de Janeiro and the state school-Faculdade-of Sao Paulo show, as might be expected, the largest budgets and the highest salaries. The Faculdade of Porto Ale- gre, a well-established school, comes next. The budget for Parana bulks large but much of this is for original equipment, the figures for annual main- 45 tenance not being given separately. In some of the other schools finances are estimated on the basis of students' fees and government subventions. The question of teachers' compensation is interest- ing. In the federal schools and the state school of Sao Paulo it is fixed by law and only in these are salaries for assistants definitely recognized. Else- where salaries, both for professors and assistants, are regulated by the faculty at so much per lecture for professors, and, as a rule, assistants are disregarded entirely except that here and there we find a state- ment that they receive a small honorarium. In most schools, outside of those specified, the director has flatly stated that assistants are not paid, but work for the school in the hope of future promotion. The "gratificacao," which figures so much in salary lists, means that if a professor gives a certain legally fixed amount of instruction he receives an extra compensa- tion. This is true also at a lower level, if the as- sistant professor takes his chief's work. Thus in the Faculdade of Porto Alegre the professors receive io milreis a lecture, and if at least io lectures are given in a month an additional 100 milreis for the month's work. Substitutes receive io milreis a lecture and an additional 50 milreis a month if 10 lectures are given. 1 he same system holds, variously modified, in all schools, but sometimes the rule is disregarded and extra compensation is paid, whether required work is done or not. It is obvious that this system of remuneration of full professors for lectures only and the failure to establish a staff of graded assist- ants, with proper basis of title and compensation, dis- courages proper laboratory work and prevents the 46 development of a group of men devoted to teaching and research. A distinct type of professor is the contract profes- sor (professores contractados), who is appointed for a term of years and usually at a larger salary than other professors. This is the result, as it has been explained to us, of the legal provision which allows only native Brazilians, who are appointed for life, to hold chairs in Brazilian schools. To get around this, foreigners are appointed by contract for a term of years, and as they usually represent special train- ing, especially in the laboratory subjects, and are frequently called from other countries, larger salaries than those received by natives are paid to them. The Faculdade of Sao Paulo, for example, has three con- tract professors, an Italian teaching anatomy and histology, at 36 1 contos a year; a second Italian teaching bacteriology, and a German teaching pa- thology, each of whom receive 12 contos a year. The German pathologist was formerly under con- tract with the faculty of Bello Horizonte, which has contract professors in chemistry and ophthalmology. One good point about the contract professor in la- boratory subjects is that, as a rule, he does not prac- tice and as he is a trained man he tends to develop teaching and research and the ideals of a full-time department. On the other hand, their presence is a criterion of the failure of the Brazilian medical sys- tem to develop among their own physicians specialists in the laboratory branches. It is significant that ex- cept in dentistry contract professors occur only in the new schools, indicating perhaps a desire on the 1 This usually large salary is due to the holding of two chairs. 47 part of these to avoid the teaching of laboratory sub- jects by clinicians; on the other hand, it may be that properly trained local men were not available. The matter of students' fees presents several points of interest. In the two federal schools the fees are 40 milreis per chair and the students must pay for matriculation and for diploma. Fees at the Facul- dade of Sao Paulo were originally only 100 milreis a year but for the present term have been increased to 200 to meet an anticipated decrease in the assist- ance from the state on account of the present financial crisis in Brazil and the cost of equipment for new laboratories. The highest fees, 400 milreis, are those of the poorer schools, as the Escola at Porto Alegre and the University of Curityba. The former charges also 100 milreis for diploma and 60 for dis- pensary facilities. The fees under all circumstances, however, are low compared with those in the United States, as the schools expect to make up deficits by subventions from the state and city in which they are located and occasionally, in the case of new buildings, by aid from the federal government. The federal government is always inclined to aid if the new build- ings or special laboratories tend to increase the pub- lic service. Thus the Faculdade at Porto Alegre, in good times, counts on 100 contos a year from the state of Rio Grande do Sul. At present it is not receiving this much. For its new building the state contributed, two years ago, 1,200 contos, but as the state cannot help at present the building remains un- finished. The director of the homeopathic school in Porto Alegre states that the school receives 5 contos a year 48 from the city and io from the state, and the director of the Escola of the same city says that similar amounts have been promised his school by city and state but both statements were qualified to indicate that the monies were really intended for the dispen- saries maintained by these schools. The University of Parana receives 36 contos from the state of Parana and 10 from the city of Curityba annually, but these sums are for all courses and not for medicine alone. Bello Horizonte has had subventions from the state of Minas Geraes and the city of Bello Horizonte amounting to 65 contos. When the school was started it received 30 contos from the federal government towards professors' salaries, but this has been discontinued. The endowment of higher institutions of learning so characteristic of the educational system of the United States is unknown in Brazil. Occasionally one hears of a privately endowed travelling fellow- ship but never of general endowment for buildings or special laboratories. City, state, and federal aid, with the assistance of very moderate students' fees, are the sources of support and the government aid is not always constant in amount, or, with the excep- tion of the federal schools and the state school of Sao Paulo, regularly given. It must be admitted, however, that the federal and state governments do everything in their power to aid professional educa- tion. Entrance Requirements: The law of March 18, 1915,1 provides that candidates for admission to 1 See Appendix IV, No. 29, with which is filed also the law of 1911. 49 schools of medicine, as all other professional schools, must be: (i) At least 16 years of age.1 (2) Of good moral character. (3) Must present evidence of having had a pre- liminary education equivalent to that of the official gymnasium. (4) Must pass an examination covering the work of the gymnasium course.2 Foreigners have to present consular certificates concerning their primary education. The examina- tions are both oral and written, the latter being lim- ited to translation from the French and the choice of translation from either English or German. The oral examinations include the elements of physics, chemistry, and natural history.3 These requirements are those stated in the law of 1915, but one finds in many catalogues provisions for examination also in geography, mathematics, and history. The poorer schools, as the Escola at Porto Alegre, under the freedom of the lax medical laws of Rio Grande do Sul, require (1) Portuguese; (2) the choice of French, German, English, or Italian; (3) geography and history; and (4) arithmetic and plain geometry. The homeopathic school of the same city does not state the subjects required for entrance examination. 1 Our inquiries indicate that the average age is about 18. 2 All schools controlled by the government require also a certifi- cate of vaccination, as also one stating that the individual is free from infectious diseases. 3 This includes zoology, botany, geology, and mineralogy. 50 The Curriculum: A glance at Table IV will in- dicate the length of the course in the various schools. Six years is the traditional course of the federal schools and this has been adopted by the schools of Porto Alegre, Parana, Bello Horizonte, and Sao Paulo, all schools recognized by the government. The second rate schools, as the Escola of Sao Paulo, offer a five-year course, and the Escola and homeo- pathic schools of Porto Alegre a four-year course. These latter, operating under the medical laws of the state of Rio Grande do Sul, make no attempt to conform to federal requirements. Both these schools run two terms each year, cutting the vacation down to about one month. They speak, therefore, of an eight-term course. All other schools run six terms, each from April to December, with about three months' vacation. The first year of all courses is given over largely, and in some schools entirely, to subjects really pre- liminary to medicine as (i) medical physics; (2) medical chemistry; and (3) medical natural history.1 Most schools call this year the first of the six-year course in medicine. The Faculdade of Sao Paulo, however, frankly terms it a preliminary year, fol- lowed by five years of medical instruction. The poorer schools of Porto Alegre finish off these sub- jects in the first term of their four-year course of eight terms. Some schools, as Bahia and Rio de Janeiro, include the first course of anatomy in the first year, as does Parana, which places here also histology, but relegates physics and chemistry to the 1 This includes zoology, botany, geology, and mineralogy. 51 second year. This year, except for a little anatomy in some schools, is essentially a preparatory year, the real medical course being one of five years. The distribution of courses 1 as provided by the federal law of 1915 is: 1st Year: Medical physics, medical chemistry, natural history of medicine. 2d Year: Descriptive anatomy (first part), his- tology, physiology (first part). 3d Year: Descriptive anatomy (second part), physiology (second part), microbiology, propae- deutic clinics in medicine and surgery. 4th Year: General pathology, pathological anat- omy and physiology, clinical dermatology, clinical ophthalmology, clinical surgery. 5th Year: Medical and surgical anatomy and practical surgery, therapeutics and prescription writ- ing, clinical surgery, clinical medicine, pediatrics, oto- rhino-laryngology, orthopedic surgery. 6th Year: Hygiene, legal medicine, clinical medi- cine, clinical obstetrics, clinical gynecology, clinical neurology, and clinical psychiatry. This arrangement is followed, in a general way, by all schools though here and there minor changes are found. Thus the Faculdade of Sao Paulo places pharmacology and materia medica in the second year and dermatology and laryngology in the third year and bacteriology in the fourth year. These, however, may be the temporary arrangements of a new school, which has not yet completed its entire faculty and is 1 For courses as advertised at Rio school see Appendix IV, No. 176. 52 still equipping laboratories for the fourth year work in pathology. It is worthy of note that the final examinations in anatomy and physiology are held in the 3d year and that practically all schools put pathology 1 in the fourth year, which brings it in after the completion of the study of normal anatomy and physiology and in close relation to the clinical subjects, an arrangement which is difficult in our American four-year course. Instruction in the Laboratory Branches: In con- nection with our statements concerning the actual teaching of medicine in Brazil it must be borne in mind that we visited Brazil during the summer vaca- tion and saw towards the end of our stay only two schools-the Faculdade of Sao Paulo and Rio de Janeiro-in session, and these, during the first days of the course when all was in confusion, and neither teachers nor students had settled down to practical laboratory and clinical work. We have, however, by careful examination of equipment, the question- ing of instructors, and the careful studying of cata- logues reached the opinion that instruction in the laboratory branches is almost entirely a matter of lectures and demonstrations, the latter being to the class as a whole, or in sections, and with very little of the thorough individual work by the student that is characteristic of the better type of American school. Anatomy and Dissection: The only exception to 1 General pathology in the Brazilian course is practically our theory and practice of medicine-pathological anatomy and physi- ology corresponding to our course in pathology, except that patho- logical histology is not so thoroughly given by the Brazilians. 53 the above statement is dissection, for which adequate facilities and material are almost always supplied. We have not, however, seen a dissecting room in operation and have no first hand knowledge as to how dissection is supervised. All departments of anatomy, except in the four poorer schools, have an abundance of charts, models, and wet and dry preparations to illustrate lectures, and the anatomical department of the Faculdade of Sao Paulo, with its modern equipment, is really a most complete plant for work in both descriptive and applied anatomy. Physiology: We have been told repeatedly that in physiology the students carry on experiments in sections but we have seen no laboratory, except that of the Faculdade of Sao Paulo, equipped with suffi- cient tables for such work. Usually a single large table is seen which could accommodate probably four students, and if students work at it in sections the classes at Bahia and Rio de Janeiro would necessarily be so divided that not more than four or five experi- ments could be done in a term. All equipment sug- gests demonstration by the teacher with, perhaps, students assisting, or special courses for small num- bers of students. We are satisfied that physiology, as it is taught in the better schools of the United States, is unknown in Brazil, and in this opinion we are supported by information obtained from students and recent graduates. An exception must be made in the case of the Faculdade of Sao Paulo, which has 24 tables for the simple experiments in physiology, and a second room containing the more delicate ap- paratus including an electro-cardiograph for demon- strations in large sections. Even here, however, it is 54 evident that the greater part of the practical teach- ing is by demonstration. Normal and Pathological Histology: Some effort is made in all schools to have the students study preparations of normal and diseased tissues micro- scopically, but the equipment of desks and micro- scopes is so inadequate that this is done by consider- able subdivision of classes into sections and, there- fore, results in cutting down the amount of material each class receives. For example, the Faculdade of Porto Alegre had six microscopes for histology, thus compelling a class of 30 to be divided into five sec- tions for individual work. In the same school, in a second laboratory, in which is taught pathological histology, bacteriology, clinical microscopy, and serology, only four microscopes were found. The Parana school had 16 desks for histology but only 4 microscopes/ Moreover, we have seen or heard nothing to indicate that histological study is carried on in the careful detailed way characteristic of Amer- ican schools. Also we have found no evidence to indicate practical instruction in embryology. We had the good fortune to see one class in normal his- tology at work. The procedure was for the profes- sor to find a field under the microscope and the class then took turns looking at the preparation while those not so occupied loafed about the room awaiting their turn. This class room had a good supply of desks but only two other microscopes were at hand. It must be admitted that we were told that other microscopes had been ordered but had not yet ar- rived. Some recent graduates tell us that the in- structors in both normal and pathological histology 55 direct the classes' attention to a certain field and then rapidly pass on to another, allowing no time for special study. The careful drawing of preparations by the student so characteristic of the American sys- tem is unknown in Brazil. In some schools, as the Escola at Porto Alegre and Sao Paulo, no distinct laboratory for pathology is at hand and in each of these schools only one microscope was found. At the Faculdade in Sao Paulo new laboratories now be- ing built for both normal and pathological histology should permit individual study of the best type. Pathological Anatomy: In pathological anatomy, on account of prejudice against autopsies and the rule that any relative may claim a body, the students see few post mortem examinations and little fresh mate- rial except that from operations. We have been unable to obtain definite figures concerning autopsies except that at the Santa Casa of Sao Paulo, which sends its material to the Faculdade of that city, 239 were made in a period of three years; that last year 120 were made at the Santa Casa of Rio de Janeiro, and 99 at the Santa Casa of Bello Horizonte in a year and a half. There i's, however, one other source of material for the demonstration of autopsy technique and that is the custom of some hospitals to send unclaimed dead to the pathological department as well as to the anatomical department. As a rule our questions concerning the amount of pathological material available were evaded and we were generally taken to the pathological museum, which, in Brazil, is not very well cared for, containing usually a col- lection of interesting specimens, both wet and dry, but with few preserved in natural colors, and the 56 entire collection, as a rule, of little value for practical instruction or detailed study by the student. At the Rio school it was stated that much fresh material comes from the insane asylum, where practically all dead are autopsied, and our visit to the asylum sup- ports this statement. Also at the Bahia school, al- though it is not in proximity to the hospital, we found an autopsy room in which, we were told, bodies were examined frequently in connection with instruction in pathology. Bacteriology: What has been said about normal and pathological histology is true at Parana and Porto Alegre of bacteriology as far as the supply of microscopes is concerned and at these schools it is difficult to see how the course in bacteriology can be anything else except a demonstration course. On the other hand, Bello Horizonte has a well equipped laboratory of 20 desks supplied with Zeiss micro- scopes, and the course given by Dr. Diaz, an asso- ciate of the Oswaldo Cruz Institute, appears to be a good one. At Sao Paulo plans for the laboratory now being equipped under the direction of Professor Carini, formerly state bacteriologist, promise indi- vidual work by the student. The bacteriological laboratory at Bahia is well equipped but small, that at Rio deficient in microscopes and it is difficult to see how the large classes of these two institutions can receive proper instruction in bacteriology. Re- cent graduates state frankly that the course at Rio is poor and that students desiring a practical knowl- edge of bacteriology take the special courses offered by the Institute Oswaldo Cruz. Chemistry: This is for the most part inorganic 57 chemistry with a modicum of organic and practically no work in biological chemistry as this subject is taught in the United States. Only a few experiments (6 exercises at the Rio school dealing chiefly with digestive secretions, blood, urine and milk and es- sentially clinical tests) can be classed in any way as in the territory of biological chemistry. Again the courses in chemistry are largely demonstrative. The desk space-at Porto Alegre for about 6 to 8 men, at Curityba for 8-is indicative of the failure to pro- vide actual detail work by the student. At Sao Paulo, two chemical laboratories will each accommodate 16 men but even here, where most of the instruction is good, no attempt is made to teach biological chem- istry. The best chemical department is at the new school of Bello Horizonte, which has a laboratory of 50 tables, all well equipped, and also an excellent assortment of special chemical apparatus of all kinds. This laboratory, under the direction of Dr. Alfred Shaeffer, a contract professor, is the best in the school, but while some attention is given to food analysis, biological chemistry as a well arranged course is neglected. The chemical laboratories of Bahia are well equipped but small and inadequate for the large classes of that school. At the Rio school the director declined on our first visit to show us the chemical laboratories, stating that he was ashamed of them. When we saw them on later visits we quite agreed with him. Pharmacology: In connection with the course in materia medica and therapeutics some laboratory work, largely of a chemical or pharmaceutical nature, is done. This is called a course in pharmacology, 58 but pharmacology (or better pharmaco-dynamics) as given in the better schools of the United States is unknown in Brazilian schools. Certain demonstra- tions of the actions of drugs are naturally given in courses in physiology and toxicology but systematic instruction in pharmaco-dynamics is not a part of the course in any school. The Sao Paulo school (Facul- dade) announces, however, a course of systematic demonstrations in pharmaco-dynamics for next year. Museums: Every school has its museum of natu- ral history, including animal and plant types, min- erals, etc., and also for physics a room, essentially a museum, with physical apparatus and a large demonstration table. These rooms constitute, with a certain amount of space for inorganic chemistry, the laboratory equipment for the first, or prelim- inary, year. The courses are essentially demonstra- tion courses, but of the value of the museums in connection with these we have no opinion to offer.1 Other museums are found in connection with de- partments of anatomy, pathology, and legal medi- cine, and of these some, as that of legal medicine at Bahia, are of great interest and capable of prac- tical utilization and instruction. The anatomical 1A noteworthy exception to the usual method of teaching zoology, botany and mineralogy in the course of so-called medical natural history is that practiced at the Faculdade of Sao Paulo. Here the entire work under this head consists of the study of parasitic worms (22 exercises), protozoa (8 exercises), insects (n exercises), yeasts and moulds (8 exercises), and venomous animals (2 exercises). This course was inaugurated by Professor Brumpt, formerly connected with this school, and as it is of dis- tinct medical value is a great advance over the usual natural history course in zoology, botany, mineralogy, etc. 59 museums are collections chiefly of models and charts with very little evidence of the frozen sections and carefully selected preparations of the American school. The pathological museums of Rio and Bahia are of interest chiefly on account of the num- ber of old and rare specimens which they contain, but from the teaching point of view they are un- satisfactory on account of the absence of common lesions preserved in natural colors or of a large number of "hand specimens" which may be given freely to the student for study. In the newer schools the museums of pathology are necessarily in the process of making. Laboratory Hours: Additional evidence of the scanty attention paid to laboratory work is shown by the short periods scheduled for practical study. Brazilian medical schools do not, as a rule, publish the roster in their catalogues, and the only ones which we have been able to procure upon request are those of the first four years of the Faculdade of Sao Paulo and Bello Horizonte, and an old one of the Rio school. The latter shows that few prac- tical exercises exceed a period of one hour and that the exercises number either two or three a week, usually equalling the total time given to lectures. On the American principle that every lecture needs at least a two-hour laboratory period if it is to be properly explained by laboratory study, the Bra- zilian arrangement is quite inadequate. It is note- worthy, however, that the best of the newer schools, as Sao Paulo and Bello Horizonte, show a general tendency to give at least two hours to laboratory work and sometimes three, the number of labora- 60 tory periods equalling the number of lectures. For example, at Bello Horizonte chemistry has two- hour laboratory periods two or three times a week, with a daily one-hour period for histology, and a daily one and one-half hour period for general pa- thology and pathological anatomy. Physiology, how- ever, still trails behind with one hour of practical work three times a week. Our inquiries on this subject at various schools indicated that the older institutions still persist in continuing one-hour laboratory periods and that it is only in the newer schools that there is a tendency to increase periods of laboratory instruction. In this connection it may be recalled that the professors responsible for chemistry and pathology at Bello Horizonte are contract professors imported from Germany, and that professors of bacteriology at both Sao Paulo and Bello Horizonte are men of modern training who have devoted their lives to work in this subject. It is very evident that these men have brought into their school work ideals of laboratory instruction quite different from those of the native Brazilian instructor. Animal Quarters: As regards the teaching of physiology, bacteriology, and experimental pathol- ogy, it is of importance that at only one school- the Faculdade of Sao Paulo-did we find suitable quarters for animals and an abundant supply of ani- mals on hand. The arrangements for animals in this school are excellent. The University of Parana, on the other hand, had one cage containing two guinea pigs and a small aquarium for frogs. In no other school were special arrangements for keeping 61 animals observed. This does not mean necessarily that animals are not used, for they may be kept in out of the way places or be purchased or brought in from the outside as needed, but it does indicate that facilities for experimental teaching have not been developed to the extent they should. Finally, it is to be understood that these criticisms of laboratory instruction do not refer to the Escola at Porto Alegre and Sao Paulo, nor to the two homeopathic schools of Rio and Porto Alegre, for these four schools have no laboratories worthy of description, to say nothing of criticism. (For de- tails of laboratory equipment and instruction see descriptions of individual schools, immediately fol- lowing this section.) To sum up, instruction in the medical sciences in Brazilian schools differs from that in the United States in (i) failure to give systematic courses in embryology, biological chemistry and pharmacol- ogy, and (2) the absence of independent observa- tional and experimental study by the student. It must be recalled, however, that the Brazilian schools were established on the plan of the French schools, and naturally have followed, as do all things Bra- zilian, the lead of the French. The possibility of better things in the future lies with the newer schools, particularly the Faculdade of Sao Paulo and Bello Horizonte, which already have some well- equipped laboratories, and what is more important, a few men who have been trained outside of Brazil and know what laboratory instruction should be. If these men can bring about the general adoption of the full-time plan for laboratory departments and 62 thus force clinicians out of the chairs devoted to the medical sciences, medical education in Brazil will be assured of a proper scientific foundation which, at present, it does not have. Any attempt to aid medical education in Brazil must have for its chief object the improvement of laboratory teaching and the encouragement of research through the estab- lishment of adequately manned and equipped labora- tory departments in one of the more progressive schools, of which the best type is the Faculdade at Sao Paulo. Instruction in the Clinical Branches: Here again we cannot give first-hand information concerning the methods of clinical teaching, as our experience is limited, on account of the vacation period, to our visits to the Faculdade of Sao Paulo and Rio de Janeiro, and these we saw only during the confusion of the opening weeks of the term. From what we did see, however, and the information we have gained from the faculty and graduates of these schools, clinical education would appear to combine all the advantages of both the German and English systems. The student receives about the same amount of didactic and clinical lecturing as in the American and German schools, but in addition has as great freedom in the hospital wards as under the English clinical clerk system. Lectures are so ar- ranged that the students may be free for work in the wards in the morning when the visiting staff is present. Not only do they "walk the wards" with the teacher, but they are given patients to examine and study, including in this the necessary laboratory tests, and later report on such cases to their teacher 63 in the presence of other students. At such times they are questioned concerning various doubtful points, their mistakes pointed out, and their opinion as to treatment is asked and criticized. There is also an interesting arrangement by which students of the higher classes take turns in sleeping in the hospital, partly in order to follow their cases and partly to see emergency work. This arrange- ment, however, is not entirely satisfactory, for the one-night turn comes, so we were informed, only eight or ten times during the year. In the Santa Casa of Rio de Janeiro and Sao Paulo we have seen students at work either singly or in pairs and have been greatly impressed by the system. As these hospitals have clinical laboratories for the simpler laboratory tests, it is possible to combine clinical and laboratory study without loss of time. Although the clinical teaching in the wards has impressed us most favorably, we are not so certain that advantage has been taken in full measure of the out-patient or dispensary facilities, except in the Polyclinic controlled by the Rio faculty. Wherever seen, it is of the usual character-both in general work and in the specialties-that is, one or two stu- dents assisting the staff of each department in the guise of doctors. Our inquiries concerning obstetrical teaching show that there is no lack of opportunity to see deliveries in the various Santa Casa and maternity hospitals, but there is some difficulty in regard to students taking charge of obstetric cases themselves. The midwife is a prominent institution in Brazil and employed by all classes of society. Her im- 64 portance is due to her definite character as a Latin tradition. We have been surprised to find promi- nent physicians, and several who received their medical education in the United States, stating that they always insisted on a midwife for their wives and relatives. On the part of the women there is also, of course, the question of modesty. With this attitude it is not surprising that out-patient obstetric clinics for student work develop slowly. At least one school-Parana-has overcome the difficulty by establishing its own maternity hospital,1 and another -Sao Paulo-by appointing the head of the ma- ternity hospital as professor of obstetrics. In other institutions the schools must be content with a ma- ternity ward of a Santa Casa and arrange for stu- dents to see and assist childbirth under the direction of an instructor. In this connection it may be said that the licensure laws do not demand of physicians definite qualifications in obstetrics. The Interne Problem: One adjuvant to medical education highly developed in the United States, the interneship, we found, much to our astonishment, to be lacking in Brazil. While the problem of the interne is primarily one concerning the hospital rather than the medical school, the interneship has become, in so many countries, so valuable an aid to medical training that its absence in the medical system of Brazil justifies discussion of the subject from an educational point of view. No Brazilian hospital has resident internes serving for a period of years without salary and solely for the sake of 1 The school at Bahia also has its maternity hospital. 65 the experience gained. Some institutions, as insane asylums, isolation and emergency hospitals, have resident salaried staffs, and the military hospitals have graded resident staffs, and to these in all such institutions doubtless falls the work of the interne under the American system, but the general hospitals of the Santa Casa type have only the visiting staff or, in some instances, what the Brazilian hospital terms internes-a small group of salaried physicians in active practice, who spend a part of each day or the night in the hospital. This Brazilian system of so-called internes we investigated carefully at the Santa Casa at Sao Paulo, one of the best, if not the best, general hospital in Brazil, and on the basis of this investigation we offer the following description. The director of the Santa Casa appoints four graduate 1 physicians who are known as "internes" and four who are known as "substitute internes." The four internes take turns during regular periods of hours in being on duty in the hospital, and de- vote the rest of their time to their practice and affairs outside of the hospital. For example, if the internes are labeled A, B, C, and D, the first, A, goes on duty from 12 noon to 8 P.M., B from 8 p.m. until 12 noon on the following day. Then follow internes C and D for like periods; thus each interne is on duty every second day, and there is always one interne on duty at night. When any one of the four internes is out of town or ill his place is taken by a substitute. These men admit patients, are respon- 1 The Santa Casa at Rio, with over a thousand beds, has only six such "internes" and one resident physician. 66 sible in a case of emergency, and, in general, have charge of the patients, subject to orders from the regular staff. These internes receive 400 milreis a month and the substitute internes 25 milreis for each period of duty, this being deducted from the salary of the absent interne. These men are not necessarily young men-indeed, sometimes they are regular members of the staff who take upon themselves this extra duty. This arrangement obviously is of little im- portance as a means of post graduate instruction in medicine, for the men appointed are always men of some experience. As a matter of fact, the only way the hospital is used as an educational factor is in those cities that have medical schools where the students in the clinical years have free entry to such hospitals as are controlled by the schools. There they do some of the work usually falling to internes, but their work is rather that of the clinical clerk under the English system, and at best they are stu- dents, not doctors, and have none of the responsi- bility of the American interne or house physician. It is true they take turns spending nights at the hos- pital, but in the course of one term have this oppor- tunity for only ten or twelve nights. After their graduation, having "walked the wards" for half a day during two or three years of their course, they turn, as a rule, immediately to practice, though a few of the best go elsewhere, usually Paris, Berlin, or Vienna, for further study. This latter course, however, is followed only by those who look for- ward to work in surgery or the specialties, or to a consultation practice. The average man goes from 67 the medical school immediately into practice. It is obvious that the Brazilian schools are not worrying about a law demanding the fifth or hospital year as a prerequisite to the practice of medicine, and also it is clear, in view of the absence of the interne sys- tem, why the student receives a maximum of in- struction in the hospital wards during his clinical years. But from the point of view of the hospital, as well as that of education, the situation is bad. The director of the hospital, who is appointed, according to the character of the hospital, by the state, city, or charity organization supporting the hospital, may or may not combine the duties of chief medical officer and superintendent, and may or may not live in the hospital. The attending staff, of course, do not live in the hospital. This organ- ization, in the absence of internes of the Brazilian type, leads to a curious situation in some hospitals. For example, we were told that the chief hospital of Porto Alegre, with 500 beds, is without a physi- cian from 6 p.m. to 9 A.M. In an emergency, such as necessity for operation, a surgeon may be called, but for practical purposes the care of patients and authority for procedure at night rests with the nurs- ing sisterhood in charge of the hospital. In the ordinary "Santa Casa" the absence of internes ap- pears, to the American observer, to be a serious matter. Not only does it decrease the amount of detailed study of the patients, and hence intelligent diagnosis and treatment, but it deprives the newly graduated physicians of the country of a thorough practical clinical training, with the responsibility of care of patients. The absence of internes is appar- 68 ently the explanation of the paucity of clinical his- tories in all Brazilian hospitals. We have seen no really complete system in any hospital, except that for the insane at Rio, and have been told that clin- ical histories are taken only when the case is of unusual interest or is to be used for clinical teaching or for publication.1 That some modification of the present system is necessary is indicated by the pro- posed plan at the Santa Casa of Sao Paulo. This school, because of its close connection with the medi- cal school, is about to attempt a system of student interneship. Elsewhere in Brazil, as has already been explained, students take turns in spending a night at the hospital in addition to the time they usually give during the morning to the study of patients. This arrangement, however, in larger cities does not allow the student to average more than io or 12 nights a year in the hospital. The Santa Casa of Sao Paulo is about to try the scheme of allowing a small number of students to live in the hospital, giving them their board and washing free, and in addition 100 milreis a month. In re- turn they are supposed to spend all their time not given to medical class work in attendance at the hospital. This will apply to students of the fourth, fifth, and sixth years, and it will thus be possible for a student to live in the hospital almost continu- ously for three years. Their duties will be the care of patients, the writing of histories, the making of laboratory examinations, and assisting generally in 1 An honest effort to keep fair histories is made at the Santa Casa of Sao Paulo. 69 the ward work. They will not be given great re- sponsibility, being expected to call the regular graduate interne or a member of the staff when an emergency arises. The plans allow one student for each ward, which will thus give about ten internes of this type to the hospital. The men will be se- lected, nominally at least, on their class record. It may be added that this system, or a somewhat simi- lar system, already exists in certain general hospitals in the city of Rio de Janeiro, as the "San Sebastian" and the "Beneficia Porgugueza." The Sao Paulo plan is obviously a makeshift, but its value lies in the possibility of its being the first step towards a system of graduate resident internes, and such a system must become a part of general medical edu- cation in Brazil if the country is to have a sufficient number of properly trained physicians. We are so firmly convinced of this that we consider the greatest impetus that could be given to clinical medicine in Brazil would be the financing of a proper interne service in a strong hospital of the Santa Casa type, such as that at Sao Paulo. (For catalogues and other pamphlets with information concerning the medical schools of Brazil, see Appendix IV, Nos. 10-19.) Textbooks: For example of a textbook on neurol- ogy by a Brazilian (Dr. Castro, Director of Rio School), see Appendix IV, No. 175. Most of the textbooks used are by French authors, but we have unfortunately been unable to obtain a list, despite repeated requests. 70 Schools of Dentistry and Pharmacy These exist, either one or the other, or both, in con- nection with (i) medical schools, or (2) as inde- pendent schools. All the medical schools of Brazil, with the excep- tion of the Faculdade of Sao Paulo, offer courses in these subjects.1 Of the independent schools com- bining dentistry and pharmacy the most important are those at Juiz de Fora and Sao Paulo. Schools of pharmacy alone exist at Ouro Preto, in Minas Geraes, and at Belem, in Para. A school of dentistry alone is found also in Bello Horizonte. Other schools may exist, but if so we have been unable to obtain details concerning them. The entrance requirements in dentistry and pharmacy, according to the fed- eral law of 1915, include an examination in Portu- guese, French, geography, arithmetic, and the ele- ments of physics, chemistry and natural history. The two-year course in dentistry includes descriptive anatomy, especially of the head, microscopic anatomy, physiology, general pathology, pathological anat- omy, odontological technique, clinical odontology, dental therapy, dental prothesis, general hygiene, and hygiene of the mouth. The three-year course in pharmacy includes physics, hygiene, bacteriology, natural history, inorganic and organic chemistry, analytical chemistry, industrial chemistry, toxicology, pharmacology, and the study of food adulteration. In the schools of dentistry and pharmacy associ- ated with medical schools, the laboratories and other 1 Bello Horizonte has recently abandoned its school of dentistry. 71 facilities are used in common, and it is therefore dif- ficult to determine exactly what are the facilities for dental and pharmacy teaching, independent of medical teaching. This holds true also of the teachers, for much of the theoretical work is combined with the medical instruction. The facul- ties are seldom listed separately. The relative proportions of the various faculties may be judged, however, from the list of teachers in the Escola be- longing to the University of Sao Paulo: medicine 26, pharmacy 7, dentistry 10, and veterinary medicine 10. This is a poor institution to use as an example, but it is, unfortunately, the only one for which we have definite figures concerning the general subdivi- sion of the faculty. Concerning the equipment for dental teaching there is never any doubt in regard to at least two rooms always found in every medical school. These are (1) the dental clinic with anywhere from one to half a dozen chairs, and (2) the laboratory for prosthetic work. In the schools independent of medi- cine it is likewise impossible if both dentistry and pharmacy are taught, to separate the equipment for each. For this reason and also because of our un- familiarity with the teaching of these subjects, our inspections have not been of great value, and we will content ourselves with describing a visit to the "Escola de Pharmacia e Odontologia de Sao Paulo." This, an independent school, was established in 1898. Sometimes it receives subventions from the state amounting to 12 contos a year, but it is run practically on the fees of students at a cost of 300 to 400 contos a year. The student fee, both in den- 72 tistry and pharmacy, is 450 milreis a term. The classes in pharmacy, for 1915, numbered 80, 56, and 53, and those in dentistry 66 and 34, respectively- a total of 289. About 33 per cent of the students in both courses are women. The conjoint faculty num- bers 18, and the information given about their com- pensation was rather hazy. Our guide, who is the professor of hygiene in the school and also a doctor of medicine, and director of the state isolation hos- pital, states that he receives for his services 500 mil- reis a year, but whenever the school is hard up this is not forthcoming. The building is in the form of a rectangle, with open court, two stories at the entrance from the street, and one story elsewhere. All of the second story of the front is devoted to administrative office, faculty room (the largest room in the building), the director's room, library, and a lecture room. Else- where are (1) three lecture rooms; (2) three chem- ical laboratories for inorganic and organic chemis- try and toxicology respectively; (3) a laboratory for bacteriology; (4) a laboratory for pharmacology and museums of (5) natural history, (6) botany, (7) materia medica, (8) physics, (9) a dental clinic, and (10) a dental laboratory. The laboratories for chemistry are small, one ac- commodating perhaps 20 students and the other two 10 each. The single hood of each room is small, and it is evident that not very elaborate chemical work is done. The apparatus for physics is fair, but the museums of natural history, botany, and materia medica are small and contain very poor collections. On the other hand, the laboratory of bacteriology, 73 with 8 desks and 7 microscopes, though small, was excellently equipped for demonstration and teaching in small groups. The laboratory of pharmacy aroused our amazement on account of the unusually large number of massive, complicated and very expensive pieces of apparatus. We counted 25 "machines," many of them of the type used by manufacturing pharmacists. The presence of these we understood when we were told that the school makes and sells to the hospitals of the city many standard medicinal preparations. The dental clinic had 9 chairs and the prosthetic laboratory about 60 desks. In no other school, independent or otherwise, have we seen such an extensive array of pharmaceutical machinery, but otherwise the equipment, except for the excellent ap- paratus in bacteriology, does not vary much from the usual outfit. (For catalogues of this school, see Ap- pendix IV, No. 20. For details of courses in den- tistry and pharmacy given in cooperation with facul- ties of medicine, see catalogues of the various med- ical schools, Appendix IV, Nos. 11 to 19, and for the dental and pharmacy schools of the Faculdade of Rio de Janeiro, Appendix IV, No. 30.) Schools of Midwifery These scarcely deserve to be classed among pro- fessional schools, as the entrance requirements are low and their existence is based on the desire to guar- antee adequate training to the midwives who do the great bulk of obstetrical work among all classes of Brazilians. The schools are of two types-those connected with medical schools and those represent- 74 ing a phase of activity of maternity hospitals. The law of 1915 gives no definite requirements for admis- sion to the course, and the only requirements we have been able to find definitely stated are a knowledge of (1) Portuguese; (2) French (or English or Ger- man); and (3) arithmetic (including fractions). Our inquiries concerning the course directed to mem- bers of medical faculties have yielded but little infor- mation, and there has always been an evident ten- dency to avoid discussion of, or to belittle the course -an attitude of patient tolerance, but at the same time of indifferent approval. The course everywhere is two years in length. Formerly it appears to have been merely a course of (1) lectures and demonstrations on the anatomy of the female pelvic and genito-urinary organs; (2) practical obstetrics; and (3) the care of the mother and child after delivery. This course, however, has been elaborated and we present, as an example of such course, that of the "Escola de Parteiras de Sao Paulo," 1 maintained in connection with the Maternity Hospital (Maternidade) of Sao Paulo, as given in 1914: 1 st year: (1) obstetrical anatomy and physiology; (2) elements of histology, bacteriology, and clin- ical laboratory examinations; (3) obstetrics, theoret- ical and illustrated by the manikin. 2d year: (1) Clinical obstetrics; (2) clinical gyne- cology; (3) care of the child and mother during the puerperium. 1 For details see catalogue of this school filed herewith, Appen- dix IV, No. 21. 75 This school, at the time of our visit, had two classes of 8 students each, and to the work of the school were devoted two fairly large rooms contain- ing a simple but adequate equipment of anatomical and obstetrical models and charts, manikins, etc., with a small laboratory equipment for clinical micros- copy. The director of the hospital is the director of the school of midwives and, as we were told confi- dentially, is to be appointed professor of obstetrics in the Faculdade of Sao Paulo when it initiates its obstetric course next year. Our attempts to determine the number of mid- wives in certain cities have been unsuccessful. Alma- nack Laemmert gives 40 for the city of Rio de Janeiro and 62 for Sao Paulo, but we are told that these figures are far below the actual totals. Our inquiries concerning the fees received by midwives indicate that in the average well-to-do family they receive 200 milreis for the first and 150 for later deliveries. Fees among the poor are necessarily much less, but among the wealthy may go as high as 500 milreis or more. These fees include the care of the mother and of the child during the post partum period. Veterinary Schools No separate schools of veterinary medicine such as we have in the United States are to be found in Brazil. What little veterinary medicine is taught is incidental to the teaching in the agricultural schools, and is usually theoretical and without laboratory or practical clinical facilities. The Institute de Agro- nomia e Veterinaria of Porto Alegre (Rio Grande 76 do Sul), located in the cattle-raising district, adver- tises in its catalogue for 1913 a five-year course in veterinary medicine (see Appendix IV, No. 22), but upon visiting this school we found that only agricul- ture was being taught and that the course in veteri- nary medicine was on paper. No class, thus far, has been entered, and the only equipment on hand for veterinary teaching was found in one room and con- sisted of a set of anatomical models of several of the domestic animals and a number of pathological speci- mens preserved in Kaiserling, all of which had been bought in Germany. The director of the school stated that they expected shortly to inaugurate not only a complete course for the training of profes- sional veterinarians, but also short practical courses for agricultural students and farmers who wish to care for their own animals. In Rio de Janeiro is a school founded in 1913 of Agriculture and Veterinary Medicine, with 12 trav- eling professors, who are said to investigate prob- lems in animal pathology arising in various parts of the country. No one seems to know anything about this school, however, and as our inquiries at the fed- eral department of health, the medical school, and several newspaper offices, and a search of the tele- phone directory failed to reveal its location we had no opportunity to inspect it. The University of Sao Paulo advertises a school of veterinary medicine with 10 professors and courses in comparative anatomy, histology, embryology, physiology, general pathology and bacteriology, pathological anatomy, zootechnic, veterinary phar- macology and therapeutics, veterinary medicine and 77 surgery, and veterinary hygiene. This is one of the departments concerning which, at the time of our un- satisfactory visit to the director of the medical school, we could get no information, and our verbal and written requests for catalogues and general in- formation have not been acknowledged. We have found no other references to institutions giving instruction in veterinary medicine and our in- quiries concerning veterinarians in Brazil indicate that they are scarce. An examination of the pro- fessions listed in the Almanack Laemmert, 1915, shows only four in the city of Rio de Janeiro, 2 in the state of Espirito Santo, and 1 each in the states Santa Catharina and Sao Paulo. Undoubtedly this list is incomplete, but veterinarians are not abundant, as may be shown by the fact that in all Brazil the fed- eral government employs only 10 veterinarians for the official inspection of slaughter houses.1 Professors' Pensions As professors are government employes they share in the system of government pensions, which applies to all officials appointed for life, and it may be added that all important officers not elected are so appointed. As far as it concerns professors-and the system in- cludes professors of medicine-the arrangement for pensions is about as follows: Of his stated salary each professor receives 90 per cent, the government withholding 10 per cent 1 Figures given by the American Consul General at Rio de Janeiro. 78 each month. The sum thus withheld goes into a gen- eral pension fund from which, at the death of a pro- fessor or assistant professor, his family receives 30 contos ($7,500), and one conto for funeral expenses. Contract professors, who are not appointed for life, are paid their salaries in full and do not share in the pension system. After 25 years of service a profes- sor may retire with full salary for life. If a pro- fessor is incapacitated for any reason connected with his work as a teacher (as, for example, the result of infection or exposure to X-rays, etc.) he is retired with full salary for life. This provision does not refer to accidents occurring outside of professorial activities. If, while in active service, a professor is absent from his post without official permission for one year he loses all right to a pension. Upon re- tirement, however, there is no restriction against tak- ing up other remunerative work, or an educational or research appointment with the federal or another state government.1 Under the latter circumstances the appointment is made under contract and the indi- vidual is not eligible for a pension under the second government. For example, Dr. Adolpho Lutz, ento- mologist of the Institute Oswaldo Cruz of Rio de Janeiro, took this position when pensioned by the Sao Paulo government, and now serves in his present position under contract. 1 This explanation of the pension system was given us by a professor of the Faculdade of Sao Paulo. Literature on this sub- ject requested of the federal government has not been received at the time of writing. 79 The Libraries of Brazil As an index of the interest of Brazil in special and general education and in the dissemination of knowledge we have collected from various sources a list of important libraries.1 We have no reason to believe that this list is complete but we are certain it contains all important libraries open to the public in large centers. This attempt to make a list of libraries indicates how difficult it is to obtain statistics in Brazil even when one goes to the institution which one would suppose would be familiar with the in- formation sought. For example, we attempted to obtain this from the officers of the Bibliotheca Na- cional at Rio de Janeiro but they could give us no assistance, stating that they knew very little about the libraries outside of a few of the large cities. The total number of libraries in our list (see Ap- pendix VI, No. 6) is 56, of which 10 are in the federal district, 21 in the city of Sao Paulo, 4 in the state of Rio Grande do Sul, 3 each in the states of Bahia and Sao Paulo (outside of the capital), 2 in Minas Geraes, and 1 in each of thirteen other states. The states not represented are Goyaz, Piauhy, Rio Grande do Norte, and the Territory of Acre, which are among the most backward sections of Brazil. It is noteworthy that with the exception of three cities in the state of Sao Paulo, two in Rio Grande do Sul, and one each in the states of Rio de Janeiro and Minas, all libraries listed are in capital cities. 1 Chief source of this information is the Almanack Laemmert, the compilation from which may be found in Appendix VI, No. 6, which gives also the population of cities in which libraries occur. 80 The most important of all these libraries is un- doubtedly the Bibliotheca Nacional, which is magnifi- cently housed, is being properly catalogued, and contains the most important collections of the im- perial as well as the republican government. The other libraries are, for the most part, departmental libraries of the various governments, or libraries connected with professional or other schools. Medi- cine is represented only by the libraries of the medi- cal faculties at Bahia and Rio de Janeiro, and that of the medical society of Sao Paulo. Similar libraries of law and engineering exist in the schools devoted to training in these professions. Fourteen states, including the federal district, are, however, credited with at least one city having a public or general library, while three cities are listed in each of the states of Sao Paulo 1 and Rio Grande do Sul. II. HOSPITALS AND DISPENSARIES The hospitals of Brazil may be grouped as fol- lows : (1) General hospitals of the type known as the Santa Casa do Misericordia, and usually referred to briefly as the Santa Casa. (2) Military (or Naval) hospitals. (3) Hospitals for the acute infectious diseases, usually known as isolation hospitals. (4) Maternity hospitals. 1 For complete list of libraries in State of Sao Paulo, received too late for abstracting, see Appendix IV, No. 171, Vol. II. 81 (5) Hospitals under the control of fraternal societies. (6) Private hospitals. (7) Special hospitals, as emergency hospitals and those for children, the insane, the tuberculous, lepers, etc. (8) The dispensaries may be grouped under three heads: (1) in connection with hospitals; (2) in connection with medical schools; (3) independent. (9) Sanatoria. (1) d'he Santa Casa is the name throughout Brazil of the principal general hospital which cares for the sick poor in each community. Sometimes it may be called, as in Curityba, Hosp. Caridade (Charity hospital), but this is rare. When more than one charity hospital is present the others are generally designated by the name of a saint. In cities with a medical school the Santa Casa is used freely for clinical instruction. Although such hos- pitals are primarily intended for the poor, nearly all have some private (pay) rooms. Management and Finance: Practically all hos- pitals of this type are supported by charitable organ- izations,1 which raise the necessary funds and are assisted by subventions from the city, state, or Fed- eral governments. Three other sources of income are found in connection with certain hospitals. 1 These societies frequently support other charities, as, for ex- ample, at Sao Paulo, a foundling asylum, a home for invalids, a leper lazaretto, and a school for children; at Curityba, an insane asylum, and as in Rio de Janeiro, a foundling asylum and several subsidiary hospitals for children, the tuberculous, etc. 82 These are (1) gifts from lottery companies; (2) the profits of funerals, and (3) cemeteries. These lat- ter sources of profit are due to the fact that in many cities the conduct of funerals and the management of cemeteries is placed entirely in the hands of the society managing the Santa Casa, such societies hav- ing, essentially, a monoply of funeral arrangements.1 Thus the Santa Casa at Pelotas reports the receipt during the years 1913 and 1914 of 15,524 milreis from lotteries and a profit from funerals of 56,053 milreis, and on its cemetery of 49,418 milreis.2 These three sources of income make up about two- fifths of the entire income for the two-year period. Some hospitals of this type also receive the tax on alcohol which is turned over to them by the govern- ment. One or more of these various methods of support may be found in connection with nearly all hospitals and to these must be added government subventions and private contributions. Few hospitals have a large endowment. For example, the report of the oldest hospital in Brazil-the Santa Casa of Santos- founded in 1543,3 gives an income for 1914 from sale of land of 11,200 milreis and from rents of 134,916 milreis. This is the largest income 4 of 1 This interesting phase of hospital function is worthy of de- tailed study. We have not had time to work it up in detail, but its financial importance may be surmised from the fact that the Santa Casa of Rio de Janeiro controls all funerals in a city of more than a million inhabitants. 2 See Appendix IV, No. 37. 3 See Appendix IV, No. 36. 4 With possible exception of that of Santa Casa of Rio de Janeiro. 83 this kind we have encountered in Brazil but it must be admitted that we have not seen the financial state- ments of all hospitals. The city and state subven- tions vary considerably. The Santos hospital received (1914) from the state of Sao Paulo 100,000 milreis and from the city of Santos 72,000 milreis; the hos- pital of Pelotas, on the other hand, received only 37,000 from the state of Rio Grande do Sul and the city of Pelotas in two years. The method of government of the hospital varies somewhat but the following description of the con- trol of the Santa Casa at Bello Horizonte,1 Minas Geraes, is, in general, characteristic of all hospitals of this type. The Bello Horizonte hospital is owned by a society composed of 500 members which meets every two years and elects an active board of 25 members. This board, in turn, elects 6 trustees and the trustees appoint the director of the hospital. The director then nominates the hospital staff to the trustees, who confirm or reject the nominations as they see fit. The chief of each clinic is permitted to select his assistants. Sisters of Mercy serve as nurses. The members of the medical staff in many hos- pitals receive a small fee and others serve without salary. When the staff is paid only the heads of departments receive salaries and these, as a rule, are small. Thus in the Santa Casa of Sao Paulo, the director, the chief of each ward, and the head of each dispensary department receive 50 milreis per month. In smaller hospitals, in which the staff usually con- 1 See Appendix IV, No. 34. 84 sists merely of a director and two physicians, the amounts paid are somewhat larger, as at Curityba, where the director receives 250 and each of the two doctors 200 milreis. In all cities containing medical schools the staff of the Santa Casa and the faculty of the medical school usually correspond and in such instances it is found that the amounts paid to visiting physicians are smaller than in those hospitals located in cities where no medical schools exist. As to the cost of running hospitals, we have made no special inquiries, except in connection with the hospital at Bello Horizonte.1 Such estimates, how- ever, that we have received vary greatly. Thus the Santa Casa at Bello Horizonte, with 180 beds, is run at an average cost of i| milreis (37^c.) per patient per day. On the other hand, at Santos, the cost per day of a hospital of 500 beds was given at 2 contos, or at the rate of $1 per patient per day. Buildings and Equipment: The usual arrangement is a one- or two-story building in the form of a square or rectangle, with central garden. In the case of medium sized hospitals one side of the square may be lacking and in very small communities the arrange- ment is a central building with wings on either side. Sometimes, in very large hospitals as at Rio, where the available space for buildings is small, the wards are arranged in parallel rows. A garden of some size is always present and sometimes surrounds the buildings entirely. The corridors are placed, as a rule, along the inside of the building with wards running off at right angles. The ceilings are high 1 See special MS. statement of expenses filed with Appendix IV, No. 39. 85 and good light and ventilation are usually assured. Screens we have not seen in any general hospital in Brazil but netting is sometimes found over the beds. On account of the absence of screens flies, in large numbers, are found in all hospitals which has always impressed us as an exceedingly serious fault, but our questions in regard to this matter are always met with the statement that screens keep out the air. Aside from these faults the hospitals are, as a rule, fairly clean; some, as that at Sao Paulo, spotlessly so. On the other hand, that at Santos struck us as unnecessarily dirty. It may be said, in general, that not as much attention is given to cleanliness as in American hospitals. The equipment as to beds, blankets, etc., is, as a rule, of the simplest and cheap- est. Baths and toilet arrangements, particularly the latter, are generally poor and inadequate. I'he operating rooms and their equipment vary from the most perfect, as at Sao Paulo, to a simple room partitioned oft a ward, as seen at Paranagua. With the exception of one or two hospitals, as at Sao Paulo and Pelotas, the furnishings and aseptic precautions and the general management of the operating room did not impress one as perfect. All hospitals in Brazil appear to feature diagnostic and therapeutic electrical apparatus of all kinds and no hospital of any size is without its X-ray outfit. Another impressive feature of every hospital is its ornate pharmacy with usually a considerable staff of clerks. Prescribing is apparently a matter of great satisfaction to the Brazilian physician. At the Santa Casa at Santos, for example, the pharmacy put up during the month of January, 1916, 20,499 Pre' 86 scriptions, of which 10,522 were for patients in the hospital and 9,977 for out-patients. As the hospital has about 500 beds the average was 21 prescriptions per patient (bed) per month, which indicates that overprescribing is perhaps a fault of the Brazilian physician as well as explanatory of the large amount of space and the large staff allotted to the apothe- cary's department. Every hospital has its out-patient department, al- ways well attended. Whenever we have visited a hospital during the dispensary hours the out-patient department, located always at the main entrance, was filled with a mob, sometimes of several hundred awaiting attention. Thus the out-patient depart- ment of the Santa Casa of Rio de Janeiro cares for 900 to 1,000 patients a day, but for this purpose has only 16 doctors. The out-patient department presents, as a rule, the appearance of disorder, is generally dirty, and has a poor equipment for work in the specialties. Applicants are admitted to the hospital at once if their illness is serious enough to demand it, but most of the patients seem to receive a hasty examination and symptomatic treatment. That this must be the case is evident by the figures presented for the dispensary of the Santa Casa at Rio de Janeiro. Nursing: Nursing in most Brazilian hospitals is done by members of religious sisterhoods. The only hospitals in which we have found nurses other than these are the Santa Casa of Rio de Janeiro, Santos, and Sao Paulo. Training schools exist in the last two of these hospitals but at the former is a very indifferent course, with the lectures given at night. 87 At Sao Paulo, on the other hand, adequate facilities are provided for and considerable attention given to the training school.1 At the Santa Casa of Bello Horizonte a training school is about to be inaugu- rated and the new addition to the hospital will con- tain very excellent facilities for this school. Laboratories: Laboratory facilities are meager and unsatisfactory in all hospitals of this type, ex- cept that at Sao Paulo, which not only has a labora- tory for simple work in each ward but a large detached laboratory presided over by a pathologist who does not practice medicine. This combination exists only at Sao Paulo although at Bello Horizonte each ward has its laboratory and at Rio there is a laboratory for every two wards. Also at Bello Hori- zonte the hospital is so near the medical school that it has the assistance of its laboratories. Some idea of the backward state of hospital laboratory work is shown by the fact that the Santa Casa of Sao Paulo is the only hospital in Brazil publishing in its annual statement a pathologist's report.2 In some cities, as Rio Grande (Rio Grande do Sul), the hospitals have no laboratory equipment whatever. It was in this city that physicians showed us in the wards of the hospital cases of supposed liver abscess, and when we asked if amebas had been found in the stools were told that the hospital had no laboratory equipment for this work. It seems almost impossible that it could be true but we found that these physicians were treating patients supposed to have malaria, or amebic dysentery, or filariasis, 1 See Appendix IV, No. 35, for printed curriculum of this school. 2 See Appendix IV, No. 34. 88 hookworm disease, and even syphilis, without con- firming the diagnosis by laboratory test. In fact, we were shown a case which was said to be amebic abscess because the patient had improved under the use of emetin, the diagnosis never having been con- firmed by microscopic examination.1 Autopsies are few in number even in hospitals controlled by members of the teaching faculty. Rio, with over 1,000 beds, had only 100 to 120 autopsies last year. Santos, with 500 beds, averages 100 to 120 a year, Bello Horizonte has had 99 during the past year and a half, and Sao Paulo 239 during the last three years. Internes: Internes of the type in hospitals of the United States are not to be found in Brazil. (For discussion of this subject see educational section, page 65.) Records: The taking and filing of complete medi- cal histories of each patient is not a common prac- tice in the general hospitals, although it may be found in some special hospitals, as the Insane Asylum at Rio de Janeiro and to some extent in the records of the military hospitals. Except at the Sao Paulo hospital we have seen no evidence of the proper his- tory taking in any hospital of the Santa Casa type, and have been told that complete histories are taken only when a patient is to be used for clinical instruc- tion or when the condition is of sufficient interest to warrant publication. Overcrowding: Overcrowding is a common fault in the Santa Casa type of hospital, but even the most 1 See further notes on this subject in Appendix II, No. 2. 89 conscientious management cannot at all times avoid it because of the provision that hospitals receiving government aid cannot turn away patients applying for treatment. The result is, as we have frequently seen, the placing of mattresses on the floors of the wards and in corridors in order to take care of extra patients. With this general summary of hospitals of the Santa Casa type we offer a detailed description of (1) the Santa Casa at Sao Paulo, as an example of the best type seen in large cities, and (2) of that of Para- nagua as typical of small communities. Between these two extremes come a large group of very in- different hospitals. Santa Casa-Sao Paulo This is a splendid hospital controlled by a Cath- olic charity society, the building of which was started about thirty years ago and completed about ten years ago. The total cost was 1,800 contos. Its capacity is about 480 beds, but at present it has nearly 1,000 patients, who are sleeping on mattresses, on the floor under and beside the regular beds. This excess of patients is due to the necessity of admitting all ap- plicants on account of the support (800 contos) which the hospital receives from the state. Despite this overcrowding, orderliness and cleanliness pre- vail, and the usual discomforts of overcrowding have been reduced to a minimum. (This hospital receives no support from the city inasmuch as the affairs of the city of Sao Paulo are practically administered by the state.) The buildings are in the form of a rectangle with 90 a central garden and corridors running along the in- ner side of each building. From these corridors the wards lead off at right angles. It is of light brick structure with an abundance of foliage plants in the corridors, making a most attractive picture. Except at one end, the front of the rectangle where the build- ing rises to two stories, all wards are of one story. The two-story front is used for administrative pur- poses and out-patient departments. The wards, ten in number, average about 36 to 40 beds. In addi- tion, there are 18 private rooms for men and 18 for women. For these rooms the patients pay from 5 to 10 milreis per day. For the wards there is no charge. In addition to a general laboratory, to be described later, each ward has, at one end, its own laboratory for simple work in clinical diagnosis. Adjacent to this ward laboratory is a room for the examina- tion of patients. It is of interest that both of these rooms, the laboratory and examination room, are of great value in teaching the students. Students work- ing in the wards can pass to the laboratory for the simpler clinical examination or they can take a pa- tient who is not too sick to the examination room for detailed study, with or without an instructor. At the opposite end of each ward is a small room in which new patients are bathed and barbered, and a room also for the nurse. These bath rooms, or at least the one bath room which we entered, was the only room in the entire hospital that appeared disorderly and not clean. Everywhere else the greatest clean- liness prevailed and no odors were noted, and al- though screens were not present flies were not much in evidence. 91 The hospital has the usual staff room, chapel, and pharmacy, but these are not as prominent as in most hospitals visited. The equipment for therapeutic baths of all kinds, including electric, carbonic, and light baths, as also the x-ray and photographic outfit, were excellent, and in connection with these were found what is not unusual in Brazilian hospitals, a special staff and a nurse in charge. The hydrothera- peutic and electro-therapeutic outfit, with a room for massage, is as complete as any we have seen in the United States. The kitchen is excellent with modern equipment and few flies. The present general laboratory of the hospital is a four-room building of one story, comprising one large room used as a morgue and for autopsy work and for the storage of specimens and three other small rooms for pathology, bacteriology, and serol- ogy, respectively. The staff consists of a director, who does not practice and gives a large part of his time to the work, one full-time assistant, and four student assistants. This is the most active hospital laboratory we have seen in Brazil, and much of its activity and efficiency is entirely due to its director, Dr. Alex. Pedroso, M.D., University of Pennsyl- vania, 1905, a student of Dr. Simon Flexner, Dr. Longcope and other American pathologists. A new laboratory is now being built, photographs of which are filed herewith (Appendix V, No. 5). This is a separate, two-story building about the size and built on the general plan of the Ayer Clinical Laboratory of the Pennsylvania Hospital, Philadel- phia, containing seven rooms on the first floor and 92 six on the second, with a large basement. The build- ing cost 5 5 contos and the equipment is estimated at 65 contos, and is to be of the type of laboratory equipment seen in the United States, including a some- what extensive library. As evidence of the interest in hospital laboratory work in Sao Paulo, it may be noted that about half this sum was raised by the director by private subscription. The operating rooms of the hospital, half a dozen in number, are divided into those for clean work and those for septic cases, as well as additional rooms for gynecology, ophthalmology, throat work, etc., and are all modern, perfectly equipped, absolutely clean, with tiled floors and enameled walls. The operating technique seems to be perfect as far as aseptic pre- cautions are concerned, this being one of the few hos- pitals in which we have found operators wearing gauze masks. The hospital is managed by a Catholic sisterhood, but for the last five years a training school for nurses has been in existence, with the enrollment of two classes totalling 46 nurses. The course is a two- year course, a printed statement concerning which is filed herewith.1 The nursing school has a special lec- ture room containing charts, diagrams, blackboard, etc. This is the only hospital in Brazil in which we have found a special room for nurses' lectures. The hospital which is used for instruction of stu- dents of the Faculdade de Medicina e Cirurgica of Sao Paulo contains no clinical amphitheatre, the stu- dents working in small groups in the wards or 1 See Appendix IV, No. 35. 93 grouped about the operating table. In this connec- tion it may be said that the director of the hospital is also the director of the medical school. This is one of the few hospitals in Brazil in which a regular history of every patient is taken. This was started 5 years ago and the hospital now has good records. The hospital has no large amount of space for ma- ternity cases, these going to an independent maternity hospital in another part of the city. Emergency ob- stetrical cases are, however, admitted. Diseases of special interest occurring in the hos- pital are (I) ankylostomiasis, of which about 900 cases are received each year, mainly from the inte- rior, (2) much dysentery of both amoebic and bacil- lary type, and (3) much trachoma. The report of the laboratory, for 1914, shows the following examinations: Wassermann 1,478 Feces 547 Sputum 210 Urine 428 Nasal mucous 22 Histologic 92 Widals . 244 Autopsies 28 Diverse examinations 30 3,079 The total number of autopsies at this hospital from January 1, 1913, to March 1, 1916, were 239. The records for the pharmacy, for 1915, show prescriptions filled for: 94 Patients in hospital 172,218 Out-patients 93,816 266,034 The out-patient department treats two hundred pa- tients daily and has good special rooms for gynecol- ogy, children's diseases, etc. The staff of the Santa Casa consists of a director appointed by the trustees of the society, who, in turn, recommends to the trustees the physicians and surgeons he desires as his associates. The director receives 50 milreis a month, as does also the chief of each ward and the head of each dispensary depart- ment. Other members of the staff receive nothing. Internes: In this hospital we investigated the sys- tem of so-called "interne service," which prevails in a few Brazilian hospitals and which is entirely dif- ferent from the method as used in connection with hospitals in the United States. The Santa Casa ap- points four graduate physicians who are known as "internes" and four who are known as "substitute internes." The four internes take turns in being on duty in the hospital, having the rest of their time for their practice and affairs outside of the hospital. For example, if the internes are labeled A, B, C, and D, A goes on duty from 12 noon to 8 P.M., B from 8 P.M. until 12 noon on the following day. Then follow internes C and D for like periods, thus each interne is on duty every second day, and there is always one interne on duty at night. When any one of the four internes is out of town or ill his place 95 is taken by a substitute. These men admit patients, are responsible in a case of emergency, and, in gen- eral, have charge of the patients, subject to orders from the regular staff. The regular internes receive 400 milreis a month and the substitute internes 25 milreis for each period of duty, this being deducted from the salary of the absent interne. These men are not necessarily young men, indeed, sometimes they are regular members of the staff who take upon themselves this extra duty. Student Internes: This hospital, on account of its close connection with the medical school, is about to attempt a modified system of student interneship. Elsewhere in Brazil, particularly in cities containing medical schools, students take turns in spending a night at the hospital in addition to the time they usu- ally give during the morning to the study of patients. This arrangement, however, in larger cities does not allow the student to average more than 10 or 12 nights a year in the hospital. The Santa Casa of Sao Paulo is going to try the scheme of allowing stu- dents to live in the hospital, giving them their board and washing free and in addition 100 milreis a month. In return they are supposed to spend all their time not given to class work at the medical school in at- tendance at the hospital. This will apply to the stu- dents of the fourth, fifth, and sixth years, and it will thus be possible for a student to live in the hospital almost continuously for three years. Their duties will be the care of patients, the writing of histories, the making of laboratory examinations, and to assist generally in the ward work. They will not be given 96 a great responsibility, being expected to call the regu- lar graduate interne or a member of the staff when an emergency arises. It plans to have one student for each ward, which will thus give about ten internes of this type to the hospital. The men will be selected from the best in the school and it is obvious that other influences will operate. It may be added that this system, or a somewhat similar system, already exists in certain hospitals in the City of Rio de Ja- neiro as the San Sabastian and the Beneficia Portu- gueza, and also in the Insane Asylum. It is said also that in the Institute Paulista of the City of Sao Paulo there is one paid resident physician who, how- ever, can see patients by appointment outside of the hospital. The association which supports the Santa Casa also supports: i. Foundling asylum, 2. Home for chronic invalids, 3. Leper lazaretto, and 4. School for children. The foundling asylum, located just outside the city on high ground, is well kept, clean, and with modern furnishings and equipment. It cares for 175 children. When mothers arrive at the Santa Casa with their infants, if the mother does not wish to keep the child it is sent to a wet nurse who keeps the child in her home for one year and then it goes to the asylum, remaining there until old enough to work. Some remain in the asylum until adult life as serv- ants. The children have daily lessons, learn to sew, 97 and are given plenty of exercise. All were brought out for our inspection and they appeared a very healthy lot. Dr. Pedroso, who is pathologist in this institution, states that there is very little illness among the children except for a slight epidemic of amoebic dysentery a few years ago. He has known of no serious general illness. Home for Invalids: This is removed a consider- able distance from the city, about three-quarters of an hour by automobile, and was built four years ago. The buildings are grouped about a rectangular court with corridors on the inside and the wards leading off at right angles. The total of ten wards accom- modate 370 patients-men, women, and children suf- fering from chronic and more or less disabling dis- eases. The general management is in the hands of a sisterhood, with a visiting physician, who visits the hospital twice a week and whenever necessary. This physician receives a salary of 400 milreis a month. Leper Lazaretto: The leper lazaretto is located about one-quarter of a mile from the home for in- valids and accommodates 146 patients. On account of lack of time this institution was not visited by the commission. (It may be said here that in the state of Sao Paulo there are about 3,000 lepers.) The school maintained by this society was estab- lished years ago when the public schools of Sao Paulo were insufficient. The latter are now fairly abundant, but the hospital still maintains a school for poor children. This institution was not visited. 98 THE SANTA CASA OF PARANAGUA1 This is a small hospital of six buildings con- nected by corridors. The buildings are respectively, from left to right, chapel, a ward, administration building, including apothecary, and two other wards. In the rear is the kitchen surrounded by a large gar- den. The wards contain 12, 14, and 16 beds re- spectively. At the time of our visit only 25 patients were in the hospital. The hospital is run by a sisterhood and there are no nurses. The director is Dr. Moreira, who is also port physician, and with whom two other physicians are associated. In 1915 the hospital entered 809 patients, with 43 deaths. It also has an out-patient department. Here again was seen the great tendency to overprescribe, the total number of prescriptions, in 1915, being 20,163, 1 Paranagua is a town of about 10,000 inhabitants, the chief port of the State of Parana (591 ships entered and cleared in 1915), communicating with the capital, Curityba, by rail, a jour- ney of about four hours. The city is located on a river emptying into the bay at this point and has no wharves to which steamers may approach. It is located in low, marshy land surrounded by several arms of the bay. Its principal streets are paved with rough stone, and the buildings are simple, two-story type of the usual Latin-American structure. Outside the center of the town the streets are of dirt, with numerous pools of water and generally ill-kept and dirty. The water supply is from the mountains across the bay, four miles distant, and this is supplemented by wells. The sewage system serves at present 300 houses, and other houses are being connected as rapidly as possible. On account of the fact that the town is only a few feet above sea level, two pumping stations raise the sewage to the highest point of the town, from which it passes by gravity to the bay (See plans in possession of Dr. Ferrell). The markets of the town are new and fairly well kept as regards cleanliness. 99 of which 10,362 represented cases in the hospital and 9,801 out-patients. The support of the hospital is in part from the state of Parana, which gives 8 contos annually, and in part from the city of Paranagua, which gives 4 contos annually. Also, as in the case of most Bra- zilian hospitals, it receives a definite proportion of the alcohol tax, which, in this instance, amounts to 400 to 600 milreis a month. The building is clean, but the windows are not screened; the operating room is very poor, being merely a space partitioned off from the general ward, with partitions rising only half way to the ceiling. The commonest disease is malaria. This, how- ever, is not of the pernicious type and the hospital records show only three deaths in the last 600 cases. Uncinariasis is quite prominent but patients with this disease come mainly from outside the city. An ex- amination of the records shows in March, 1915, 8 cases of this disease, and in April of the same year, 14 cases. As elsewhere, the diagnosis of uncinari- asis is made on the clinical picture and not upon examination of the stools or of the blood. For additional data concerning other hospitals of this type see Commission's notes, as follows: Appendix II, No. i, Rio Grande by R. M. P. " " " 2, Rio Grande by R. M. P. " " " 3, Pelotas by R. M. P. " " " 4, Florianopolis by R. M. P. " " " 5, Curityba by R. M. P. " " " 6, Bahia by R. M. P. " " " 7, Bahia by B. K. A. 100 Appendix II, No. 8a, Bello Horizonte by B. K. A. " 8b, Bello Horizonte by J. A. F. " 9, Rio de Janeiro by B. K. A. (This last includes statis- tics from 1914-15 report.) " " " 11, Santos by R. M. P. For printed reports and other literature of hos- pitals see Appendix IV, No. 31, Rio de Janeiro, 34, Sao Paulo, 36, Santos, 37, Pelotas, 38, Curityba, 39, Bello Horizonte, " 174, Juiz de Fora. For photographs see Appendix V, No. 6, illus- trating Santa Casa of Bello Horizonte, and No. io, that of Pelotas, and No. n, Military Hospital at Rio. (2) Military Hospitals: These, under the control of the medical service of the army, are uniformly well equipped and man- aged. Several have been visited by the commission, but as their function does not include medical relief of the community at large, details will not be given here. Descriptions of several of these hospitals may be found in Appendix II, No. 2, Porto Alegre, by R. M. P.; Appendix II, No. 4, Florianopolis, by R. M. P.; Appendix II, No. 10, Rio de Janeiro, by B. K. A. 101 (3) Isolation Hospitals: As these are always under the control of health departments, usually state or federal, they are de- scribed in the section on public health organization. Notes by individual members of the Commission may also be found in Appendix II, Nos. n, 12, 13, and 14- (4) Maternity Hospitals: In small cities and those of moderate size the Santa Casa usually contains a ward for obstetric service, but in large centers, as Bahia, Rio de Janeiro, and Sao Paulo, maternity hospitals are found sometimes connected with, and sometimes in- dependent of, the Santa Casa. These are main- tained by charitable organizations for the poor, but have, as a rule, a small number of pay rooms. A generous subdivision of space gives small wards with semi-privacy. The delivery rooms have every convenience and every safeguard against infection. The ward for infective cases is always in a separate building somewhat removed from the main hospital. In connection with these hospitals it is customary to allow the instruction of medical students or mid- wives, or both. (For description of Maternity Hospital at Sao Paulo see Appendix II, No. 12.) (5) Society Hospitals: The hospitals known as society hospitals, or fra- ternal hospitals, are maintained for the members of the society owning the hospital and for such char- itable cases as the members may care to recommend. They are, as a rule, of indifferent equipment and 102 inadequate staffs. As they are not open to the pub- lic generally and therefore lie somewhat outside of the scope of work of this commission, they have not been especially studied. We have, however, visited the hospitals of the Portuguese Societies in Rio Grande and Pelotas, but our inspection did not in- crease our respect for Brazilian hospitals. The so- ciety hospitals, or at least the two we saw, are no better than the Santa Casa type, and sometimes in- ferior. (6) Private Hospitals: As these are, for the most part, devoted to sur- gical work or to the various specialties, and with little or no provision for the medical relief of the poor, we have given them no attention. (7) Special Hospitals: (a) Emergency hospitals: The only hospital of this type that we have heard of is the one at Rio, which is excellent in every way. (See Appendix II, No. 15, for description by B. K. A.) (b) Children's hospitals: The only separate chil- dren's hospitals we have found is that belonging to the Santa Casa of Rio de Janeiro. While on the grounds of the Santa Casa, it is a separate building on higher ground and reached by an inclined rail- road. It has 245 beds and is in every way excellent in arrangement and equipment. In all other cities the children are cared for in a ward of the general hospital. (c) Insane asylums: An asylum at Rio, under federal control, is a most complete hospital for 103 the care and study of the insane, with excellent labor- atory staff, a satisfactory history service, and every evidence of careful clinical and research study by the staff.1 The asylum at Sao Paulo, distant one hour by train from the city of Sao Paulo and under state control, we did not visit but from descriptions given us it would appear to be in every way an excel- lent institution. That at Curityba 2 is a very well planned institution, clean and cheerful, with excellent provisions for the health of the inmates and for light work by the more active cases. We saw, however, no evidence in this institution of the careful study of the patient or of any attempt at investigative study. The only other asylum visited was that at Porto Alegre, which, although a new building, was badly crowded, poorly ventilated, not very clean, and, at the time of our visit, the inmates were afflicted with an epidemic of dysentery. Built for 250 patients it contained at the time of our visit about 600.3 No attempt to interest inmates in light work or to pro- vide for their comfort was evident, and the staff ap- peared to be indifferent to the better type of clinical study. (d) Hospitals for the tuberculous: With four ex- ceptions we have seen no provisions for the tubercu- lous except in the general hospital wards.4 Two exceptions are the separate pavilions of the Santa 1For details see description in Appendix II, No. 15, B. K. A. 2 See details in Appendix 2, No. 5, R. M. P. 8 For notes see Appendix II, No. 2, R. M. P., and for photo- graphs Appendix V, No. 8. 4 See Appendix IV, No. 173, for literature of Anti-tuberculosis League of Minas and description of its dispensary at Juiz de Fora. 104 Casa at Bahia and Bello Horizonte, which, while on the grounds of the main hospital, are somewhat re- moved from the other buildings and have a special service. The third exception is the Santa Casa at Santos, the building for the tuberculous being some- what removed from the hospital proper and located on a cliff high above the main hospital, communica- tion with it being by an elevator running up the side of the cliff. The fourth instance is a hospital for tuberculous women at Rio de Janeiro, a part of the Santa Casa but housed in another section of the city. All these special provisions for the tuberculous indi- cate the use of every new factor in the care of such patients and the buildings at Santos and Rio de Janeiro are in every way satisfactory. (For details see Appendix II, No. n, Santos, by R. M. P., and Appendix II, No. 16, Rio de Janeiro, by B. K. A. For photographs of Rio institution see Appendix V, No. 9.) (e) Leper lazarettos: None of these have been visited except that of Rio de Janeiro for the reason that, as a rule, they are too far removed from large centers. (For description of the hospital at Rio see Appendix II, No. 7, by B. K. A.) (8) Dispensaries: With one exception we have seen no dispensary that is not under the roof of a hospital or medical school. The former (See page 87) have not been developed as they should and have indifferent equip- ment. The latter type was seen only in connection with the poorer type of school, both regular and homeopathic, as at Porto Alegre, Sao Paulo, and Rio 105 de Janeiro, and had for their object, apparently, the obtaining, in the absence of hospital affiliation, of clinical material for the instruction of students. They are all indifferent institutions but it must be stated that the attendance at all is large and indi- cates therefore the real need for proper dispensary service in Brazil. No matter how poor the dispen- sary may have been every one visited by us has been besieged by large numbers of patients. The excep- tion mentioned, that is, a dispensary with its own building, is the Polyclinic of Rio de Janeiro, situated on its main avenue in the center of the city, magnifi- cently housed and well equipped. This building was erected by the Federal Government, which still sup- ports it to some extent. It is controlled by the Facul- dade of Rio de Janeiro and is used extensively for clinical teaching.1 With the possible exception of some of the out-patient departments at the Santa Casa of Sao Paulo, the Polyclinic of Rio is the only dispensary we have seen in Brazil that is properly equipped for good clinical work. (9) Sanatoria: The establishment of sanatoria, either under gov- ernment supervision or private institutions, does not appear to have made much headway in Brazil. The hospital for the tuberculous at Rio represents an at- tempt to separate the tuberculous from patients in the wards of general hospitals, but sanatoria for such patients, similar to those existing in the United States, are not to be found. At least, although we 1 For a brief description of this dispensary see educational sec- tion, p. 163. 106 have made numerous inquiries, we have no knowledge of such. The Brazilian takes care of the leper to some ex- tent and, of course, has hospitals near large centers for the isolation of those suffering from epidemic diseases, but there is no development of special in- stitutions such as those so common in the United States. In this connection we describe (Appendix II, No. 5, by R. M. P.) an interesting sanatorium for diseases of the ear, eye, nose, and throat estab- lished by a Russian exile in the wilds, 20 miles from Curityba.1 General Distribution of Hospitals All attempts to obtain exact knowledge concern- ing the number and distribution of hospitals in any section or state of Brazil have failed. Inquiries of federal and state health departments and search in various statistical compilations show the same neglect here as in the field of education. In conferences with persons interested in the compilation of com- mercial and other statistics we have been told flatly that only by a canvass of each city could we gain the desired information. As it was impossible for our commission to undertake this task we were forced to abandon our plan of a complete summary, includ- ing a map showing the location of hospitals, and can give only a general impression gained from the incomplete statistics of the Almanack Laemmert.2 The state of Sao Paulo alone is said to have pub- 1 See also Appendix IV, No. 40. 2 See Appendix VI, No. 7, for general list from this source. 107 lished a report containing a list of schools, hospitals, libraries, etc., within its boundaries, but we have been unable to obtain it on account of the early ex- haustion of the edition.1 The list prepared from Laemmert shows that large communities have, as a rule, a considerable number of hospitals. Thus, the city of Rio de Ja- neiro has 19 hospitals and n asylums;2 Sao Paulo 18 hospitals and 9 asylums; Bahia 6 hospitals and 2 asylums, and Recife 5 hospitals and 4 asylums. These are all cities with a population of 200,000 or more. Other important capital and port cities, with lesser population, usually have several hospitals, as Santos (population 83,000) 2 hospitals and 4 societies offering hospital facilities, and 2 asylums; Maceio (population 45,000) 3 hospitals and 3 asy- lums; Porto Alegre (population 147,000) 3 hospi- tals; Pelotas (population 65,000) 2 hospitals and 2 asylums; Rio Grande (population 75,000) 2 hos- pitals and 1 asylum. In a large proportion of the smaller towns of the more prosperous states at least one hospital of the Santa Casa type is to be found. Thus, in the state of Sao Paulo, "Laemmert" credits 78 communities out of 164 listed with possession of at least 1 hos- pital. Of these 78 communities, 25 have a popula- tion of less than 20,000, only 15 running over 30,000, and at least 12 having less than 10,000 in- habitants. As to what the situation may be in less prosperous and more sparsely settled states we have 1 See Appendix IV, No. 171, Vol. II (received too late for ab- stracting). 2 These are, for the most part, homes for foundlings. 108 no figures, for outside of the state of Sao Paulo few statistics are available for cities other than capitals. It is doubtful, however, if the same effort is made in other states to provide hospitals. It is our im- pression, from what we have heard and seen in the states we have visited, that Minas Geraes and Rio Grande do Sul approach the State of Sao Paulo in the development of hospitals and that the rest of the southern group of states are backward in this matter. III. THE MEDICAL PROFESSION AND THE PRACTICE OF MEDICINE 1. General Impressions of Medicine in Brazil To properly understand the state of medicine in Brazil it is necessary to keep the following points in mind: (i) That medical education is based on the French system and medical practice on French ideals. (2) The degree of Doctor of Medicine, as also the degrees in law and engineering, bestow great social prestige and aids in political preferment. (3) School and hospital appointments, and in fact all phases of medical activity, are closely bound up with federal and state politics. 1. The questions concerning medical education have been taken up in detail elsewhere, where it has been shown that instruction all tends to purely prac- tical clinical utilization and not to the drilling of the student in observation or to training for power. The practical side of individual laboratory instruc- 109 tion is neglected, only the immediately fruitful meth- ods of clinical value being emphasized. The result is the development of a group of men interested only in the clinical side of medicine and in the finan- cial rewards it may bring. Efforts to advance sci- entific medicine for its own sake, either among teachers or practitioners, is rare. With few excep- tions no full-time teachers or investigators are to be found in the medical school, and naturally none of the latter in that part of the profession actively practicing medicine. The only men giving all their time to investigation are a mere half dozen con- nected with the Oswaldo Cruz Institute of Rio de Janeiro and the Serotherapeutic Institute of Sao Paulo at Butantan, the first a federal, the second a state institution. Moreover, the absence of the in- terne system in the hospitals and the political char- acter of appointments to hospital staff prevents thorough clinical study on a large scale, as also a better type of clinical investigation. The hospitals are essentially resting places for the sick, who must necessarily be studied sufficiently for rational treatment, but the idea that the hospital is a clinical laboratory for the study of disease and the ultimate advancement of the knowledge of medi- cine is not recognized. These failings which retard the higher development of medicine may be traced back, so it seems to us, to the neglect of systematic individual laboratory studies in the early years of the medical curriculum and the absence of the sound drill of an interneship. 2. The social importance attached to medical and other degrees has a very important bearing on the 110 number and distribution of physicians. Sons of wealthy and prominent Brazilian families are ex- pected to win a degree in either medicine, law, or engineering. The possession of a doctor's degree in any one of these professions is highly prized. As has been explained to us many times, it means social recognition and prestige, is essential to political pre- ferment, and of great value in arranging a financially desirable marriage. As a result many men enter the medical school, as also schools of law and engineer- ing, who never intend to practice their profession. The possession of the title of "doctor" leads to work of minor importance for the government or to special missions and eventually to more important political appointments or a semi-political life. If this course is not followed the individual goes into business or banking and the six years of medical training are lost. If this were not the case, Rio de Janeiro with its annual matriculation of 1,700 stu- dents, Bahia with 6oor and Porto Alegre with 250, would by this time have lessened the paucity of physicians in Brazil, as shown in Tables VII to XI. From what has been said thus far it will be readily understood that if a physician regards his calling as a matter of social distinction he will prefer to treat only his social equals. As a matter of fact, the average physician of Brazilian training pre- fers no practice at all to one made up of the less important and less prosperous members of the com- munity. Particularly does he object to the foreign population, which is so abundant in southern Brazil. For the same reason he prefers the large cities where he may occupy the position his social ideals demand. 111 The result is a relative abundance of physicians in large cities, as capitals and important ports, and a definite paucity in the interior and smaller com- munities. Another phase of this social question which is of importance, or at least so it seems to us, is the fact that only the well-to-do can go into medicine. The fees for medical instruction are not high, but the cost of living in large centers, such as Rio de Janeiro, and the expense of "keeping up with the game" prevent, except in exceptional cases, the "poor boy" from entering medicine. It follows also that if a wealthy son can study medicine he also can practice, or at least maintain an office, without spe- cial regard to the income he derives from it. As active competition with those who have to earn a living in medicine is not important, he is particular as to the social standing of his patients, and it is easy to charge relatively high fees. He can live in a center without anxiety about an income, whereas, if conditions were different, he would be forced into a smaller community in order to earn a living. It is these various factors, intimately connected with the social position of the doctor, that explain, we believe, to some extent at least, the paucity of physi- cians outside of capital cities and a few other large important centers. 3. A very definite association of physicians with politics causes many of them to regard medicine as of secondary importance and as but a means to political preferment. As their chief thought and best efforts are given to other fields than medicine, its develop- ment suffers from the withdrawal of the intellectu- 112 ally able, who, under different social conditions, take pride in the development of their profession. 2. Number and Distribution of Physicians in Brazil The data presented under this heading are to be considered merely as indicative of actual conditions and not by any means as complete or accurate. Definite and trustworthy statistical information on any subject does not exist in Brazil, with the pos- sible exception of that relating to exports and im- ports. (For these statistics see Appendix IV, No. 23-) Business men, bankers, educators, and representa- tives of the diplomatic service all make this com- plaint and add that if one wants statistical informa- tion on any subject it is necessary to go out and collect it personally, and even then it is usually incomplete and contradictory, if one has to depend on local estimates or opinion. Certain fairly accu- rate information is available concerning some phases of commerce, but these have, as a rule, been prepared by private agents or consular representatives. Edu- cational statistics have been largely neglected, and we soon discovered that government statistics, both federal and state, in regard to educational and pro- fessional matters, are of little or no value. Nowhere, for example, is there a list of the present distribu- tion of physicians. A physician entering upon prac- tice is obliged to register his diploma with the Federal Health Department at Rio de Janeiro, and some states request, but do not enforce, local regis- 113 tration. The record which is kept, however, is merely an accession list, giving only the name and date of registration, and sometimes the list for a state gives the name only. (For list for Sao Paulo see Appendix IV, No. 24.) The eventual distribu- tion of physicians and the changes due to death or to migration are not controlled. As these lists run back for many years-that in the federal office, for example, the middle of the past century-it is ob- vious that they are of no value for statistical pur- poses. Moreover, lax medical laws, as in the state of Rio Grande do Sul, allow men to practice on insufficient training, and such do not register in the federal capital. Moreover, the demand for physi- cians in the sparsely settled districts, as in Goyaz and Matto Grosso, encourages the health officials to allow the settlement of physicians without fed- eral registration and without very definite local restriction. For these various reasons complete state records -at least in the states we have investigated-do not exist. Inquiries concerning physicians in the state or city results always in a reply which is merely a rough estimate, and the estimates of any two or three offi- cials always vary remarkably. The larger cities, as the capitals, do have more or less complete lists (See Table VIII), but these are of little value in the absence of lists for the outlying country. The lists for the capitals, however, are not prepared by the government, but are usually based on the tabulation made by some local directory. Despite these difficulties it seemed necessary to our report to present a statement, if only approxi- 114 mately correct, of the distribution of physicians, and we have, therefore, after consultation with Dr. Seidl, the Director-General of the Federal Health Depart- ment, and with Mr. Gottschalk, the American Con- sul-General at Rio, and others interested in medical statistics, taken as a basis for discussion the informa- tion contained in the "Almanack Laemmert" for 1915.1 This publication, although a private under- taking, is the only general source of information about Brazil. It utilizes all the information to be obtained from the incomplete government reports, collects material from directories and from institu- tional and other reports, and brings all together in three volumes 2 in which the material is grouped by states and under each state by cities. In connection with each city is given a list of professional men, and it is from such lists that Tables VII to XI have been prepared. That the information thus obtained is not free from inaccuracies must be admitted. This may be seen in the matter of population. Seldom do the figures for the state agree with those obtained by summing up the figures given for the component cities and towns. Moreover, communities with less than four to six thousand-of which there are many -are seldom entered. Census figures for Brazil are notoriously unreliable. The census was attempted in 1911 and abandoned on account of lack of funds. 1 Almanack Laemmert; annuario administrative, agricola, pro- ffissional, mercantil, e Industrial da Republica dos Estados Unidos do Brasil para 1915 (71st year). 2 One volume is devoted to the Federal District, another to the state of Sao Paulo, and a third to all of the other states; a di- vision which indicates the relative prominence of Rio de Janeiro and Sao Paulo in the affairs of Brazil. 115 All figures are, therefore, estimates based on the census of 1906, which again was poorly made. Another difficulty is the dependence, under such circumstances, on local estimates for towns and cit- ies which, as a rule, are always higher than those of the federal authorities. Local pride insists on padding, which is very disturbing to one desiring com- parable figures. The difference between federal and local statistics may sometimes amount to as much as 100 to 500 per cent. Laemmert's figures for popu- lation tend, however, to be conservative, and we have found, in so far as it has been possible for us to check them up, that of several estimates the lower is gen- erally given. A more serious matter in connection with Laem- mert's tabulation is that of omissions. Many towns of considerable size, sometimes cities with popula- tion of 20,000 to 50,000, are entered without fig- ures concerning physicians. It is improbable that in all instances communities of this size are without doctors, and in checking up some of these towns we find that it is merely a question of absence of statis- tics. The editors of Laemmert do not send men into the field to obtain the data which they desire, and when a community does not furnish information it simply is not given. It has, of course, been impos- sible for our commission to fill in these gaps, and a calculation of the total number of physicians and total population by states for Brazil as a whole is therefore impossible. On the other hand, where information is given in Laemmert we are satisfied that it is essentially correct, for we have checked up the figures given by 116 Laemmert by those obtained from health and other officials of the states and cities we have visited, and find a close correspondence. Thus, for the State of Parana we were given by health officials the follow- ing figures for physicians: Curityba 30; Paranagua 4; Ponta Grossa 4; Antonina 1. Laemmert's figures are respectively 25, 4, 4, and 2. So also a list for the city of Rio Grande furnished by a physician, gives 19 names while Laemmert gives 17, and the list for the state of Minas made by the Director of Public Health in the state of Minas, gives 348, while Laemmert gives 371. These figures all show very close correspondence. On the other hand, printed lists of (1) the physicians for the city of Sao Paulo, and (2) in the rest of the state total 565 for the entire state, which is somewhat in excess of the Laem- mert figures, and the figure (288) for the city of Sao Paulo alone are greatly in excess of that (72) given by Laemmert. It is obvious, therefore, that the figures we present in Tables VII to XI are to be re- garded as correct enumerations in some instances and in others as estimates only, and must be regarded as suggestive of the general distribution of physicians, and not as, in all instances, representing actual con- ditions. For this reason in Table VII,1 which shows the distribution by states, the populations and ratios have been calculated in several ways. Column II gives the total population, while Column III gives the sum of the populations listed for the different cities and towns, and column IV gives the population of cities and towns credited with doctors. The ratio 1 For original summaries on which Tables VII to IX are based see Appendix VI, No. i. 117 I II III IV V VI VII VIII IX Name of State Total Popula- tion Popula- tion Listed in Cities and Towns Popula- tion Credited with Doctors Doctors Den- tists Pharma- cists Ratio of Doctor to Total Popula- tion Ratio for Popula- tion Credited with Doctors 1. Alagoas 1,500,000 300,000 2,500,000 1,200,000 297,000 350,000 560,000 180,000 4,000,000 660,000 600,000 700,000 1,310,000 400,000 360,000 1,700,000 1,305,481 1,000,000 500,000 3,500,000 480,000 70.000 813,000 341,500 2,947,415 1,319,493 344,674 433,894 639,877 145,000 4,760,200 662,009 641,650 635,751 1,794,600 381,100 242,100 1,677,299 1,305,481 1,117,040 505,063 2,502,400 450,700 19.000 391,000 137,000 1,817,415 556,000 141,300 122,000 79,150 64,000 3,991,000 200,100 228,000 246,174 1,064,900 124,000 117,000 1,631,700 1,305,481 1,007,040 310,004 1,920,600 212,000 19.000 48 26 203 59 28 16 31 11 371 67 25 47 99 13 20 387 1,125 167 27 507 29 7 10 6 49 21 25 5 11 281 18 8 35 30 8 4 207 330 71 10 319 5 4 23 27 152 78 29 47 34 10 451 28 36 69 126 33 22 238 70 170 39 571 36 5 1-31,250 1-13,135 1-14,519 1-22,364 1-12,310 1-27,118 1-20,640 1-17,272 1-10,781 1- 9,880 1-25,666 1-14,894 1-18,127 1-30,769 1-18,000 1- 4,651 1- 1,160 1- 6,688 1-18,518 1- 6,903 1-16,551 1-10 000 1- 8,145 1- 5,270 1- 8,952 1- 9,425 1- 5,046 1- 7,625 1- 2,553 1- 5,818 1-10,757 1- 2,986 1- 9,120 1- 5,237 1-10,756 1- 9,538 1- 5,850 1- 4,592 1- 1,160 1- 6,030 1-11,481 1- 3,788 1- 7,310 1- 2 714 2. Amazonas 3. Bahia 4. Ceara 5. Espirito Santo 6. Goy az 7. Maranhao 8. Matto Grosso 9. Minas Geraes 10. Para 11. Parahyba 12. Parana 13. Pernambuco 14. Piauhy 15. Rio Grande do Norte 16. Rio Grande do Sul 17. Rio de Janeiro (Fed. Dist.).. . 18. Rio de Janeiro (State) 19. Santa Catharina 20. Sao Paulo 21. Sergipe 22. Territory of Acre Distribution by States of Doctors, Dentists and Pharmacists in Brazil (Calculated from "Almanack Laemmert," 1915) TABLE VII 118 in column VIII is of little value, as it is based on the total population; that of column IX is, however, in- structive, inasmuch as it is based on the population listed as having doctors. However, when it is re- called that Laemmert seldom lists communities of less than 5,000, thus presumably neglecting large country districts, the ratio in column VIII may not be so very far from the actual conditions. Certainly the ratio of column IX may be taken as accurately representing large communities definitely listed as having doctors. Chief interest in this column lies in the fact that with the exception of the city of Rio de Janeiro the proportion of doctors in Brazil varies from 1 to 2,553 t0 1 to 11,481. The Federal Dis- trict of Rio de Janeiro alone approaches the condi- tions found in the United States, England, France, and Germany, and only three Brazilian states are, in part at least, served by doctors in numbers ap- proaching the 1 to 2,000 ratio tentatively suggested by Flexner 1 as sufficient for communities of certain types. In his table is given also information concerning the number of dentists 2 and pharmacists 2 in each state. An attempt was made also to collect informa- tion concerning midwives and veterinarians and the relative proportion of homeopaths, but this was aban- doned because of almost total failure to list such. 1 Flexner, A., "Medical Education in the United States and Canada," Bulletin No. 4, Carnegie Foundation for the Advance- ment of Teaching, 1910, New York; "Medical Education in Eu- rope," Bulletin No. 6, Carnegie Foundation for the Advancement of Teaching, 1912, New York. 2 We have made no attempt to determine the accuracy of figures referring to dentists and pharmacists. 119 Distribution of Doctors in State Capitals of Brazil (Calculated from "Almanack Laemmert," 1915) TABLE VIII State Capital Population Doctors Ratio 1. Alagoas Maceio 45 000 27 1 -1 666 2. Amazonas Manaos 60,000 19 1:3 157 3. Bahia Bahia 300,000 74 1-4 054 4. Ceara Fortaleza.... 56 000 27 1 -2 074 5. Espirito Santo.. Victoria 15,000 13 1:1'153 6. Goyaz Goyaz 17,000 7. Maranhao Sao Luiz 50,000 28 1:1,785 8. Matto Grosso... Cuyaba 15,000 9. Minas Geraes. . BelloHorizonte 40,000 33 1:1,212 10. Para Belem 120 000 58 1:2,068 11. Parahyba Parahyba do N 18,000 12 1:1 500 12. Parana Cnritvba. 66 000 25 1-2 640 13. Pernambuco.. . . Recife 230,000 65 1:3,538 14. Piauhy Therezina. 55 000 8 1 -6 875 15. Rio Grande do Norte Natal 20 000 10 1-2 000 16. Rio Grande do Sul Porto Alegre.. 147,149 64 1-2 300 17. Rio de Janeiro (Fed. District). Rio de J aneiro. 1,305,481 1125 1:1,160 18. Rio de Janeiro (State) Nictheroy 65,000 43 1:1,511 19. Santa Catharina Florianopolis.. 25,000 8 1:3,125 20. Sao Paulo Sao Paulo 400,000 72 1:5,555 21. Sergipe Aracaju.... 40 000 16 1 -2 500 22. Territory of Acre No capital... . As the figures for physicians in capital cities are seldom missing and apparently prepared with greater care than those for other cities, these have been listed in a separate table (See Table VIII). Inaccuracies undoubtedly occur here also, but a comparison with the figures of Table VII show the world-wide ten- dency for physicians to settle in large and important centers. Even with this tendency in the large cities important 120 of Brazil, the ratio does not show the overcrowding characteristic of cities of relatively the same impor- tance in Europe and the United States. The ratio, however, with one or two exceptions, more nearly approaches what may be regarded as the normal. The study of cities and towns other than capitals shows how serious is the paucity of physicians out- side the important centers. A study of Laemmert's statistics shows that in northern Brazil a few doctors serve relatively large communities. Thus in Ala- goas, cities of 13,000 to 67,000 population have only one to four doctors each. In Amazonas, towns of 12,000 to 24,000 are credited with only one or two. In Ceara, only four towns are listed with more than two physicians. The same ratio holds in many large communities of Para, Maranhao, Parahyba, Per- nambuco, Piauhy, Rio Grande do Norte, and Sergipe. There may, of course, be some inaccuracies in Laem- mert's statistics concerning these states but as they are those of tropical Brazil, sparsely settled, with a large negro populaion and more or less backward in economic development, we believe them, as a result of inquiries we have made, to be essentially correct. Even in Bahia, the most populous and prosperous state of northern Brazil and an important medical center, with a medical school since 1808, the ratio is not much better. The state has, it is true, the fourth largest number of physicians of any state in Brazil but outside of the capital only six cities (pop- ulation 17,000 to 103,000) have more than four physicians, and several cities of 20,000 to 65,000 are listed as having only one physician. As regards the interior states, the hinterland of 121 Brazil, as Goyaz and Matto Grosso, the available statistics are of little value. Even in the capital of these states no enumeration of physicians has been made, or if made, has not been published. The listed cities, however, show no community with more than four doctors and a ratio varying from i to 3,000 to 1 to 31,000. In southern Brazil, if capital cities are omitted, the situation is not very different in the states of Espirito Santo, Santa Catharina, and Parana, and even in the more prosperous states-Sao Paulo, Rio de Janeiro, Minas Geraes, and Rio Grande do Sul- the ratio is not as high as one would expect. As we TABLE IX Distribution of Doctors by Population in State of Minas Geraes1 (Calculated from "Almanack Laemmert," 1915) Total population of State, 4,000,000 Population No. OF Cities or Towns Average No. of Doctors for Each Ratio2 145,000 1 22 1 : 6,590 10,000 5 2.6 1 :38,615 50,000 to 100,000 22 3.3 1 : 18,257 20,000 to 50,000 50 2.5 1 :31,160 10,000 to 20,000 19 3.63 1 : 3,780 2,500 to 8,000 7 2.1 1 : 5,214< 37 towns with tc ital population if 993,700 have io doctors listed 14 towns, in addition, are given without population, and of these 10 are credited with a total of 24 doctors. 1 Capital, Bello Horizonte, not included; its population is 40,000; number of doctors, 33; ratio 1 to 1,212. 2 Figured on basis of total population of the cities under consideration. 2 This high average due to presence of three cities of 12,000, 15,000, and 15,000 popu- lation, with 10,14, and 13 doctors, respectively; no other city of the group has more than four. < With this table compare list prepared for the commission by the Director of the Department of Health of the State of Minas; the only official list we have been able to procure for any State. The list gives a total of 348 doctors, whereas Laemmert gives 371. This list may be found in Appendix IV. 122 have for three of these states (Minas Geraes, Rio de Janeiro, and Rio Grande do Sul) fairly complete figures-at least more complete than for other states -the distribution of physicians in them is presented in separate tables (Tables IX, X, and XI). TABLE X Distribution of Doctors by Population in State of Rio Grande Do Sul1 (Calculated from "Almanack Laemmert," 1915) Population of State, 1,700,000 Population No. OF Cities or Towns Average No. of Doctors for Each2 Ratio 65,000 to 75,000 2 25.5 1 : 2,768 30,000 to 50,000 15 6.3 1 :5,653 11,000 to 26,000 30 4.5 1 :4,210 6,000 to 10,000 6 3.0 1 : 2,822 Four cities with a total population of 55,600 have no doctors listed. 1 Capital, Porto Alegre, not included; its population is 147,149; number of doctors 64, ratio 1 to 2,300. 2 This statement has no restrictions as to licensure. TABLE XI Distribution of Doctors by Population in State of Rio de Janeiro1 (Calculated from "Almanack Laemmert," 1915) Population of State, 1,000,000 Population No. OF Cities or Towns Average No. of Doctors for Each Ratio 153,156 1 9.0 1 : 17,017 30,000 to 60,000 10 6.0 1 : 7,062 10,000 to 26,000 20 2.5 1 : 7,126 3,000 to 9,000 4 2.0 1 : 2,573 Eight cities with total population of 110,000 have no doctors listed. 1 Does not include Federal District of Rio de Janeiro, population 1,305,481, with 1,125 doctors and ratio 1 to 1,160, or the state capital, Nicthercy, population 65,000 with 43 doctors and ratio of 1 to 1,511. 123 Rio Grande do Sul and Minas Geraes, with al- ways Sao Paulo (which is not tabulated), are the most important and progressive states of Brazil, and the state of Rio de Janeiro, though less important, reflects the progress and reforms of the adjacent federal capital. Minas Geraes, moreover, has the largest population of any state of Brazil but without many very large communities, and moreover, it is the best type of an interior state. Rio Grande do Sul is the most prosperous of the southernmost three states and combines the difficulties of an extensive coast line and export activities with an undeveloped interior. They, therefore, are fairly representative states for special tabulation. In this selection we have been influenced also by the distribution of medi- cal schools. The city of Rio de Janeiro has had an active medical school for over 100 years, which should have an influence on the distribution of phy- sicians in the adjacent State of Rio de Janeiro. Rio Grande do Sul has had a medical school for less than 20 years, while, on the other hand, Minas Geraes has been without a medical school.1 If medical schools influence the distribution of physicians in the immediate neighborhood of the location of the school, the three states selected for tabulation would reflect this. In connection with these tables may be considered some data taken from printed lists 2 furnished by a physician of Sao Paulo. These are under date of 1 A school now exists at Bello Horizonte but will not graduate its first class for two years. 2 See Appendix IV, No. 25. Furnished by the editor of a medi- cal journal; not complete. 124 1912. The number of physicians outside of the city of Sao Paulo is given as 277 for 117 communities. Of these 19 are in Campinas (population 100,000), 31 in Santos (83,000), and 19 in Ribeirao Preto (55,50°). Eight other communities had 5 to 10 physicians; 12 had 5 apiece, and all other communi- ties had a lesser number. The figures for the city of Sao Paulo itself-288-are very much higher than those given by Laemmert. On the other hand, the figures given in connection with the three cities named above are lower than the figures 24, 43, and 25, respectively, given by Laemmert; all of which indicates how difficult this phase of our task has been. 3. Requirements for Licensure to Practice Medicine, Dentistry, Pharmacy and Midwifery To register and to enter upon the practice of medi- cine, dentistry, or pharmacy it is sufficient, if entire education in these branches has been in Brazil, for the candidate to exhibit his diploma at the office of the federal department of health. If the candi- date has received his degree outside of Brazil, or if he is a native receiving his degree from a Brazilian school not recognized by the government, he must observe the following provisions as laid down in Decree No. 3890, of January 1, 1901:1 (1) Candidate must present: (a) Diploma, (b) Evidence of identification, and (c) Certificate of residence during previous year. 1 See Appendix IV, No. 177, for law as printed in 1914 and furnished commission by Director of Federal Public Health Service. 125 (2) Candidate must then pass an examination 1 held by the faculty of a Brazilian school recognized by the federal government, and pay the examination fees connected therewith. (3) The service of an interpreter at examinations is prohibited. Diplomas granted as a result of such examinations are registered in a special book on the payment of the same fees as are required of those receiving their diplomas in Brazil. (4) Professors of foreign schools whose regula- tions concede the same privileges to professors of Brazilian schools may be admitted to practice in Brazil without examination. This privilege is given also to foreign doctors who are authors of valuable books on medicine, surgery, or pharmacy, if the sanction of the health department is obtained. Can- didates registering under either of these provisions must, however, submit documents certifying to the correctness of their statements, from the diplomatic agent representing the country from which they come. (5) Pharmacists, dentists, and midwives of for- eign training shall pass the same final examination as the native students and must register with the depart- ment of health. Other points in the laws concerning practice of medicine and allied subjects are: (1) That persons pretending to cure by spiritual- 1 The subjects of examination include (i) physiology; (2) ap- plied anatomy; (3) surgical preparations; (4) therapeutics; (5) ophthalmology; (6) dermatology; (7) clinical medicine; (8) clin- ical surgery; and (9) obstetrics. The fee for these examinations is 500 milreis. 126 ism, magic, or other occult means, or who pretend to cure diseases recognized as incurable by the faculty will be prosecuted. (2) The practice of medicine and pharmacy by the same person, even though that person possesses diplomas for each subject, is forbidden. (3) Midwives are forbidden to carry out any procedure which should be performed by a physician and may not prescribe medicines except antiseptics or remedies indicated in an emergency. (4) Dentists are forbidden to perform operations not within the field peculiar to their profession and may not prescribe internal medication or give anes- thetics. (5) No pharmacy may be established without the consent and according to the regulations of the de- partment of health. (6) Definite rules govern the sale of toxic drugs and prohibit dispensing by the pharmacist. These are federal laws and theoretically cover all Brazil, but in one state, Rio Grande do Sul, with its own peculiar laws, they do not prevent licensure of the inadequately trained. In this state is found an exception to the laws concerning the practice of medicine common to other states of Brazil. The state demands no training as a preliminary to licensure. Anyone who pays 300 milreis for a li- cense and an annual tax can pose as a doctor and practice as he sees fit. Men without the degree of M.D. who take advantage of this provision are known officially as "licentiates," but as they use the title "Dr." the general public has no way of dis- 127 tinguishing between them and properly qualified men,1 except by special inquiry. The provision of the state constitution which allows this deleterious practice is based on the doctrine of equal rights and the philosophy of Auguste Comte, whose teachings have had a great influence upon Brazil and whose "positivism" is still a living thing in the provinces. Although these licentiates are given equal privileges with graduates of medical schools, they are held strictly responsible for mistakes in practice as are, of course, also the regular physicians, and as malpractice suits are common, a not unexpected result is the frequency of consultations among doctors. The director of one of the medical schools stated that in almost every case of serious illness the attendant physicians-whether licentiate or "regular"-ask for a consultant in order to diminish responsibility in case of untoward result. As the minimum fee for con- sultation is 50 milreis and usually more than one consultant is called, the expense of illness in Rio Grande becomes considerable. A more serious matter, however, is the encourage- ment which the absence of requirements for practice gives to those who wish to establish poor medical schools. The Escola Medico-Chirurgica and the Faculdade Homeopathica of Porto Alegre are ob- vious attempts to encourage, by a semblance of medi- cal training, the increase of licentiates. Fortunately for the people of Brazil, outside of the state of Rio Grande do Sul, graduates of these two schools are eligible to practice only in their home state. 1 The Brazilian doctor seldom places the degree M.D. on either sign or card. 128 To return to the federal laws, it is evident that the Brazilian-trained physician finds no obstacles to the entrance to practice. For the foreign-trained physician it is quite otherwise-and this applies also to Brazilians educated abroad-and the procedure for such is both expensive and time consuming. The law, in its wording, is innocent enough but as Brazil has no state medical boards for either examination or registration but arrange for examination by the faculty of a Brazilian medical school, the foreigner, or the native physician trained away from home, has to face the prejudice of this faculty. Local institu- tions naturally resent the entrance of foreign phy- sicians into Brazilian practice and especially do they resent the fact that some of their own people should go abroad for medical training. This feeling is ac- centuated in the case of those-both doctors and dentists-who have been educated in the United States, for the success of the latter in Brazil is most striking. As a result the foreign trained-whether Brazilian or not-have great difficulty and are put to great expense in securing registration, as the exam- inations are held at the pleasure of the medical faculty and may stretch out for several months sub- ject to the whims of the examiners. The expense, if the candidate is not living in his home town, is con- siderable. Moreover, it is not unusual for the can- didate to be told, after the first examination, that he has failed and be obliged, after a lapse of some time, to go through with the ordeal again. Almost every American physician and dentist has a story to tell about this period of trial. The Faculty of Rio de Janeiro, for example, has such a bad reputation 129 for "flunking" graduates of American schools that two recent graduates of medical schools, both of whom, however, were Brazilians, went to other faculties, as Bahia and Porto Alegre, several days journey by steamer, in order to avoid the antagonism of the Rio Faculty. One of these men has told us that the expense of registering under these circum- stances was about $1,500. Some go so far as to say that after a candidate has failed once or twice he is sure of passing if he takes a perfunctory course of instruction with the examiner and pays well for the course. Our informant states that the first examina- tion, in which he failed, cost him 500 milreis ($125) ; for the second examination which he took six months later and passed, he contributed 2,000 milreis ($500). The implication in this statement is evident. Whether this attitude of the Brazilian faculties is adopted to discourage Brazilians from going abroad for their medical education or whether it is due to the rather bad reputation which medical education in the United States has as the result of the publicity given some years ago to its diploma mills, it is impossible to say. American physicians in Brazil say that it is neither, but is pure cussed- ness.1 What has been said about physicians applies with even greater force to American dentists, who, on account of their great success in Brazil, apparently are not desired. Many find registration so difficult 1 It must be admitted also that the Brazilian, ignorant of our preliminary requirements and of our hospital interne system, can- not understand how medicine can properly be taught in the United States in four years, when it takes six in Brazil. 130 that they practice under the name-as the law allows -of another dentist or firm of dentists. When a physician has once conformed to the regulations he can practice anywhere in Brazil but some states require the formality of a local registra- tion. All physicians, however, whether native or foreign have to pay a tax of 100 milreis a year in Sao Paulo. Whether this tax is collected in all states we have not been able to determine. As to the relation of physician to pharmacist we have quoted above the law forbidding the simulta- neous practice of medicine and pharmacy. This, we are told, is frequently evaded by the pharmacist, who, if he controls a certain number of patients, provides an office in which a physician sees patients during certain hours. The physician charges nothing for this service but receives a commission from the pharmacist who collects from the patient for the pre- scriptions. 4. Miscellaneous Information FEES OF PHYSICIANS Brazil is notorious for the high cost of living and the expenses connected with luxuries or necessities outside of the ordinary. The fees of physicians do not, however, appear to be higher than those of the better type of practitioners in the United States. The usual fee of the family physician in less popu- lous districts appears to be 5 milreis 1 for an office 1 It is impossible to give exact values of Brazilian money on account of fluctuating rate of exchange. At the time of our visit a milreis equalled approximately 25 cents of United States money. 131 visit and 10 for a visit to the home of the patient, and in the larger cities 10 and 20 respectively. In some outlying districts these figures are reduced to 2 and 5 milreis. On the other hand, in the prin- cipal centers, as Rio de Janeiro and Sao Paulo, the prominent physician usually charges higher fees, but we have found some difficulty in getting exact fig- ures. For a consultation the minimum fee appears to be 50 milreis and rises above this figure accord- ing to the importance of the consultant. Surgeons' fees vary according to city and prominence of sur- geon. The following figures are said to be repre- sentative of the larger cities of Rio Grande, Sao Paulo, and the city of Rio de Janeiro: Operation for appendicitis. . . . 300-1,000 Milreis Operation for hernia 300- 500 Tonsillectomy 300- 500 Mastoid operation 500-1,000 Operation for cancer of breast. 500-1,500 Dressing simple fractures 200- 500 Specialists, as ophthalmologist or laryngologist, usually receive an office fee of 20 milreis and the fee for confinement in ordinary practice is 300 to 500 milreis. SPECIALTIES In the large cities, particularly the medical cen- ters, as Rio de Janeiro, Sao Paulo, Porto Alegre, Bahia, and the prosperous cities of Santos, Cam- pinas, and Pelotas, specialization is much the same as elsewhere in the world, but outside of cities of these types the physician is an .all-around practi- 132 tioner, combining, as a rule, surgery with internal medicine. The almost universal employment of midwives deprives the family physician of some in- come and cuts down the number of specialists in obstetrics. These, however, may be found in large centers; Sao Paulo, for example, has two, but as a rule they combine gynecology with obstetrics. Homeopaths are not abundant in Brazil, but they are recognized by the Government and have been able to start schools, very poor ones it is true, in Rio de Janeiro and in Porto Alegre. The school in Rio de Janeiro (see description elsewhere) has about 125 students, that of Porto Alegre about 30. That homeopaths are tolerated by the regular school is shown by the fact that the secretary of the medical school of the University of Parana (at Curityba) is a homeopath. We have been unable to obtain exact figures concerning homeopaths. Laemmert lists 22 in the city of Rio de Janeiro, 4 in the state of Rio Grande do Norte, 10 in Rio Grande do Sul, and 3 in the state of Pernambuco.1 There appears to be a general impression among Brazilian physi- cians with whom we have discussed homeopathy that physicians take up this method of practicing medi- cine only when they are unsuccessful as physicians of the regular school. This may have been true in HOMEOPATHY AND OTHER SECTS QUACKS 1A member of the faculty of the homeopathic school at Rio states that there are not more than 100 in all Brazil and of this number about 30 are in the city of Rio de Janeiro and 4 or 5 in the city of Sao Paulo. 133 the past, but the new schools of homeopathy recently established will undoubtedly increase the number of homeopathically trained men. Osteopaths and others of allied schools are not much in evidence, but quacks abound, largely, it is said, on account of the great incidence of syphilis. Advertisements of quack specialists and of patent medicines, particularly in the field of venereal dis- eases and diseases of women, are seen on all adver- tising boards and in all newspapers. In Rio Grande do Sul spiritualism has a great vogue, but we have heard little of Christian Science. WOMEN IN MEDICINE There is apparently no restriction against women entering medicine, but few are found in practice or in the schools. The director of the "Faculdade de Medicina" of Porto Alegre states that his school usually has two or three women in the courses at one time, the director of the "Escola Medico-Cirurgica" of the same city says that his school has "one or two" in its first year, and four are matriculated in the classes of the "Faculdade" of Sao Paulo, and three or four in that of Rio. If we are good judges of feminine names in Portu- guese there is only one woman physician practicing in the City of Sao Paulo, according to the printed list of 288 for this city.1 This individual is a grad- uate of the Woman's Medical College of Philadel- phia. The other city directories we have examined show no woman doctors. 1 See Appendix IV, No. 25. 134 FULL TIME MEN IN TEACHING AND RESEARCH: EXTENT OF MEDICAL RESEARCH Full time teachers practically do not exist. At Rio de Janeiro the entire faculty is engaged in the practice of medicine, those having hospital appointments working in the hospital from 7 to 11 A.M. and giving the afternoons to private prac- tice. All heads of laboratory departments are clini- cians. This holds in general in other schools, except for the contract1 professors of anatomy at Sao Paulo 2 and chemistry at Bello Horizonte. Occasion- ally one hears of a professor who has no private practice, but on inquiry it turns out that he is very wealthy, or is interested in real estate, or plantations, or other non-medical work, and thus is not a full time man in the sense that he gives all his time to teaching and research, and is compensated for so doing by the medical school. It is the absence of full time teachers in the sci- ences of medicine that explains the non-productivity of the medical laboratories of Brazil. The only re- search is in the direction of the acute infectious dis- eases, and this is as a rule done by clinical teachers with a working knowledge of bacteriology or histol- ogy from the clinical point of view. Research in anatomy, histology, embryology, physiology, physio- logical chemistry, and pharmacology does not exist. 1 For explanation of term "contract professor" see page 43. 2 The contract professors of Pathology and Bacteriology re- spectively, at Sao Paulo cannot be classed as clinicians in the ordinary sense, but they reserve the right to practice to a limited extent. 135 Pull time men in research work are found only in the two important research institutions, the Oswaldo Cruz Institute of Rio de Janeiro and the Sero-Thera- peutic Institute at Butantan, near Sao Paulo. At the former (federal laboratory independent of the health department) work the most celebrated med- ical scientists of Brazil, Cruz, Lutz, and Chagas, with their groups of assistants; at Butantan, Dr. Vital Brazil and his assistants. Even in these instances, the work is not entirely research, for the Oswaldo Cruz Institute prepares serums and vaccines for dis- tribution to all Brazil, and at present the institute is partly maintained by the income thus derived. So also in Brazil's Paulista laboratory, wrhich is part of the state health department, a large share of the work of the institution is devoted to the prepa- ration of serums, and especially to anti-sera for snake poisoning. If other institutions or schools support full time men in research they have not been brought to our attention. It is possible that the situation may change as the influence of the few contract professors, essen- tially full time men, at Sao Paulo and Bello Hori- zonte is felt, but at present there is little evidence of productive investigation outside of the Oswaldo Cruz Institute. We have inquired at every institution we have visited for reprints of publications by staff or fac- ulty during the past three years, and have made sim- ilar requests in writing to a number of institutions, with but slight results. (For such reprints as have been collected see Appendix IV, No. 9.) In the government laboratories, as those connected with the department of health, the work, even un- 136 der full time men, is entirely routine with little at- tention to the possibilities of research. An exception is the bacteriologic laboratory of the state of Sao Paulo (see Appendix IV, No. 9). As to laborato- ries of general hospitals we have found only one with a full time director, who does not practice and who takes an interest in research. This is the laboratory of the Santa Casa of Sao Paulo, the Director of which is Dr. Alex. Pedroso, an American trained bacteriologist and former student of Dr. Simon Flexner. INDEPENDENT MEDICAL LABORATORIES The Institute Oswaldo Cruz: The only medical laboratory of Brazil not connected with a medical school or a department of health is the Instituto Os- waldo Cruz, located in a suburb of Rio de Janeiro known as Manguinhos, a name frequently applied locally to the Institute itself. This laboratory was established in 1901 by the federal government and was originally under the control of the federal de- partment of health, but is now independent, with the director, Dr. Oswaldo Cruz, responsible only to the Minister of Justice and Interior Affairs. It is a magnificent structure of Moorish type of architec- ture and embellishment with complete equipment for all phases of work in connection with research in the acute infectious diseases, and the preparation of vac- cines and serums, and includes a library, a museum, printing, carpenter, and machinery shops. The gen- eral plan of the building and illustrations of its vari- ous parts may be seen in a descriptive pamphlet filed herewith (Appendix IV, No. 172). 137 The original cost of the building is said to be about $1,000,000. The subventions from the Fed- eral Government have reached at times almost half a million milreis, but for the present year are 331,240 milreis ($82,810), divided as follows:1 For the salaries of professional and administrative staffs 134,000 milreis Servants, etc 57,240 For material and equipment 110,000 For the maintenance of the branch institute located at Bello Hori- zonte (Minas Geraes) 30,000 In addition to government aid the institute de- rives some income from the sale of biological prod- ucts. The professional staff of the laboratory, with the annual salaries, follows: A director receiving 18,000 milreis Two chiefs of service at 14,400 each. 28,000 milreis Six assistants at 10,800 each 64,800 milreis In addition are three administrative officers with total salaries of 17,600 milreis, an artist (salary 4,800 milreis), and 19 mechanics,2 servants, etc., to- talling 57,240 milreis. The personnel of the labora- tory includes Dr. Oswaldo Cruz, the director; Drs. Vasconcellos and Rocha Lima, chiefs of service; and 1 Taken from "Orcamento do Ministerio do Justica e Negotios Interiores" for 1916, page 63 (See Appendix IV, No. 98). 2 For details see Appendix IV, No. 31, page 63. 138 six assistants. Of the latter, Dr. Carlos Chagas, who elucidated the disease which bears his name, and Dr. Ezequial Diaz in charge of the branch institute at Bello Horizonte 1 are perhaps the best known. In addition the Institute has had from time to time, under contract, the services of Dr. S. von Prowazek (Hamburg), Dr. G. Giemsa (Italy), Dr. M. Hart- mann (Berlin), and Dr. Adolpho Lutz, the latter at present being entomologist to the Institute. In addition to research work the Institute offers regular courses in bacteriology to advanced students. Important investigations which have been carried out in this laboratory include: i. Studies of pest with special reference to cura- tive vaccines and serums. 2. Studies of malaria and ankylostomiasis. 3. Entomological studies. 4. Studies of trypanosomes, parasites of birds, etc. (For complete list to 1910, see Appendix IV, No. 172.) The Institute has an excellent library which re- ceives about 400 medical and other scientific publica- tions. The early reports from the laboratory appeared in various medical journals, but now it has its own pub- lication, a copy of which is filed herewith. (See Ap- pendix IV, No. 172.) For a description of some of the problems now engaging the attention of the staff see Dr. Ashford's 1 It was in connection with this branch that the Commission's field dispensary was operated. 139 notes (Appendix II, Nos. 19 and 20; See also photo- graphs, Appendix V). Oswaldo Cruz must he considered as one of the most important factors, and probably the most potent influence, in the improvement of public health af- fairs in Brazil. First as Director-General of the federal health department he was directly responsible for the cleaning up of Rio de Janeiro, for the institution of mosquito eradication, and thus for the present free- dom from yellow fever. The plans adopted at this time have been followed by his successor, Dr. Seidl, to great advantage. It is worthy of note that this campaign against yellow fever met with great oppo- sition, became a political issue in the election of 1904, and led to riots in the city of Rio de Janeiro. De- spite all opposition Dr. Cruz put the work through, and as his plan was adopted by other port cities it is to him that southern Brazil is indebted for freedom from yellow fever. The regard in which the man is held is shown in almost every conversation with health authorities. Sooner or later some refer- ence to his work or views comes out. Also his name is used freely in connection with medical institutions; thus the streets in Santos (Sao Paulo), on which the isolation hospital is located, is called "Rua Oswaldo Cruz"; a pavilion of the marine hospital (quaran- tine service) of the federal government at Rio de Janeiro is named "Oswaldo Cruz Pavilion"; the official launch of the port physician at Rio Grande (in Rio Grande do Sul) is named "Oswaldo Cruz"; one of the laboratory buildings of the principal med- ical school at Porto Alegre is named "Institute Os- 140 waldo Cruz," and a room at the institute at Butantan is dedicated to him. At present Dr. Cruz, as the head of the research institute known by his name, combines the knowledge of a practical health authority with that of the in- vestigator in solving the medical problems of the country and advising as to means of the practical con- trol of disease. MEDICAL SCHOOLS REPRESENTED BY BRAZILIAN PHYSICIANS It is obvious that with the Rio de Janeiro school having an annual enrollment of fourteen to sixteen hundred students most of the physicians of the country are trained in this school. Bahia, with an enrollment of 600, naturally comes next. The rest of the physicians are graduates either of the school of Porto Alegre or of foreign schools. We have made several attempts to obtain a census of the degrees represented by physicians in one or more cities, but have been successful only in the case of the city of Rio Grande (in Rio Grande do Sul), concerning which information was furnished us by Dr. Pio de Angelo da Silva. Of the total number of physicians in Rio Grande ten received their de- gree from the "Faculdade" of Rio de Janeiro, and one from that of Bahia. The other eight physicians are all graduates of foreign schools, as follows: 2 from the medical school of Rome (Italy) ; 2 from the medical school of Naples (Italy) ; 1 each from the schools of medicine Oporto (Portu- gal), Coimbra (Portugal), Paris (France), and the 141 University of Pennsylvania (U. S. A.). The num- ber of licentiates 1 (curanderias) in Rio Grande is 6. This list shows a high proportion both for the Rio school and for foreign schools, and a rather poor showing for Bahia and Porto Alegre. In and about Bahia and Porto Alegre graduates of these schools would undoubtedly have a larger represen- tation in their respective territories. The propor- tion of foreign physicians in Rio Grande is perhaps a little higher than elsewhere. Nevertheless, the list supports the impression we have gained as a result of conversation with physicians in the various parts of the country we have visited that Rio grad- uates dominate clinical medicine and that the pro- portion of foreign physicians is high in all of the larger cities. ATTITUDE TOWARDS PHYSICIANS OF FOREIGN TRAINING Although the Brazilian law of licensure states very innocently that to practice in Brazil it is only necessary for graduates of foreign schools to take an examination at one of the Brazilian faculties (Rio de Janeiro, Bahia, Porto Alegre) recognized by the government, great difficulties are placed in the way of foreign students both in medicine and dentistry. Moreover, these difficulties are encoun- tered not only by the foreign-born but by native Brazilians who have taken their degrees outside of 1 See page for lax laws of Rio Grande do Sul, which allow licensure without medical degree or training. 142 the country. Holders of foreign degrees have to pay a fee of 500 milreis for the examination, and as the examinations are scattered over a period some- times of several months, at the pleasure of the ex- aminers, they involve necessarily great expense to the candidate, if, as is usually the case, the exami- nation is not held in his home city. Moreover, the candidate usually fails once or twice before he is finally passed. The accounts of this ordeal as given by several physicians trained in the United States are very entertaining, but not worthy of de- tail here. The object of this harassing examination is apparently to spread the implication that Bra- zilian medical training is superior to that given else- where, especially to that of the United States, and thus to discourage the migration of Brazilians to foreign schools. Whether opposition exists on the part of the gen- eral profession to foreign-trained physicians we have no way of knowing. It may be said, however, that whether or not it does exist the graduates of schools in the United States are uniformly successful and prosperous, and are exceedingly popular with their clientele. In fact, the American physician is almost as much of an institution in Brazil as the American dentist. We have been unable to make a complete census of American physicians in Brazil, but the majority appear to be graduates of the University of Pennsylvania and are especially numerous in Sao Paulo. 143 MEDICAL SOCIETIES In Rio de Janeiro: Academia Nacional de Medicina. Soc. de Medicina e Cirurgica do Rio de Janeiro. Soc. Brasil de Dermatologia. Assoc. Imprensa Med. do Brasil. Soc. Med. dos Hospitals do Rio de Janeiro. Soc. Brasil de Pediatria. Soc. Brasil de Psychiatria. Institute Hahnemannia do Brazil. In Bahia: Soc. de Medicina. In Sao Paulo: Soc. de Medicina e Cirurgica. In Bello Horizonte (Minas Geraes) : Soc. de Medicina, Cirurgica e Pharmacia. In Porto Alegre (Rio Grande do Sul) : Soc. de Medicina. From this list, which we believe to be complete, it is evident that there is no national organization of the medical profession and, outside of Rio de Janeiro, little interest in the cultivation and discus- sion of the special phases of medicine. As each of the cities represented by societies are medical cen- ters and, moreover, are the capitals of the most pro- gressive states of Brazil, the list doubtless indicates accurately the degree to which medicine in Brazil is to be considered as something more than a mere means of earning a living. 144 The National Academy at Rio is more or less an honorary body. Its membership, in 1915, was divided as follows: active members, 95; honorary members, 62, of whom 17 are native and 45 for- eign; corresponding members, 51, of whom 24 are native and 27 foreign. The society at Sao Paulo has 100 members, while the Homeopathic Institute of Rio has 30.1 For other societies we have no figures. An attempt to obtain a list of important societies representing other subjects than medicine has not been successful. Some information concern- ing these, however, may be found in Appendix VI, No. 5. THE MEDICAL PUBLICATIONS OF BRAZIL The following list of medical publications for Brazil was furnished by officers of the Bibliotheca Nacional of Rio de Janeiro and includes all of which they have record :2 Federal District 3 Annaes de Medicina Homeopathica-Rio de Janeiro. Archives Brazileiros de Medicina-Rio de Janeiro. Boletim Hebdomadario da Estatistica Demo- grapho-Sanitario-Rio de Janeiro. 1 For an account of this society see Appendix IV, No. 33. 2 For a printed list of Brazilian periodical literature of various kinds-from which this statement of medical journals was pre- pared-see Appendix IV, No. 170. 3 Copies filed with this report (See Appendix IV, No. 32). 145 Boletim Mensal da Estatistica Demographo- Sanitario-Rio de Janeiro. Boletim Pharmaceutico-Rio de Janeiro. 1 Brazil Medico-Rio de Janeiro. Gral-Rio de Janeiro. Medicina Militar-Rio de Janeiro. 1 Registro da Maternidade-Rio de Janeiro. Revista Dentaria Brazileira-Rio de Janeiro. Revista de Gynecologia-Rio de Janeiro. Revista Homeopathica Brazileira-Rio de Ja- neiro. Revista de Medicina-Rio de Janeiro. Revista Medica-Cirurgica do Brazil-Rio de Janeiro. Revista Syniatrica-Rio de Janeiro. Semana Medica-Rio de Janeiro. Tribuna Medica-Rio de Janeiro. In the States 1 Annales Paulista de Medicina e Cirurgica-Sao Paulo. Archives da Sociedade de Medicina e Cirurgica de Sao Paulo. Boletim Mensal da Estatistica Demographo- Sanitaria da Cidade de Belem. Boletim Mensal do Estatistica Demographo- Sanitaria da Cidade do Salvador, Bahia. Gazeta Clinica-Sao Paulo. Imprensa Medica-Sao Paulo. Jornal de Medicina de Pernambuco-Recife. Physiolatra-Curityba. 1 Copies filed with this report (See Appendix IV, No. 32). 146 Revista Homeopathica Brazileira-Curityba. Revista Medica de Minas-Juiz de Fora. Revista Medica de S. Paulo-Sao Paulo. Revista Pharmaceutica e Therapeutica-Sao Paulo. Rio Grande Medico-Porto Alegre. Brazilian medicine is not, however, represented solely by these journals, for many physicians publish in European, especially French, journals. VI. FINAL COMMENT AND SUGGES- TIONS (I) Medical Education. Medical education in Brazil suffers from: i. Lack of proper preliminary training. 2. Lack of detailed laboratory work in the sciences of medicine. 3. Failure to provide instruction in biological chemistry and pharmaco-dynamics. 4. Absence of an interne service in the hospital. 5. Failure to encourage research. The faults are all the result of the system which magnifies the importance of the clinician and gives to clinical medicine a prominence which makes the science of medicine subordinate to the practical ends of diagnosis. Clinicians in laboratory chairs, the cutting down of laboratory work to the minimum bearing on the practice of medicine, and the pres- tige of the clinician in social and political life all 147 combine to minimize the importance of the labora- tories and make them merely the servants of the clinician. Graded salaried laboratory staffs do not exist, thorough laboratory training for its own sake is not appreciated, and research languishes. Men with a temperament which inclines them to scientific work see no opportunity for a career in the laboratory and go into clinical medicine as the only avenue to recog- nition in medicine. The result is that the only well- trained full-time laboratory scientists are the few contract professors at Sao Paulo and Bello Hori- zonte. These men offer the only hope of eventual improvement in laboratory teaching but at present their influence is slight for they are few in number, have small budgets and cannot impress upon the clinician the importance of detailed laboratory courses. On the other hand, the contract professors are not Brazilian and find it difficult to change the Brazilian point of view, that is, they cannot impress upon the student their view that there is something in medicine besides, and of vastly more importance for progress than, the clinic. Still, the hope of Brazilian medicine would appear to be in these con- tract professors, for as long as the more ambitious Brazilian sticks to the clinic as the surest path to a career, men will not be trained as laboratory teachers, and any school desiring well trained men for its laboratories will have to go outside of Brazil as Sao Paulo and Bello Horizonte have done. This the older schools (Bahia and Rio) will not do for the present at least. With a hundred years of tradition back of them they look with amused tolerance on the attempt of the newer schools to encourage laboratory 148 training, and will continue to hold their laboratory chairs for the successful clinician. To the hope of- fered by the contract professor must be added that based on the modern attitude of the new schools. With one or more of the new schools not pampered by tradition and demonstrating this by encouraging individual laboratory training and employing, in order to accomplish this, foreign professors would appear to lie the opportunity of establishing medical education in Brazil on a sound basis. To hasten this, however, it is essential that the number of con- tract professors with sound fundamental training should be increased. An opportunity to do this exists at Sao Paulo. Its departments of anatomy and bacteriology appear to be satisfactory but its department of pathology is weak, and a professor of hygiene has not yet been appointed as this latter course will not be inaugurated until next year. The German professor of pathology coming to Sao Paulo this year from Bello Horizonte will not be retained, it is said, when his two-year contract expires. The appointment of well trained men to chairs of pa- thology and hygiene in this school would give Sao Paulo the strongest laboratory combination in Brazil, and doubtless influence other schools to improvements. So also Bello Horizonte has good departments of chemistry and bacteriology, but for the present is without a pathologist. The dean of the latter school seems to recognize the value of the contract professor and would welcome more men of this type on his faculty. Sao Paulo, however, is in better shape financially than is Bello Horizonte. It is a state medical school with definite financial support from 149 the state and a faculty containing many foreign trained men, and already has in hand money for a new school and hospital. Moreover, the state is the wealthiest and most progressive in all Brazil.1 Again the school has shown in the three years of its existence a desire to obtain (see page 169) the best laboratory instruction for its students and has dis- regarded Brazilian standards by allowing two of its teachers trained in medical schools in the United States to introduce American methods of teaching. Also it offered two years ago its chair of pathology to an American trained Brazilian,2 who was obliged to decline on account of the small salary which the chair carried. In many ways the Sao Paulo Faculdade suggests that it may repeat in Brazil the history of the Johns Hopkins Medical School in the United States and become a revivifying influence in Brazilian medicine. To accomplish this, however, it must have more for- eign trained men in its laboratories and funds to equip adequately these laboratories for individual work by the student. Any attempt to help medical education in Brazil should, in our opinion, take ad- vantage of the opportunity offered at Sao Paulo to fill within the next two years the chairs of pathology and hygiene. With a successful demonstration of American methods in these two departments the school would probably see the wisdom of itself de- 1 One-quarter of all the revenue of the Federal Government is furnished by the state of Sao Paulo. 2 Dr. Alex. Pedroso (U. of P., 1905), former pupil of Dr. Simon Flexner and now pathologist of the Santa Casa of Sao Paulo. 150 veloping departments of physiology, physiological chemistry, and pharmacology.1 Sao Paulo appears also to be the strategic point for an attempt to modify the methods of education preliminary to medicine, inasmuch as this city al- ready has MacKenzie College (affiliated with the New York Board of Regents, see pages ) with good laboratories for physics and chemistry and plans for immediately equipping a biological labora- tory. The Faculdade of Sao Paulo, on the other hand, has definitely recognized the status of the first of its six years of medicine as a preliminary course and has frankly labeled it as such. If assistance could be given to MacKenzie College to conduct an adequate course preliminary to medicine and if the Faculdade would agree to such an arrangement and cut out its preliminary year, the saving of time, space and budget in the medical school would give addi- tional opportunity for the prosecution of legitimate medical work and perhaps eventually influence the Brazilian system of preliminary medical education. Moreover, MacKenzie College if given sufficient sup- port should be able to offer a course far superior both in scientific and cultural value to those given by any Brazilian medical school in its first year. In connection with these remarks it must be re- 1 Theoretically the initial effort might be made with these de- partments but the closer relation of pathology to other laboratory branches on the one hand and its importance on the other to clini- cal medicine renders effort in pathology the most important from the point of view of results to be gained. So also the filling of a chair of hygiene on account of the possible influence of the right sort of man in state health affairs would be strategically of the greatest value. 151 membered that the influence of Sao Paulo throughout Brazil is as great, if not greater, than that of Rio de Janeiro. The absence of the interne system (see page 65) in Brazil is, from the point of view of practical training in clinical medicine, a most serious fault. All the schools, it is true, give the student of medi- cine the greatest freedom in the wards on the basis essentially of the English clinical clerk system but this does not give the young medico the drill and responsibility that is obtained only through pro- longed residence in a hospital and, moreover, the absence of the interne system inasmuch as it prac- tically assures him that he is competent to practice medicine at once imbues him with a false impression of his training. In our conversations with Brazilian medical men all admit the value of the interne system as established in the United States and no argument against it has been advanced. Makeshift arrange- ments, as the intermittent student interneship and the paid graduate on duty once in several days, exist and tradition alone appears to block the introduction of the continuously resident interne. Sao Paulo is about to experiment with resident student internes and it would appear to be the logical place to en- courage frank recognition of the American system. It might be tried at the Santa Casa but better still at the new hospital to be built in connection with the new medical school. At present no Brazilian hos- pital has quarters for housing internes and the in- troduction of internes in any number would necessi- tate a change in the hospital plans to the extent perhaps of providing a special building. Also the 152 tradition of paying for service of this kind might cause at first an additional expense. The experi- ment, however, is worth while and if it could be attempted in connection with the new hospital of the Sao Paulo Faculdade it might eventually be adopted universally in Brazil and thus lead to a larger num- ber of well-trained practitioners. To sum up, the conditions of Sao Paulo are such as to warrant an attempt to aid medical education in Brazil by financing for a time at least: i. A course preliminary to medicine at MacKen- zie College. 2. Some of the laboratory chairs especially those of pathology and hygiene in the Faculdade of Sao Paulo. 3. An interne system in a Sao Paulo hospital, preferably in the new hospital about to be built in connection with the new school of the Faculdade. With assistance along such lines Sao Paulo might gradually overcome the traditions of the schools of Rio de Janeiro and Bahia and exert a most important influence on the system of medical education in Brazil. The plan proposed might likewise be put into effect at Bello Horizonte, the Faculdade of which controls the adjacent Santa Casa and has an intimate relation with the state department of health but the financing of the Sao Paulo school by the state and the prominence of Sao Paulo in the affairs of Brazil as well as the progressive attitude of the Sao Paulo faculty all point to the Sao Paulo school as the best place for the experiment. 153 II. Research in Medicine: We have pointed out elsewhere that not only is research neglected in the medical school, but, moreover, that no medical school has either the equipment nor the organized staff for sustained effort. Also it has been stated that only two research institutions (the Instituto Oswaldo Cruz at Rio and the Sero-therapeutic Institute of Sao Paulo at Butantan) independent of medical schools are to be found in Brazil. As for hospital laboratories, only one, that at Sao Paulo, is equipped for research work, and has an active director who does not practice medicine. Improved opportunities for research must come as a result of changes, such as we have outlined above, in the system of medical education. Only when the laboratories of medical schools are placed on an efficient basis as to space, equipment, budget, and staff will they attract men who can advance medicine by research. When that time comes the development of laboratories in hos- pitals, in connection with departments of health and upon independent foundations will naturally follow. At present, however, the existing laboratories are of considerable importance to the International Health Commission if it is planning, in connection with its new school of hygiene, field work in the trop- ical diseases. Such field work could be done with the smallest outlay of money by cooperating with existing laboratories interested in the study of trop- ical diseases. The two Brazilian laboratories with which such cooperation might wisely be attempted are the Instituto Oswaldo Cruz under a director of the same name and the sero-therapeutic institute of Sao Paulo under Dr. Vital Brazil. These laboratories 154 are well equipped for work in the acute infectious dis- eases, and both would eagerly welcome the oppor- tunity to undertake field investigations in conjunc- tion with foreign organizations. The Rio Institute is under federal control but independent of the de- partment of health. The Sao Paulo institute, on the other hand, is an arm of the state department of health. Work undertaken with either therefore would be in cooperation with governmental interests and be assured of governmental support. If in con- nection with the new school of hygiene it is planned to send members of the faculty or students into for- eign countries for either technical training or research effort friendly cooperation with these two institu- tions would be of great value. This is particularly true of the Rio laboratory, which has a branch field station at Bello Horizonte in the state of Minas- in connection with which the present Commission's field dispensary operated. So also if the school of hygiene wishes its stu- dents or graduates to have opportunities for work in Brazilian hospital laboratories this may be found at the Santa Casa of Sao Paulo now completing a new laboratory which will be well equipped and under the direction of an American trained pathologist. III. Hospitals and Dispensaries: Brazilian hospi- tals are essentially boarding houses for the sick with little effort to study patients thoroughly or to use clinical material to advance medical knowledge. The present faults can be remedied only through changes in the system of medical education-more thorough laboratory training and the adoption of the interne system-such as we have outlined for Sao Paulo. 155 A more serious matter is the failure to provide a system of medical relief in the smaller and outly- ing communities. A system of state dispensaries would solve the difficulties, but Brazil has at present so many other problems before her and her finances are so strained that the country will not in all prob- bility face this task for many years. That dispensaries are badly needed is shown by: (i) crowds attending the outpatient departments of all hospitals we have visited; (2) large attendance at the dispensaries of even the poor type of medical schools; and (3) the great number-nearly 1,500 in a little more than three weeks-who besieged the Commission's dispensary in Capella Nova. This problem is one that must be solved by the cooperative efforts of the federal, state, and local governments, but an educational campaign through the establish- ment of temporary rural dispensaries might come legitimately within the field of effort of an outside agency. The Commission's dispensary at Capella Nova is a thing of the past, but its work created pub- lic opinion which demanded the continuance of dis- pensary work under local authorities. Further efforts of this kind here and there in the different states of Brazil if carried on with a definitely educational point of view might show Brazil the way to do its duty to its rural communities. 156 PART II Description of Medical Schools THE FEDERAL DISTRICT OF RIO DE JANEIRO Population 1,305,4s!;1 No. of physicians 1,125; Ratio 1 to 1,160. (State of Rio de Janeiro: population 1,000,000; Doctors, 166; Ratio 1-6,030.) Number of medical schools-2. (1) Faculdade de Medicina do Rio de Janeiro: Established in 1808 under the Empire and contin- ued under the Republic, and has always been sup- ported by the national government. It maintains, in addition to medicine, departments of pharmacy, dentistry and midwifery. Entrance Requirements: Examination based on education in secondary schools. Attendance: Total matriculation for 1915 was 1,703, divided as follows: medicine 1,492, pharmacy 168; dentistry 30; and midwifery 13. The medical classes were divided as follows: 290 in the 1st year; 207 in the second; 331 in the third; 118 in the fourth; 293 in the fifth; and 253 in the sixth year. 1 Wherever a discrepancy exists between the figures given in these summaries and those of earlier tables it is to be understood that the former are local estimates. 157 Teaching Staff: 52 professors and 37 teachers of other grades. Resources Available for Maintenance: The chief item is an annual subvention from the government, which, according to fiscal report of the school for 1915, was 1,008,992 milreis. To this may be added 317,691 milreis received from other sources, includ- ing students' fees, making a total budget of 1,326,- 683 milreis ($331,670.75). These figures, how- ever, include the expenses of the schools of phar- macy, dentistry, and midwifery as well as that of medicine. Students' fees are 15 milreis for matricu- lation, 40 milreis for each course of lectures, and 100 milreis for diploma. (For detailed statement of expenditures see Appendix IV, No. 11, Relatorio, opp. page 48). Laboratory Facilities: Most of the laboratories are housed in an old building of the usual open square type, which is in very poor repair. As the labora- tories have long outgrown this building another equally old building on the opposite side of the street is utilized for hygiene and histology and the library. With the exception of anatomy, as represented by the dissecting room, no laboratory department has ade- quate space or equipment. This, however, we were told, will be remedied in the new building about to be built and which, it is expected, will be ready in two years. The plans, however, which were shown us do not indicate that even in the new building proper attention has been paid, either as to space or arrangement, to the needs of modern medical in- struction in the laboratory courses. 158 In the present building, anatomy, with its four dissecting rooms containing over 50 tables, would appear to be adequately served, especially as the re- port shows that during that year the first-year class in anatomy was supplied with 66 cadavers and the second-year class with 102, while 66 were used in the course in pathological anatomy and physiology, 68 in the course of applied anatomy and practical surgery, and 41 in special courses. The laboratory of pathology, apparently remod- elled recently, has a modern equipment of tables ar- ranged in four rows of eight each, giving a total of 32 seats, and is used for both gross and micro- scopic pathology. Only eight microscopes were seen in this laboratory, but we were told that more were kept in storage. In general, the equipment is good and the adjacent autopsy room, with 2 tables, is perfectly equipped for this purpose with a small am- phitheatre in which the men stand while autopsies are going on. It is said that the autopsies made in this room average two or three a week. The only criticism that can be made of the space or equip- ment is that the large classes of this school have to be taught in four or more sections. The laboratory of bacteriology is a good-sized room fitted with tables for 50 men, but as micro- scopes (20) are only on the row of tables in front of the window it is evident that every student does not have his microscope, but after making his prepa- rations is obliged to go to the window and take his turn examining them. Adjacent to this laboratory are small rooms for the teaching staff well equipped with apparatus. 159 The laboratory of physiology is a small demonstra- tion room with one large table, and the course is, as we were told by our guide, one largely of demon- strations. A number of very small single tables were seen, but these are not such as could be used in physi- ological experimentation. The laboratory of histology has about 22 tables seating three to four men each, and is supplied with 50 microscopes. The room is very crowded and the light is poor, coming from the side. The equipment of microtomes, etc., was satisfactory. No laboratory exists for pharmacology (phar- maco-dynamics). The laboratories of chemistry, including phar- macy, were not shown us on our first visit, as the Director, Dr. Castro, stated that he was ashamed to show them to us. On a later visit, however, we found in this laboratory 3 double tables and 2 single tables, which might accommodate comfortably 16 men, and, with crowding, 24. The equipment was of the simplest. It is in this laboratory that the large classes of several hundred men are taught, which means, if any real work is done, subdivisions into 10 or 15 sections. In this connection it may be added that the catalogue shows that in this, the first medi- cal school of Brazil in popular estimation, biological chemistry, in its modern phases, is not taught. The summary of the one-year course in chemistry (chim- ica medica), arranged under headings indicating the special matter studied, allots in the theoretical part, 35 headings to inorganic chemistry, 30 to organic chemistry, and 15 to biological chemistry. These latter, however, have to do largely with the diges- 160 tive secretions, blood, urine, and milk, and of the laboratory work only 6 out of 30 headings refer to what might be termed biological chemistry. These include (1) general reactions of albuminoids, (2) chemical reactions of the blood, and (3) examina- tions of urine for albumin, sugar, urea, and chlorides. The course, it must be apparent from this, is not bio- logical chemistry, but the old-fashioned course of so- called medical chemistry. The department of Natural History, including a lecture room, museum, and laboratory, has a fairly good collection, but the only space for actual labora- tory work appears to be four tables, each accommo- dating about three men. The library of this school, said to contain 40,000 books, is housed on two floors of the second building; has a comfortable reading room for about 40 or 50 students, and, according to the report of 1915, was used during that year by 13,246 readers. It is an excellent library in every way, and receives about 60 current medical periodicals from all parts of the world. To sum up, the laboratory facilities, the space and equipment for anatomy, including applied anatomy and experimental surgery, is satisfactory. The equip- ment for bacteriology and pathology and histology is fairly complete, but the small amount of space com- pels such great subdivision of classes that teaching must suffer by repetition. In all other laboratory de- partments the equipment is inadequate as also the space, and in no laboratory department is there evi- dence of detailed thorough individual work by the student. 161 (In connection with this it must be borne in mind that these laboratories serve also for most of the laboratory instruction in courses in dentistry and pharmacy. These two departments have their own buildings across the street from the medical school, but these are merely remodelled dwelling houses used, on the one hand, for a dental clinic and prosthetic laboratory, and, on the other, for a pharmaceutical laboratory. Clinical Facilities: The clinical teaching is done in the Santa Casa and Polyclinic. The Santa Casa, which is the next building to the medical school, has over 1,000 beds in its general wards, 245 in its childrens' building, and a daily dispensary movement of 800 to 1,000 patients, and is controlled entirely by the medical faculty. For psychiatry the federal insane asylum is used, and occasionally students go to other hospitals, in small groups, for clinical clerk work, but all officially scheduled clinical work is at the Santa Casa. The hospital has a small amphi- theatre available for clinical demonstrations, but most of the student work is in small sections or as individuals studying single patients. A small clin- ical laboratory is available for every two wards and these are open, under supervision, for student work. The Polyclinic is a modern dispensary on the main avenue of the city, not far distant from the medical school, and is the only well-equipped, modern dis- pensary we have seen in Brazil. It is a large building of several stories and of the usual concrete and metal construction. The first floor is given over to stores, and it is largely from the revenue so obtained that the dispensary is supported. The upper floors, 162 scrupulously clean, contain departments for internal medicine, surgery, obstetrics and gynecology, ear, nose, throat, eye, and skin diseases, all of which have abundant space and excellent equipment, as has also the very satisfactory clinical laboratory. The appa- ratus, mainly of American or German manufacture, is thoroughly up-to-date. The thoroughness of the equipment may be shown by the fact that each de- partment has its own x-ray apparatus, the total num- ber of such machines in the building being io. The dispensary was built, in part, at the expense of the Federal Government, but is maintained through the efforts of a charitable organization. It is con- trolled by the Rio faculty and freely used for clin- ical instruction in connection with which every facil- ity is provided, as lanterns, laboratory outfit, and small lecture room. In connection with the new school to be built at Botafogo, somewhat distant from the present site, it is planned to use the neighboring insane asylum for clinical instruction in diseases of a chronic nature and to build a small hospital for acute dis- eases. This new hospital will be essentially a school hospital, owned and controlled by the school, and will offset the loss of clinical material which will be the necessary result of building so far from the present Santa Casa. (2) Faculdade Hahnemanniana: Established in 1912 and offering a six-year course in medicine and two-year courses in pharmacy and in dentistry. It also offers courses of preliminary training known as "curso annexo," that for medicine 163 being of four years' and for pharmacy three years' duration. These preliminary courses cover lan- guages, mathematics, history, geography, philos- ophy, drawing, physics, chemistry and natural sci- ences and are essentially a combination of elementary and secondary school courses. Students taking these must be at least 12 years old. The statutes state that the school was founded in accordance with the provision of the Institute Hahnemanniana do Brazil as a school of instruction for doctors and pharmacists professing homeopathy. Entrance Requirements: Directly by examination from the Annexo or from other schools by exami- nation based on secondary education as provided by the federal law. Attendance: 125 in medicine, 15 in pharmacy, 25 in dentistry, and 40 in preliminary courses. These figures are for the year 1915. Teaching Staff: No definite figures were given, but the secretary stated that there is one professor for each of 22 chairs. In addition certain regular physicians are employed to teach some of the lab- oratory subjects. No subordinate staff is recog- nized, but students are used as assistants.1 Resources Available for Maintenance: Students' fees, which are 370 milreis per year for all courses. The diploma in pharmacy and dentistry costs 150 milreis and in medicine 200 milreis. When the school was started the federal government made a subvention of 30 contos, but this has not been con- 1 No literature of this school is available except the "Estatutos" for 1912 (See Appendix IV, No. 14). 164 tinued. The secretary states that the money spent annually for all courses is about 50 contos. The homeopathic members of the teaching staff have to date received no salary, but the 12 non-homeo- pathic teachers, who have charge of the laboratory branches, each receive 150 milreis a year. The deficit each year is made up by the faculty. Laboratory Facilities: The curriculum as given in the Statutes for 1912 corresponds, in general, as far as names and subjects are concerned, to that of the regular faculty, with the natural exception that homeopathic materia medica and therapeutics are included and that natural history, inasmuch as it is taken care of in the preliminary course, is not given in the medical course. At the time of our visit (April 3) the school was about to move to new quarters. The old quarters are on the third floor of a building in the center of the city which is otherwise given over to stores and offices. The single floor of the homeopathic school consists of four rooms, one used as an office, the second as a combined lecture room and laboratory of chemistry, a third as a room for physics and physiology, and the fourth as the lecture room and laboratory of histology. The latter contains two small tables for microscopic work and each of the other rooms mentioned has a single demonstration table. The equipment is most scanty and not enough in any department to care properly for one student working independently. For example, only one microscope and one kymograph were seen, and much apparatus essential to medical teaching was missing entirely. 165 The new quarters now being equipped for all de- partments and with hospital facilities in addition were formerly used by the federal government as cavalry barracks. The ground and buildings were given to the homeopathic school by the government and the school repaired and remodelled the main building and is now preparing to move in. The second floor of this is to be used as a hospital (in- firmary) and the first floor for laboratories, phar- macy, dental clinic, and out-patient department. The rooms set aside for laboratories are the small- est, darkest, and poorest in the building. As yet they contain no equipment. Several other small buildings, now in the last stages of decay, were pointed out as buildings to be remodelled eventually for various laboratory departments. Dissection at present is done at the Gamboa Hos- pital, where each student, it is said, dissects during two years the entire body. At the same hospital students see autopsies and have their course in patho- logical anatomy. This hospital furnishes about 30 autopsies a year. Clinical Facilities: (1) The homeopathic ward of the Santa Casa, with 60 beds, the chief of this ward being the director of the homeopathic school.1 (2) A ward of 30 beds in the naval and mili- tary hospital. (3) The new school building provides for three wards, one for men and one for women, with 10 1 Most public hospitals of Brazil have a homeopathic ward in charge of a physician of that school. 166 beds each, and a small one for children with three beds. At the new site will be also a general dispensary, a pharmacy, and a dental clinic. General Comment: This school affords an ex- cellent illustration of Brazilian politics. The cav- alry barracks, in which the school is about to be housed and which had been abandoned for a long time, were at the disposal of the Minister of Army and Navy, who, at the solicitation of his personal physician, a member of the faculty of the home- opathic school, turned them over to the school with the ground on which they stood. Through the same influence the school obtained the privilege of clinical material in the army and navy hospital; but al- though thus substantially aided by one department of the government, another department, that of Justice and the Interior, responsible for secondary and superior education, refuses to recognize the school.1 The interesting situation exists, therefore, that one arm of the federal government is aiding a new venture in medical education while another arm refuses to countenance it. The school has two years before its first class in medicine graduates to settle this latter difficulty. It feels confident of eventual government recognition, but if it does not receive such recognition its students will be on the same basis as physicians holding a foreign degree, that is, they will have to take examinations at one 1 The dean of the school states that the school was recognized for a short time, but that at present it is not. 167 of the regular schools recognized by the federal gov- ernment. This school estimates that its new building, when completed, will be worth about 200,000 milreis, of which 150,000 milreis will represent ground and buildings, and the remainder equipment. With no subventions and not enough income from students' fees to pay professors' salaries, it is difficult to see how the new school and hospital are to be supported. Little help can be expected from homeopathic physi- cians, for there are only about 30 in Rio de Janeiro and not over 100 in all Brazil. Finally, if the equipment and instruction in the new school are not vastly superior to that in the old, it is difficult to see how federal recognition for its graduates can be obtained, and if it cannot be secured, its school must either cease to exist, send all of its graduates to Rio Grande do Sul, or have them examined by recognized faculties. This school is in the same class as to equipment, faculty, and ideals as the Escola of Porto Alegre and Sao Paulo and the Homeopathic School of Porto Alegre. It has, however, a better building and more clinical facilities. But, despite these, the entire plant is so inadequate and its resources so limited that it is difficult to see how it can secure recogni- tion by the federal government. State of Sao Paulo Population, 4,500,000; number of physicians, 507 ; ratio, 1:8,876. Number of medical schools, 2. 168 Population, 500,000. (1) Faculdade de Medicina et Cirurgia de Sao Paulo: Established in 1912 (first class entered in 1913), and although it charges a small fee (200 milreis), it is essentially a state school supported by the state of Sao Paulo. Entrance Requirements: Examination based on education in a secondary school, but receiving, with- out examination, certified graduates of its state gym- nasium. (For Secretary's statement on this point see below.) CITY OF SAO PAULO Attendance: 1st Year 2nd Year 3rd Year 4th Year 1913 180 1914 101 43 1915 64 58 32 1916 42 52 39 32 Teaching Staff: 22 professors and 17 teachers of other grades. Resources Available for Maintenance: Funds furnished by the state government and fees of stu- dents, which last year were 100 milreis, and this year have been raised to 200 milreis. Budget 1913 450,000 Milreis " 1914 370,000 " " 1915 420,000 " " 1916 468,000 " (expected) Laboratory Facilities: Laboratory teaching is done in two places, about 200 yards apart on the same street. Both buildings are remodelled dwell- 169 ings, but large and spacious. At the first site is the main building, with administration department, lecture rooms and laboratories for physics, chemis- try, natural history, physiology, and pharmacy, and a separate new building, especially constructed for the purpose, devoted to anatomy. The building on the second site, now being equipped, is to be given over to histology, pathology, and bacteriology. The laboratory of pharmacy is well equipped and has desks for 12 to 16 students. The department of physiology comprises three rooms, (1) a room for general class work, with tables for about 24 men; (2) a room for chemical work in connection with physiology, and (3) a room with set apparatus, including an electro- cardiograph outfit, for demonstrations. We were told that in the classroom students do the simpler experiments, as muscle and nerve work, but that most of the experiments are demonstrations by pro- fessors, assisted by the students in small groups. This general classroom is used, at present, also for histology and natural history, each of which, how- ever, have fairly large rooms in addition for the work of the staff and the preparation of material. Each department has also its own library, at pres- ent not very large, although that of physiology has several hundred volumes. In connection with the natural history department is an excellent collection of parasitic worms and disease-carrying insects, upon which the course in natural history is largely based. This collection was originally made by Professor Brumpt, who was con- nected for a long time with this school. 170 The laboratory of physics, with a single large demonstration table, has an excellent lot of appa- ratus, and apparently it is possible, as we were told is the case, for students to carry on individual work in small groups. The laboratories of organic and inorganic chem- istry, respectively, are well equipped and each offers desk space for 16 men. Biological chemistry is not taught, nor is pharmaco-dynamics, but we were told that next year the latter will be given as a demon- stration course. We, unfortunately, visited this school during the first week of its course and although lectures were going on practical work had not begun. We were told, however, that in the course in natural history each student studies 50 to 100 slides illustrating animal parasites and that for this purpose this de- partment has 50 microscopes. Histology has 20 mi- croscopes, and pathological histology (the course in which begins this year) 50 microscopes, which were ordered last year and are expected daily. In short, the aim is to provide each student with his own microscope in the laboratory courses. There was some discrepancy concerning statements as to the number of slides used in histology, the figures varying from 50 to 120. In no microscopic course does the student have to make drawings. The department of anatomy, housed in a separate building at the rear of that just described, has an excellent dissecting room of modern structure, with tiled floors and enameled walls. White, iron enam- eled tables, good light, and plenty of sinks with run- ning water are supplied. In every way the equipment 171 is excellent. Leading off this is the lecture room with two movable tables, and to one side is the depart- ment of applied anatomy, with its collection of special dissections, and two rooms for the preparation and storage of anatomical material. Also in the yard, close to the anatomical department, is a small separ- ate building for the cleaning of bones. The anatomical department is supplied with a great abundance of charts, models, diagrams, and wet and dry museum preparations of all kinds. Each student, in the course in anatomy, receives a box of bones representing the entire skeleton and dissects the entire body. The lecture room of anatomy, it may be added, has an excellent epidiascope. The annual budget for anatomy is 54,000 mil- reis; physiology 33,000; pathology 37,200, and chemistry 23,200 milreis. Animal Quarters: At the rear of the anatomical building a large yard has been utilized for the care of animals. A number of small buildings of good structure, with runways, are grouped along three sides of the rear of this yard, and here are kept the animals under the care of a special attendant. We saw about 20 dogs, 30 rabbits, 25 guinea pigs, 20 pigeons, 15 hens, and 2 sheep. This is the only medical school in which we have seen special quar- ters for the care of animals, and is apparently the only school in which they are used extensively in teaching. We were assured by the faculty of the school that animals were used freely, and there is no reason to doubt this statement, for the cost of main- tenance under the conditions of Sao Paulo are con- 172 siderable, and this expense would not be justified unless the animals were so used. The second building of the medical school, to be devoted to histology, pathology, and bacteriology, was not completed as to equipment at the time of our visit. It was possible, however, to gain a very good idea of the departments of histology and pathology. Pathology: The latter is on the first floor and in- cludes (i) the office of the professor and a small library; (2) the private laboratory of the professor with good tables and equipment; (3) an autopsy room with two tables of modern type, running water, etc.; (4) a preparation room leading off the autopsy room; (5) adjacent to this a cloak room and wash room for students, and (6) a store room. In addi- tion is a fairly large room for work in gross and microscopic pathology, with desks for about 32 students and with museum space at the rear. Un- fortunately, we had no opportunity to see classes at work, and although we only saw about ten micro- scopes in the department of pathology, we were told that 50, divided between the departments of patho- logic histology and normal histology, were on the way from the United States. The confusion regard- ing the department of pathology is due to the fact that this is the first year that the course in pathology occurs (the fourth year of the school course), and as the professor of pathology had been called but recently from Bello Horizonte, the equipment of his department had been delayed. As to material available for pathological anatomy we were told that this is furnished in part by the Santa Casa, which had, however, only 28 autopsies 173 last year, and in part through the use of unclaimed bodies, which are first autopsied at the medical school before the class of pathology and then turned over to the anatomical department for dissection. As we had no opportunity to discuss other phases of the course in pathology with the head of the department, we can offer no further information on this course except to say that the professor is an Austrian, first brought to Brazil as professor o'f pathology at Bello Horizonte, from which school he came this year un- der contract to Sao Paulo. Histology: This department, on the second floor of the same building, includes (i) class room with desks for about 20 students; (2) a preparation room; (3) a room for professor; (4) room for assistant; (5) library, and (6) storage room. Bacteriology: This department shares the other half of the second floor with histology and has a large amount of space which, however, had not been divided or equipped at the time of our visit. The head of the department, Professor Carini, formerly the head of the bacteriological laboratory of the state of Sao Paulo, trained in Italy, is said to be an excel- lent bacteriologist, and in the past has given very good private course in connection with the state laboratory. From now on he gives all his time to the school under contract, but reserves the right to private practice. American-trained students in Sao Paulo are very enthusiastic about him and state that there is every reason to believe that he will give good courses, with individual work by the student. 174 Clinical Facilities: The school has almost abso- lute control of the Santa Casa of Sao Paulo. The director and all professors and assistant professors, excepting those of the departments of anatomy, pathology, physiology, chemistry, and physics, are on the staff of the Santa Casa, which has set aside one medical, one surgical, one ophthalmic, and one dermatological board for the teaching of students, and a little later, when it is necessary, will add wards for gynecology and ear, nose, and throat work. This hospital has 480 beds. The Santa Casa has no clinical amphitheatre, and it is stated that none will be built for student work. Instead, the students will work in small groups in the wards and in the small laboratory and examining room with which each ward is equipped, and will assist at and watch various surgical and other pro- cedures. The day of our visit we saw such groups at work in both the medical and surgical wards, as also a number of students working singly. This system of individual work impressed us very favor- ably and closely resembles the English clinical clerk system. For its work in obstetrics, when that course is inaugurated next year, the school will use the mater- nity hospital (Maternidade de Sao Paulo), the director of which is to be appointed professor of obstetrics in the medical school. The obstetrical work, however, will be limited to watching cases and assisting the regular hospital staff. The school hopes later to develop an out-patient obstetrical de- partment for students. Other clinical facilities, according to the director 175 cf the school, are the Hospital do Guapira for lepers, and the Hospital de Juquery for the insane, the for- mer with 160 patients and the latter with 1,500. Comment: This school is the only school which we have found in Brazil supported entirely, or al- most entirely, by state government. In this it does not differ essentially, as far as finances are concerned, from the schools of Bahia and Rio de Janeiro, sup- ported by the federal government, but practically the relation is closer and the interest of the govern- ment more intimate. Sao Paulo is more independent and progressive than the other states of Brazil, and this is shown by the fact that this school disregards the federal requirement concerning examination for admission and recognizes, without examination, the graduates of its state gymnasium, a thing it can well afford to do in that it controls both secondary and superior school education. Matriculation is not lim- ited, however, to natives of Sao Paulo; students from other states may enter on examination. The school is also open to women. Although the course is one of six years, the faculty terms the first year a preliminary year and speaks of the other five years as the five years of a medical course. Whether this presages an eventual five-year course in medicine, with the preliminary work done before admission, it is not possible to say. Inquiries on this point were evaded by the director and mem- bers of the faculty. Although the school has only been in existence a few years, entering its fourth class in 1916, its equipment in almost every respect is superior to that of other schools of Brazil, and 176 there is also evidence of a desire to give the student as much individual work as possible. To what extent this different atmosphere is due to the gener- ally progressive condition of affairs in Sao Paulo and to what extent to the non-Brazilians on the faculty it is not easy to decide. It is of interest, however, that five teachers received their medical education outside of Brazil. These are (i) the Professor of Parasitology, Dr. Bourroul, who, although a gradu- ate of the School of Bahia, is also a graduate of the Colonial Institute of Paris; (2) Dr. Meira Filho, Professor of Applied Anatomy, a graduate of Ge- neva; (3) Dr. B. Montenegro, Assistant Professor of Anatomy, graduate of the University of Penn- sylvania; (4) Doctor Lindenberg, Professor of Laryngology, graduate of the University of Penn- sylvania, and (5) Dr. Camargo, Professor of Sur- gery, graduate of the University of Geneva. In addition, nearly all members of the faculty have had extensive post-graduate training in France, England, or Germany. The course in this school runs from March 15th to November 10th. A new building, the plans for which were shown us and for which the state has appropriated 8,000 contos, will be started as soon as the present financial stringency in Brazil is relieved. In close relation with this building will be erected also a branch of the Santa Casa, to be used solely by the medical faculty for the instruction of students. The funds for this purpose are supplied by a sum of money which was left to the Santa Casa by will, which the government has already voted to turn over to the school for its hospital. 177 The teaching staff in the laboratory subjects con- sists, for each department, of a professor, assistant professor, and one assistant, with an extra assistant for the departments of anatomy and physiology. These are all salaried (see page 181). In addition to these assistants, each department may appoint as many voluntary assistants, without salary, as it de- sires. In the clinical subjects a department consists of a professor and assistant professor and one assist- ant. The branches of medicine and surgery, how- ever, each have two departments (or chairs). It is in this school that we have found the only truly full-time teacher in all Brazil. This is the pro- fessor of anatomy and histology, who gives all his time to the teaching and development of his depart- ment. Through curious arrangements which we do not understand, he receives an unusually large salary. In addition, the professors of pathology and bacteriol- ogy are essentially full-time men, for, although they re- serve the right to practice, they have shown no desire to do this except as special consultants on subjects connected with their work. From this point of view this school is more favorably situated than any other school in Brazil. It is of interest also that the pro- fessor and the demonstrator of chemistry and the professor and associate professor of physics are not clinicians. Among subordinates, the associate pro- fessor of histology and the demonstrator of bacteri- ology apparently give their entire time to scientific work. The examinations at this school consist of four written examinations during the year and an oral 178 and practical examination at the end of the year. Practical work counts largely in the final mark. For further details see catalogues of this school (Appen- dix IV, No. 12). Addenda: The above account is based on our notes taken at the time of our inspection and inter- rogation of the director and several members of the school faculty. It contains certain statements which are at variance with those made by the secretary of the school in reply to a questionnaire which we sub- mitted to him and which was mailed to us after re- turning to Rio de Janeiro. We have asked for fur- ther information concerning these divergent views, but as yet it has not been received: 1. The secretary gives 500 as the figure for phy- sicians in the city of Sao Paulo, which is many times greater than all other estimates we have received and is almost as large as our figures from Laemmert for the entire state.1 2. Although we were told that students of the state gymnasium were admitted to the medical school without examination, the Secretary's written reply would indicate otherwise: Question-What are the entrance requirements? Answer-a. To have been vaccinated. b. To be more than 16 years of age and of good morals. 1 Printed lists furnished by a physician of Sao Paulo credit city of Sao Paulo with 288 physicians and the rest of the state with 277. 179 c. Examinations as for the Polytech- nical School and others which includes: Portuguese, French, English, Italian, Latin. Arithmetic, Algebra, Geometry, Trigonometry. Geography, Cosmography, Geography and cosmography specially of Brazil, Universal history, Brazilian history, Elementary physics, Elementary chemistry, Elementary natural history, Psychology and logic. After passing these examinations to enter the Med- ical School the students are required to pass a more advanced examination in Natural History, Chem- istry, and Physics. Other information offered by the Secretary and not fully covered in our reports follows: 180 (i) Length of course: 6 years of 8 months each with 39 hours per week in ist year 36 hours per week in 2d year 36 hours per week in 3d year 48 hours per week in 4th year Work of 5th and 6th years not yet planned. (2) Total number of teachers (for 4 years only}: (a) full professors 15 (b) assistant and associate 7 (c) demonstrators 12 (d) assistants 5 (e) general voluntary demonstrators and as- sistants without salaries. (3) Salaries: Milreis a Year (a) Professors of anatomy and physiology.9,800 (b) Other professors 8,400 (c) Associate professor 6,000 (d) Demonstrators and assistants 4,800 (e) Contract professors- Milreis a Month Prof, of Anatomy and Histology. .3,000 Prof. Pathology 1,000 Prof. Bacteriology 1,000 (4) Appointment to both laboratory and clinical chairs are on recommendation of director of school, to be approved by government. When, however, faculty is completed vacancies will be filled by "con- test." (5) Average age of student at entrance is 20. 181 (6) No free scholarships are offered. (7) School does not offer summer or post-gradu- ate course but students may work at hospital. For post-graduate instruction students formerly went to France but in recent years the tendency has been to Germany and Austria. (8) About 30 physicians of Sao Paulo received their medical training abroad, the majority in the University of Pennsylvania. (9) School library has about 800 volumes. (10) Students in pathology see, on an average, three autopsies a week. (11) Of total number of students, 50 are from city of Sao Paulo, 88 are from state of Sao Paulo, 27 are from outside the state. (12) Relation between lectures and practical work is as follows: Anatomy-2d year-Lectures 3 hours-Prac- tical 12 hours. Anatomy-3d year-Lectures 5 hours-Prac- tical 12 hours. Applied-4th year-Lectures 3 hours-Prac- tical 6 hours. Histology-3d year-Lectures 3 hours-Prac- tical 6 hours. Physiology-2d year-Lectures 3 hours-- Practical 4 hours. Physiology-3d year-Lectures 3 hours-Prac- tical 2 hours. Chemistry-1st year-Lectures 3 hours-Prac- tical 15 hours. 182 (The students are allowed to remain in the labor- atory if they want to for a longer time. From July 15th on there will be given an additional course for those wishing to get a better knowledge of albumins, lipoids, etc.). Bacteriology-4th year-Lectures 3 hours- Practical work 6 hours. Pathology-4th year-Lectures 3 hours-Prac- tical work 6 hours. The teaching in Hygiene and Pharmacology has not started yet. (13) The city of Sao Paulo has the only medical society in the state, with about 100 members. (14) The new building of the school will cost 1,800,000 milreis, the equipment 800,000 and the new hospital 2,000,000. (2) Escola de Medicina de Vn'wersidade de Sao Paulo: This was established in 1912, and with depart- ments of pharmacy, dentistry, veterinary medicine, engineering, and law constitutes the so-called uni- versity of Sao Paulo, which is more impressive in its name than in its buildings and equipment. Con- cerning this school we had great difficulty in getting any information. Our first attempt at an appoint- ment with the director failed, and, when finally, ac- companied by Dr. Godinho (director of the state isolation hospital) and Dr. Alex. Pedroso (direc- tor of the laboratory of the Santa Casa), the chair- man visited the office of the director of the school, 183 it was very evident that he did not care to talk or to have us visit the laboratories of the school. This attitude was probably due to the poor status of this school, graduates of which, it is said, will not be allowed to practice in the state of Sao Paulo, but will be forced to go to Rio Grande do Sul, where the laws concerning licensure are lax, or to the less populous parts of the interior states where any physician is in demand. Although started the same year as the Faculdade, this school has not received state aid, the latter being given solely to the Facul- dade. The course is a five-year course of one preliminary year and four years in medicine, which is one of the difficulties in the way of government recognition. The director's figures for attendance were 530 stu- dents in all courses, of which 160 were matricu- lated in medicine. It is evident, therefore, that poor schools can attract students in Brazil as in other countries. At our interview with the director, when we in- sisted on seeing the laboratories, we were shown, in the building in which his office is located, one small lecture room and museums of natural history and botany, both very small rooms and with very poor collections. Nothing else was shown us in this build- ing, which apparently is given over largely to other departments of the university, and when we inquired concerning the laboratories of pathology, bacteriol- ogy, chemistry, etc., we were referred to another ad- dress about two miles distant, where, on our arrival, we found a dispensary consisting of a department for dentistry and a department for medicine. The for- 184 mer occupied two rooms, a dental clinic and a dental laboratory, respectively, on the second floor of a re- modeled dwelling house, and on the same floor were two rooms for an ophthalmic clinic and one room with x-ray apparatus. On the first floor of the same building, the front of which was occupied by a phar- macy, was a medical clinic consisting of a consulting room, a room with an outfit for minor surgery, and a lecture room, in which was a table with a small amount of simple equipment for clinical laboratory examinations, and one microscope, apparently the de- partment for clinical microscopy, providing desk space for perhaps 6 to 8 men. We were told that the dental clinic cared for 30 patients a day and the med- ical clinic for an equal number. At this point we inquired again concerning the la- boratories of pathology, bacteriology, and chemistry, but could obtain no information concerning them. We were, however, referred to the Anatomical In- stitute, which we visited on the following day. This is located in a cemetery on the outskirts of the city and is a new concrete building of one story, consisting of two rooms, one an amphitheatre with one table, and the other a dissecting room with four tables and three salting tanks. One body was on hand at the time of our visit, as also parts of several other bodies. We were told, however, that dissecting had not yet be- gun for this term. These rooms contained a few anatomical charts, two or three wet preparations in glass jars, and a few dry bones. No models were at hand. We were told that last year 100 bodies were supplied for 130 students, but these include bodies for autopsy as well as dissection. 185 Clinical Facilities: Except for the dental and med- ical dispensary described above, this school has no clinical facilities that we could discover. It has no privileges in the hospitals of Sao Paulo, these being controlled by the "Faculdade" in the case of the Santa Casa, and affiliation with other institutions apparently has been impossible. We were told, however, that the school was now building a hospital of its own which would care for 40 patients. Details concern- ing the finances of this hospital wrere not obtainable. On account of the very evident disinclination of the director of the school to discuss its affairs with us no further attempt was made to see him, but after we returned to Rio de Janeiro a letter was sent to him asking for the information we desired, as also cata- logues, photographs, etc., if they were available. In this letter particular reference was made to de- partments of pathology, physiology and chemistry, concerning which we could obtain no information in Sao Paulo. To this letter no reply has as yet been received. It may be added that the physicians of Sao Paulo regard this school as a joke and state that lack of information concerning the work in pathology and bacteriology is due to the fact that the only instruc- tion in these subjects, outside of possible autopsy work in the anatomical institute, consists of a few demon- strations given in the office of a member of its fac- ulty, and that laboratories of pathology and bacteri- ology do not exist. (For catalogue, see Appendix X, No. 16.) 186 State of Minas Geraes Population, 4,000,000; number of physicians, 371; ratio, 1 to 10,781. Number of medical schools, 1. BELLO HORIZONTE Population, 44,000. Faculdade de Medicina de Bello Horizonte: This school with a six-year course was founded in 1911, entered its first class in 1912, and is receiv- ing its fifth class this year. It inaugurated also de- partments of pharmacy (3-year course) and den- tistry, but the latter has been abandoned. The school building is located in close relation with the laborato- ries of the state department of health and about one block from the Santa Casa. The present build- ing constitutes only about one-fourth of the final structure as planned. Entrance Requirements: Examination based on sec- ondary education. Attendance: 120 (for four classes). Teaching Staff: In the catalogue of 1915 nineteen professors are named, but the director states that with subordinate instructors the staff numbers 38. Resources Available for Maintenance: (1) 50,- 000 milreis from the state and 15,000 from the city of Bello Horizonte annually. During the first three years the Federal Government contributed a total of 30,000 milreis towards professors' salaries, but this has been discontinued. 187 (2) Students' fees of 400 milreis per term. The director states that the total expenditures for 1913 were 300,000 milreis; for 1914, 400,000 mil- reis. These figures, however, cover equipment as well as maintenance. Laboratory Facilities: The building is a new one, of stone and brick, planned for the purpose of med- ical teaching, and shows a compact arrangement of laboratories without loss of space. Each professor in the laboratory branches has an office and a private laboratory. Lecture rooms are abundant and include a large one, seating 150 students, and several smaller ones, practically all of which have special equipment for the illustration of lectures by experiment as well as for epidiascopic illustration and micro-projection. Anatomy: The dissecting room is in close rela- tion to the anatomical lecture room (for 50 stu- dents) and to the museum of anatomy. The equip- ment is modern, with tiled floors, good light, running water, and excellent ventilation, and ten marble slab tables. Each student dissects at least one body under the direction of the teacher and has to demonstrate to the teacher the results of his work. The pro- fessor of anatomy, who teaches also surgical or ap- plied anatomy by demonstrations on the cadaver, is the chief surgeon of the Santa Casa and will be, when the course is inaugurated, professor of sur- gery. In connection with the anatomical department are rooms for the preparation and storage of bodies, and for cleaning bones, all with modern equipment. During the past four years 362 cadavers have been received, allowing an average of 80 bodies a year 188 for dissection, the others being utilized for teaching surgical anatomy and autopsy technique. Physiology: This department consists of a lecture room and a room for experimental demonstrations. The apparatus is scanty and no provisions were seen here or elsewhere for the care of animals. Histology: A general class room and laboratory for 50 students, with 20 microscopes, is used for both normal and pathological histology. Pathology: This department, in addition to the room shared with histology, has a preparation room and an autopsy room with one table. It shares two microtomes with the department of histology, and has two incubators. During the last year and a half 99 autopsies were made at the Santa Casa. Bacteriology: This department has a laboratory with desks for 18 students, and each desk has a Zeiss microscope. There are also two incubators and a good supply of other equipment necessary to the teaching of bacteriology. Classes are taught in sec- tions of 12, and the course, under the direction of Dr. Ezequiel Diaz, an associate of the Oswaldo Cruz Institute, appears to be most satisfactory. Students use living organisms except in the case of cholera, etc., and from mixed cultures have to work out pure cultures. Chemistry: This department, under the charge of a contract professor imported from Germany, is the best equipped department in the school. It has, in addition to a lecture room equipped for extensive demonstrations, a laboratory of 50 tables in which 189 a detailed course is given requiring 4 hours of labora- tory work a day for three days each week. In con- nection with this large class laboratory is a small laboratory for work in toxicology and food analysis. The professor of chemistry, it may be added, is state chemist in charge of the chemical laboratory of the state department of health, which is located next door to the medical school. Pharmacy and Pharmacology: These subjects have in common a lecture room, laboratory, and museum, but are of importance chiefly in connection with the three-year course in pharmacy. The laboratory is small, and there is no evidence of apparatus for pharmaco-dynamics. Physics: The usual apparatus, somewhat scanty, is provided. Natural History: This department has a com- bined class room, museum, a laboratory with 9 micro- scopes, and the usual natural history specimens. Library: This at present is small and unsatisfac- tory. Museums: Indifferent collections of natural history specimens and of material illustrating pathological anatomy are found in the museums. Clinical Facilities: The Santa Casa, located one block from the medical school, has two wards for medicine, two for surgery, and a separate building for obstetrics and gynecology, totalling about 180 beds. In addition, there is an out-patient department with six divisions, averaging 40 to 60 patients a day. This plant is entirely controlled by the school faculty, 190 all the chiefs of the service in the hospital being mem- bers of the teaching body of the school. Additions, now under way, which includes provisions especially for gynecology and obstetrics, will increase consider- ably the capacity of the hospital. Each of the wards has its own laboratory for the simpler clinical ex- aminations; these, however, are very poorly equipped. There is evident, despite the presence of two amphi- theatres, very definite effort to give the student indi- vidual work in the hospital wards. The students have the freedom of the wards from 7 a.m. to i i P.M., and not only see patients with an instructor but are given cases to study independently, both in the wards and the dispensary. The chiefs of service spend about one-half a day in the wards and dispen- sary, and thus keep in touch with the students, who do much of the routine ward work. The hospital has, however, a resident physician. Last year 150 of 175 deliveries in the maternity ward were wit- nessed by students. No student is allowed to take charge of an obstetric case until he has witnessed at least 10 deliveries. General Comment: This school shows a tendency to provide sufficient equipment, except in physiology and pharmacology, for individual laboratory work and to encourage such work by the student. The chemical laboratory is the best we have seen in any medical school of Brazil. The close relation of school to state laboratories on the one hand, and to the hospital on the other, brings about a grouping of interest which should be of great importance in the advancement of medicine in Minas Geraes. The provision for two contract 191 professors (pathology and chemistry) is an advan- tage, as these men are essentially full-time laboratory teachers. In short, this school impresses one as second only to the Faculdade of Sao Paulo in its progressive atti- tude towards individual work by the students. (This account is based on an inspection (1) by Dr. Ash- ford and (2) by Doctors Ferrell and Smith, and (3) data contained in official publications of the school. It was not visited by the chairman of the commis- sion. For catalogues, see Appendix IV, No. 15; for Dr. Ashford's impressions, see Appendix II, No. 18; the notes of Doctors Ferrell and Smith are in- corporated in the above account.) The State of Rio Grande do Sul Population, 1,600,000; number of physicians (in- cluding licentiates), 350; ratio, 1 to 4,571. Number of medical schools, 3. PORTO ALEGRE Population, 150,000. (1) Faculdade de Medicina de Porto Alegre: Established in 1899 as an independent school and until 1915 the only medical school in the State of Rio Grande do Sul. Entrance Requirements: Examination on educa- tion obtained in secondary schools. Attendance: 250. Teaching Staff: 41 professors and auxiliary teach- ers, many of whom are student assistants. 192 Resources Available for Maintenance: Students' fees, which are 250 milreis a year, and 100 contos a year from the State of Rio Grande, but not always forthcoming. Laboratory Facilities: The laboratory teaching is done in three different places. These are the medical school building proper, the anatomical building, and the Institute Oswaldo Cruz, all of which are within five minutes' walk of one another and closely related to the hospital used for the clin- ical teaching. The medical school proper consists of two old buildings, two stories each, one of which is devoted to administrative work and to a library of 1,500 volumes, with five reading tables and a librarian in attendance. The second building has six rooms. In one, a laboratory for organic and in- organic chemistry and pharmacy, the equipment is poor, and although it is said to accommodate 4 to 20 students, it is difficult to see how more than 6 could work there comfortably. The second room, devoted to physics, has a poor equipment and little desk space. The third room is a museum of natural history, with a few charts and specimens. The fourth room is devoted to histology and has a very scant equipment, including only six microscopes, which compels a class of 30 to work in five sections of 6 each. The fifth room, devoted to legal medicine, has some good special apparatus, but this is used for demonstrations only. The sixth room in this labora- tory building is given over to a dental clinic and contains 4 chairs. 2. The second department of the medical school, known as the Institute Oswaldo Cruz, is a dwelling 193 house, the second and third floors of which are used for laboratory purposes in connection with clinical microscopy, bacteriology, serology, pathological his- tology, and physiology. The building was opened several years ago on account of lack of space in the medical school for these subjects. Although it is equipped and maintained entirely by the medical school and ostensibly for teaching purposes, it makes clinical laboratory examinations for the general hos- pital and, in return for a fee, for the physicians of the city. It is divided into small rooms devoted to (i) biological chemistry, (2) bacteriology, (3) serology, (4) pathological histology, (5) physiol- ogy, and (6) general clinical microscopy. These rooms all have a good working equipment for clinical diagnosis, but one that is inadequate for student instruction. The instruction here, as else- where, is apparently largely a matter of demonstra- tion, or of one or two students assisting an instructor in a given procedure. The equipment of the labora- tory of physiology is obviously for demonstration purposes only. The entire staff covering these important labora- tory subjects consists of a director, who is also pro- fessor of pediatrics and chief of staff, and four assistants, responsible respectively for pathological histology, clinical microscopy, biological chemistry, and serology, each of whom has a student assistant. The teaching of physiology is done by the professor of physiology, who comes to the laboratory for that purpose. The diener staff numbers three. It is claimed that systematic courses are given here to students in small sections throughout the year, but 194 it ... difficult to see how adequate instruction is pos- sible. Only four microscopes are to be found in the entire building and there is no desk space in any room where more than two or three students can vork at any one time. The chemical laboratory, for example, could not accommodate more than four students in a course of biological chemistry such as is given in the better schools in the United States. Questioning brought out the fact that (i) in pathological histology students do not study in de- tail specimens given them and that they make no drawings; (2) in bacteriology they are not given unknown cultures to study and identify; (3) that in physiology one student assists the demonstrator while the others look on. In short, the courses are demonstrative and are arranged more to bring out the practical applications of clinical medicine than to serve as a basis of scientific instruction. (4) Pharmacology is not taught by experiment, except for an occasional drug experiment in physiology; and (5) what they term biological chemistry is merely clinical or medical chemistry. It must be admitted, however, that, according to the standards of Brazil, this laboratory attempts to do all it can for the student, but there seems to be an inherent dislike, in this as other schools, to keep a student at laboratory work for more than one hour. Thus a class of 25 is divided into five sections, each sec- tion having three periods a week of one hour each. Nowhere in the laboratory was space for animals found. Animals are brought from outside when needed. Outside of its function in the teaching de- partment, the laboratory has averaged, since its 195 foundation in 1912, 1,500 to 2,000 clinical exami- nations a year. Some research work of a routine type is done, bearing for the most part on clinical diagnosis or the report of unusual cases. 3. Anatomical Building: This is three minutes' walk from the medical school and about five minutes' from the Instituto Oswaldo Cruz, and is located just back of the hospital. It is a one-story building of five rooms, three of which contain, respectively, 2, 3, and 4 dissecting tables. The fourth room is used for surgery and preservation of bodies, and the fifth is an autopsy room used by the department of pathology. It is a modern building with tiled floors, good light, good tables, and well kept as re- gards cleanliness. Anatomical material which was being used at the time of our visit by students pre- paring for re-examination was in good condition, considering the summer temperature. A good col- lection of anatomical charts and models was at hand. Autopsies are made before the class, but we were told that only four or five autopsies a year are pos- sible. This is due partly to the prejudice against autopsies, which compels the school to save as much material as possible for the dissecting course. In this connection it is in order to note that no patho- logical museum was found in this school. Clinical Teaching: The clinical teaching is done entirely at the Santa Casa, which has a capacity of 450 patients. This hospital is supported by a charitable organization and occasional aid from the state of Rio Grande do Sul or the city of Porto Alegre. As, however, the staff is the same as the 196 faculty of the medical school, the hospital is freely used by students. The operating room of the hos- pital has been built and equipped at the expense of the medical school. Instruction is in part by lecture and clinical demonstration, but, as in all medical schools in Bra- zil, the students spend their mornings working in the wards and attend lectures only in the afternoon. The system is somewhat similar to the English clin- ical clerk system, in that the students are given cases to study and examine under the guidance of an assistant. Later their results are reported to the teacher in charge. Also they take turns in sleeping in the hospital for one or two nights, and in this way average ten nights or so a term in the hospital. As the Brazilian hospitals have no interne service, a considerable amount of the routine work of the hospital falls upon the student. This faculty is now erecting a new medical school a short distance from the Santa Casa for which the state contributed 1,200 contos two years ago. Work is now discontinued on account of hard times. As far as we could de- termine from the plans, allowance for laboratory space is not much greater than in the old building. The value of the present buildings and equipment is 547,653 milreis. The receipts from all sources for 1914 were 253,368 milreis and expenditures 205,256 milreis. (For catalogue see Appendix IV, No. 17.) (2) Escola Medico Cirurgica de Porto Alegre: Established in 1915-16 and gives courses in medi- cine, pharmacy, and dentistry. It offers a four-year 197 course in medicine, thus differing from the usual six-year course of Brazilian schools. The course in pharmacy and dentistry is each two years. It does not give a degree of Doctor of Medicine, but con- fers a "licentiate." This condition is brought about by the absence of definite laws concerning the prac- tice of medicine in Rio Grande do Sul and is an evident attempt to run a school for what the fees may bring. The director, Dr. Vicente Pereira, a negro, who is apparently the chief factor in the school, states that he is a graduate of Edinburgh and has worked in Paris, Vienna, and Berlin. He speaks English very well and is quite familiar with medical educa- tion in the United States and uses many of the argu- ments heard in that country in support of the poorer type of school. He says, for example, that the state of Rio Grande needs, not well-trained specialists in medicine, but general practitioners for the country districts. He therefore has started a school which runs for 8 terms of 6 months each, without vaca- tion periods. The hours of instruction are from 8 to io A.M. and from 4 to 6 P.M., so that men in business, government offices, and the army may attend without interference with their daily work. Entrance Requirements: Examination based on elementary school training. Attendance: 90. Teaching Staff: 18 full professors, all of whom are practitioners in medicine, and no assistants. Resources Available for Maintenance: Students' fees, which are 400 milreis per year (2 courses of 198 6 months each), 100 milreis for a diploma, and 60 milreis for the dispensary privileges. It was said that the state has promised io contos for labora- tories, but this has not yet been received. The city also has promised 6 contos. This again has not been given. Some support also is expected from the state lottery, which, like some other lotteries in Bra- zil, gives regularly to hospitals and dispensaries. To start the school the members of the faculty con- tributed 15 contos. Some support is also derived from business men, who give annually about 8 contos for the dispensary, and smaller sums are received from about 180 small contributors. Laboratory Facilities: The school is a remodelled dwelling house with a dispensary in the rear. Most of the space in the medical school proper is taken up by demonstration offices and lecture rooms, with the exception of one small room with 9 desks and 2 microscopes, which is said to be used for normal and pathological histology. A bookcase containing about twenty miscellaneous volumes is called the library, and in the lecture room are a few cheap anatomical charts and no models. On the second floor there is a space said to be a chemical labora- tory, but it is as yet without equipment. At the rear, in a wing which connects the school with a dispensary, is a small clinical laboratory furnished with apparatus for the simpler methods of clinical diagnosis. Clinical Facilities: A dispensary with 7 or 8 rooms, including a waiting room, a simple operat- ing room, rooms for eye work and dentistry, a 199 dressing room, and a general consultation room. All apparatus is of the simplest and very scanty. Many patients, however, come to the dispensary, 40 to 50 being on hand at the time of our visit, and the records show that sometimes the attendance runs as high as 100 or 150 in a day. The staff, however, is quite inadequate for this number. The large number of patients attending this dispensary is doubtless explained by the fact that the Santa Casa has no out-patient department. The clinical facili- ties of the school are limited to this dispensary, for so far the school has failed to gain admission to the city hospital (The Santa Casa). The direc- tor for the medical school states that he will soon have admission to the Santa Casa, as he has played politics to overcome the objections of the other school. He also states that the school intends to build a maternity clinic. General Comment: It is very evident that the school is an attempt to develop an organization which the older school will eventually recognize and that by merger the faculty of the new school will obtain the recognition which they have not previ- ously had. In no other way can the failure to ade- quately attempt medical education be explained. For example, the school offers at present no oppor- tunity for dissection. On inquiring about dissection it was said that this was done at the morgue as a demonstration course, the professor dissecting while the students looked on. The attempt to increase the number of students is shown by the fact that a course in homeopathic treatment is given. When inquiries were made concerning the work in patho- 200 logical histology and the request was made to see the microscopic slides used in the course, none were forthcoming. Similar requests to see the apparatus used in physiology, pharmacology, and biological chemistry were ignored. Finally it was explained that all of these subjects were taught as a part of clinical medicine. In justice to Brazilian medical schools it must be said that this school could not exist else- where in Brazil. It is possible in Rio Grande on account of the absence of laws regulating practice. In this state any one who pays a fee, with or with- out medical training, can receive a license to practice. (For catalogue see Appendix IV, No. 18.) (3) Faculdade de Medicina Homeopathica do Rio Grand do Sul: This school, established in 1914, occupies the second floor of a building in the business center of the city, opposite the post-office. Its entire space consists of five small and two large rooms. This school offers a four years' course of eight months each. Entrance Requirements: No definite educational requirement specified. Attendance: 40. Teaching Staff: 16 professors and no assistants. Resources Available for Maintenance: Students' fees, which are 200 milreis a year, and 5 contos a year from the city and 10 contos from the state. Laboratory and Clinical Facilities: Space occu- pied by this institution consists of two lecture rooms, 201 a dental clinic of one chair, two rooms for dis- pensary, a chemical laboratory, poorly equipped, and two laboratories of pharmacy, one for home- opathic and one for allopathic procedures. In one of these rooms were a few anatomical charts and one anatomical model, and one microscope. There was no equipment for work in dissection, physiology, pathology or the other laboratory branches. In- quiries concerning these courses led to the statement, first, that dissection was not done, and, second, that the courses in physiology, pathology, and bacteriol- ogy were given in the city laboratories for food analysis maintained by the city department of health. This is quite impossible, for these laboratories had been visited in the morning in connection with the inspection of the health department, and they not only had no space, but, moreover, no equipment for student work. The school has no clinical facilities except the dis- pensary maintained in two small rooms of this building and a branch dispensary which it has else- where in the city. (For catalogue see Appendix IV, No. 19.) State of Parana Population, 516,781; number of physicians, 40; ratio, 1 to 12,919. Number of medical schools, 1. CURITYBA Population, 72,000. The medical department (Faculdade de Medi- cina) of the University of Parana was founded in 202 1913 and received its first class in 1914. The uni- versity offers courses in law, engineering, obstetrics (for midwives), pharmacy, dentistry, agriculture (including veterinary medicine) and commerce, and provides also preparatory courses leading to these. Entrance Requirements: Examination covering secondary education. Attendance: The director's report for 1915 shows the total number of matriculants of the entire uni- versity to be 239, of whom 29 took the course in medicine, 12 that of pharmacy, and 17 that in dentistry. Teaching Staff: 22 professors and a number of student assistants. Resources Available for Maintenance: Students' fees, at the rate of 400 milreis a term, and from the State of Parana 36 contos a year and from the city of Curityba 10 contos a year. When the uni- versity was started the Federal Government paid 50 contos, but has given no aid since. These figures refer to the finances of the university at large, and not to the medical school only. Laboratory Facilities: All the laboratories are small, and while equipped with modern apparatus, they are not prepared to give individual laboratory instruction. The dissecting room has three tables and a small room with prosector's table. The ana- tomical museum has an excellent collection of ana- tomical models. The histological laboratory has 16 desks, but only four microscopes. In this room was 203 seen one cage for guinea pigs, containing two ani- mals, and an aquarium for frogs. The natural history museum contains an excellent collection of mammals, insects, and minerals. The laboratory of physics is equipped with an excellent lot of apparatus, but has very little room for students' work. The bacteriological laboratory is a small room, well equipped, but apparently for demonstration purposes only. It contains no desks. The labora- tory of analytical chemistry contains cabinets for chemicals, one small hood, and desks for 6 workers. The laboratory for mineral chemistry, and used also for pharmacy, contains desk space for only eight men. The laboratory of physiology has an excel- lent lot of apparatus for demonstration purposes, but no desks for student's work. No course in pharma- cology is given. The general impression derived from this inspection of laboratories was that the laboratory subjects are taught by lecture and demon- stration, and with the possible exception of anatomy, the student has no opportunity for actual practical work. This view is supported by the following list of cost of original equipment for the various labora- tories as taken from the 1915 report: Dissecting room 1,215 milreis Museum of Anatomy 23,758 Laboratory of Histology 5,809 " Laboratory of Microbiology 5,298 " Laboratory of Physiology 9,353 Laboratory of General Chemistry.. . . 7,407 Physical laboratory 17,49° Laboratory of Analytical Chemistry. . 7,000 204 It will thus be seen that a great deal more money was spent upon the museum collections than upon the actual laboratory equipment, thus indicating again the apparent importance of demonstrations as com- pared with individual laboratory work. Clinical Facilities: At the time of our visit the school had two classes, and was preparing to receive a third, and thus could show us only the work of the laboratory years, as their clinical work did not be- gin until the first class reached its fourth year; the clinical work here, as in all Brazilian schools, run- ning through the fourth, fifth, and sixth years. The school has access, however, to the charity hospital of the city with 90 beds, all of the members of the staff of which are teachers in the school, and the as- sistant director of which is the director of the med- ical school. It also has a maternity hospital, known as the Uni- versity Maternity, which belongs to it absolutely. This is located about one and a half miles from the school, and is a building of two floors, very well equipped for obstetrical work, having an office and examination room, an isolation room with two beds, and a general ward of four beds on the first floor, and on the second floor a delivery room with two beds and a ward of 8 beds for post-partum cases. It also has two private rooms, one of one bed and one of two beds, and a kitchen and dining room. Two nurses are in constant attendance, and treatment is free except in the private rooms, for which a charge is made of 20 or 10 milreis per day. (When the maternity hospital was started the state contributed 10,000 milreis, and in 1914 the city of Curityba 205 gave 6,000, and in 1915, 4,000 milreis). It is said that the students will also have access to the insane asylum, with about 200 patients, and it is hoped that other institutions in the city may be available. General Comment: The inspection of this school was exceedingly unsatisfactory, as the laboratories are used, apparently, in common with several other courses, particularly that in engineering. Moreover, it was difficult to obtain any information concerning the course in obstetrics for midwives. The same holds true for the course in veterinary medicine. Al- though advertised, there is no record of students in these courses. In regard to the course in dentistry, the equipment is confined to two rooms, one the clinic with three chairs and the other a room for laboratory (pros- thetic) work. (The official cost of the equipment of the dental clinic was 6,369 milreis, and of the labora- tory 2,127 milreis.) The course in pharmacy is a very elementary one for which are used the museum of natural history and the chemical laboratories. The 1915 catalogue shows that in the first class were 21 taking the medical course, 8 the course in pharmacy, and 15 the course in dentistry, and that in the second class were 8 matriculates in medicine, 4 in pharmacy, and two in dentistry. If the figures of the second class are not increased in the future the laboratory equipment in all subjects may be con- sidered adequate, but if the classes increase it is clearly inadequate. This university, however, suffers from the present 206 financial depression affecting all Brazil, and it is possible that if in the future the conditions improve and the number of students increase, additions to its equipment may be made. About the present build- ing has been reserved a considerable amount of land which may eventually be used for new buildings. The library of the medical school contains 2,298 volumes, according to the 1915 catalogue, which are divided as follows: Medicine 328 Dentistry 126 Pharmacy 204 Obstetrics 15 The dental clinic, in 1915, had 328 patients. The maternity hospital averages about 60 patients a year. (For catalogue, see Appendix IV, No. 13.) State of Bahia Population 2,500,000; No. of doctors, 203; Ratio, 1 to 8,952. Number of medical schools: 1. City of Bahia Population: 300,000. Faculdade de Medicina do Bahia: (This school was visited during a short stop of a few hours on the outward voyage. The time at our disposal, barely an hour, allowed only a very general inspection. Un- fortunately, on the return trip the boat did not stop 207 at Bahia and our plans for a second visit were thus frustrated. Before leaving Brazil, in an attempt to obtain additional information, a questionnaire was left with the director, and through the efforts of Mr. Robert Frazer, Jr., the American Consul, answers to this have been received since our return to the United States. The school is located on the highest point of the city, commanding a view of the bay, and as the chief building forms three sides of a square, with the open side occupied by a small park, the result is that all laboratories have excellent light. The laboratories and lecture rooms are abundant and arranged, as a rule, so that each subject has its own lecture room and laboratory together. For example, the anatom- ical lecture room is on the floor below the anatomical museum and adjacent to the dissecting room. In most of the laboratory departments, particularly those devoted to microscopic study, the tables are not fixed to the floor but are, instead, small movable tables accommodating two or three people. As our visit was on Sunday, and, moreover, during the sum- mer vacation it was impossible to get any idea of the mode of instruction. Small laboratories, however, give the impression that the detailed individual in- struction such as is common in our American schools is not the method used in the Bahia school. The laboratory of physiology, for example, appears to be a place for demonstration rather than for individual work by the student. The laboratories of chemistry, bacteriology, and pathology have a fair amount of desk space but it is doubtful if these allow individual work on the part of the large classes, as, for example, 208 600 students in 1913. Also, although in every laboratory visited a considerable amount of appar- atus as microscopes, blood-counting apparatus, chem- ical glassware, physiological apparatus, etc., was seen it was not sufficient for individual work by large classes. This statement does not apply to the dis- secting room, which is a very large room with plenty of tables and of modern design. It is noteworthy also that in the court-yard is an autopsy room, with two tables, and although there is no hospital in this immediate neighborhood the director states that autopsies are made frequently before students in this room. The department of dentistry is represented by a fairly large room, which contains 5 or 6 operating chairs and on the opposite side of the corridor is a pharmacy apparently utilized also as a place for the dispensing of drugs. Both these departments were near the main entrance and serve apparently as dis- pensaries for the departments of dentistry and pharmacy, respectively. The school is controlled and financed by the Fed- eral Government, in this respect being similar in every way to the Faculdade at Rio. It has an ex- cellent library of 16,317 volumes, and its faculty numbers1 30 professors, 25 assistant professors, and 45 other instructors. 1 Figures from Almanack Laemmert. 209 Addenda Additional information received May 15th, pre- pared by the medical faculty of Bahia in response to questionnaire submitted through Mr. Robert Frazer, follows: 1. It is impossible to give the number of physicians resident in the state of Bahia, but the number regis- tered with the department of health in the capital city is 495. 2. The school was founded in 1808. 3. The school is supported by (a) The federal government, (b) Students' fees. In 1915 the sums received from these sources were (a) 1,053,000 milreis ($263,250) (b) 90,000 milreis ($22,500). 4. Total number of students for 1916 is 394, of which 243 come from the state of Bahia and 151 from outside. 5. The school term begins in March; the course is of six years' length, with eight months in each term. The total of hours of work per student per week varies from 18 in the first year to 39 in the last. 6. The total number of professors is 48, divided as full professors and assistant professors. The number of other instructors is not given. 7. Professors in the laboratory branches receive 800 milreis ($200.00) a month, and those in the 210 clinical subjects 900 milreis a month. The higher type of assistants, as demonstrators, receive 450 mil- reis a month. 8. The budget covering the cost of instruction in all courses, laboratory and clinical, and excluding in- structorial salaries and administrative expenses is 120,000 milreis ($30,000) annually. 9. The entrance requirements are the same as those of the other federal school at Rio, that is, the candidate must be at least 16 years of age, must have the usual training of the gymnasium and must pass an examination. 10. The clinical facilities are (a) A general hospital-the Hosp. S. Iza- bel, with 500 beds. (b) A psychiatric hospital-the Hosp, de Sao Jao de Deus-with 250 beds. (c) An obstetric hospital-the Maternidade. Of these the third is maintained and controlled by the medical school. The first and second are independent institutions, but closely affiliated with the medical school for purposes of instruction. (For catalogue and historical data concerning this school, see appendix IV, No. 10.) 211