BULLETIN 
OF THE 
American Academy of Medicine. 
Vol. ir . Issued June, 1897. No. 13. 
The American Academy of Medicine is not responsible for the sentiments ex- 
pressed in any paper or address published in the Bulletin. 
MODERN medical education. 
J. C, Wilson, M.D., Professor of the Practice of Medicine and of Clinical Medicine in the 
Jefferson Medical College, etc., etc. 
Fellows of the Academy: I thank you for the honor you con- 
ferred upon me at your meeting in Atlanta in choosing me to 
preside over your deliberations in Philadelphia at this, your 
twenty-Second session. d'O be elected President of the Ameiican 
Academy of Medicine is, under all circumstances, a most dis- 
tinguished appointment, but coming as it did to me, unsought 
and unthought of, at a time when the wide usefulness of our 
most unselfish organization has become apparent to the whole 
profession of the land, at an epoch in its history when many who 
have held aloof from its struggles during its years of growth, are 
entering its ranks in the day of powTer, is a compliment of which 
I may, without unbecoming elation, be justly proud. 
Your brief annual meeting affords me the pleasure of a direct 
personal relationship with you oi only short duration, but the 
duties of the office have occupied my attention during the year, 
and have impressed upon me with increasing force the great 
usefulness of the work already accomplished, and the far greater 
importance of that which remains for you to do. Nor do I dis- 
cern any end to the field which the founders have laid out for 
us to do till, seeing that new problems in medical education, 
medical ethics, and medical sociology will continue to arise, and 
that growing success will bring to us widening opportunities, 
new difficulties and responsibilities at once more arduous and 
more important- 
Since the first meeting of the Academy in this city, Septem- 
ber 6th, 1876, remarkable changes have come to pass. The 
scope of medicine itself, the character of medical teaching, the 
requirements for graduation have, in the short period of the mi- 
nority of a native-born citizen as fixed by law, undergone an ev- 
olution little anticipated by he handful of earnest men who, 
undei the leadership cf Tri Areen, of Easton, then banded 
themselves rog7 *ganize an association whose objects 
are: 
1. "To bring those who are alumni of classical, scientific, 
and medical schools into closer relations with each other. 
2. "To encourage young men to pursue regular courses of 
study in classical and scientific institutions before entering 
upon the study of medicine. 
3. "To extend the bounds of medical science, to elevate the 
profession, to relieve human suffering, and to prevent disease." 
In the interval since the date of that remarkable meeting, the 
science of bacteriology, then viewed askance by the leading 
teachers and practitioners as something new and strange, has 
become a dominant influence in medicine. It has revolution- 
ized pathology, it has recreated the art of healing in every de- 
partment, and has given us a new surgery, in whose footsteps, 
with urgent ^stride, follows a new medicine of not less brilliant 
promise. It has enabled the gynecologist to realize and surpass 
the brightest hopes of McDowell, Marion Sims, and the Atlees. 
It has rescued hygiene from empiricism and placed it upon a 
sure basis of scientific facts. It has elevated the specialities 
above the narrowness of circumscribed work, and shown the 
specialists that for the practice of their art much more is needed 
than an easily acquired operative technique and a little manual 
and intellectual dexterity. It has demonstrated the absurdity 
of much of our traditional drugging and given us new systems 
of healing, fruitful with present achievement, and pregnant with 
promise of greater things, while it has indirectly revived and de- 
fined the scope of measures of treatment, such as diet, baths, 
and climate, for which we do not send to the apothecary. It 
has warned the investigator in the laboratory that the study of 
the causes of diseases which are ever ready, sure, swift, and cer- 
tain of effect, is to-day a much more promising field of research 
than the too curious analysis of the special qualities of uncertain 
and variable drugs. In point of fact, bacteriology, the youngest 
of the medical sciences, scarcely known as a science to those 
who organized this body, has swiftly pressed to the front and 
now controls almost every department of the complex organiza- 
tion of the medical sciences. 
While these changes have been going on, other developments 
of great importance have been taking place. Histology has as- 
sumed a definite place in the curriculum, and anatomy can no 
longer be studied without the microscope. The teachings of 
physiology, yearly more definite and precise, bear with every 
advance a closer relation to the requirements of practice, so that 
no alert practitioner feels secure unless he can read his latest 
treatise upon physiology carefully through at least once a year. 
Physiologic chemistry has made corresponding advances. 
Embryology must be taught as indicating the structural bases 
of forms and the primary relations of tissues, while comparative 
anatomy is essential to a complete knowledge of the anatomy of 
the human subject. Some knowledge of medical jurisprudence 
was at one time thought necessary for the expert, but to-day 
every practising physician must be informed of the mode of pro- 
cedure in judicial inquiries, since he may at any moment be 
called upon to act for others and himself in a case involving 
questions of mental alienation, testimentary capacity, the re- 
sponsibility for injuries by accident, or homicide. 
These changes in the scope of medicine have not taken place 
without corresponding and far-reaching changes in the organi- 
zation of the medical profession, and in its relations to the public 
atlarge. Very often these changes have been like the growth of the 
knowledge to which they owe their origin, gradual and almost 
imperceptible, but very often they have been abrupt and violent. 
Progress means readjustment and this cannot take place without 
occasional perturbation and commotion-a fortunate circum- 
stance since it enables the too conservative to become aware of 
the fact that something is going on. I may remark in passing 
that constant readjustment and occasional violent reaction are 
inherent to intellectual advance and when they cease to disturb 
our quietude, stagnation ensues. 
In the medical life of the last quarter of a century, especially 
in this country, the perturbations and violent readjustments of 
. advance have been principally and most keenly felt in the teach- 
ing institutions from some of which the advances have originally 
in every instance directly or indirectly proceeded. 
The shock has usually been violent and the adjustment tardy, 
a fact for which we find an adequate explanation, first in the 
conservatism of scholastic institutions, secondly, in the tenacity 
with which men cling to customs which they have come to look 
upon as vested rights. 
Tardy as they have been, however, the successive adjustments 
of the colleges to the advances of knowledge have been com- 
plete, each in its turn, and as new adjustments take place they 
will be as nearly as possible adequate to the essential require- 
ments 8f particular times and circumstances. This prediction 
rests not only upon the experience of the past, but upon the 
ADDRESS OR THE PRESIDENT. 2 Bulletin 
fact that while the knowledge upon which medicine rests is sci- 
entific, the application of that knowledge is an art, and subject 
to the conditions by which art in all its manifestations is influ- 
enced, not the least of which is competition. 
Here we observe a fine example of action and reaction-in- 
creasing knowledge calling for better teaching, and better teach- 
ing in its turn tending to the advance of knowledge. 
The character of the teaching has, in fact, during the period 
referred to, undergone changes scarcely less radical than the 
subject-matter to be taught. 
It has become less didactic, and more demonstrative; less rhe- 
torical, and more explicit; less showy, but more convincing. 
The seven learned professors and single demonstrator that con- 
stituted the faculty of a well-equipped school in that day, pres- 
ently found the growing task too much for them. They had 
not time to do the work and worse still, they realized ere long 
that their combined knowledge was unequal to the undertaking. 
1 hey did not know enough. So it came to pass that with each 
annual announceiWent new subjects were placed in the curricu- 
lum and bright young fellows, or a trained specialist or two 
were taken on as teachers. And this went on, until to-day the 
teaching force of a modern medical college of the first rank, in- 
cluding professors, assistants, lecturers, demonstrators, and the 
members of the staff of the attached hospital and dispensary ser- 
vice is to be counted by the score. Indeed, malice has observed 
ol more than one such institution that the occupants of the 
chairs outnumbered the occupants of the benches. 
As the old faculties had not time to do the increased teaching/ 
so the student found his time too short and the time-element be- 
came a factor in the process of evolution. First, the term was 
lengthened a little, then more. This proving insufficient, a year 
was added to the course, and later another year. Now, instead 
of two annual sessions of scarcely five months each, the student 
of medicine must attend four annual sessions of seven months or 
more. The number of sessions is now determined in several 
of the states by law, but the public opinion that has made itself 
manifest by legal enactment in some places, is growing in power 
all over the land and the time is not far distant when the two 
and three years' schools will cease to exist because men will 
be ashamed of their diplomas. Such schools, it is true, have 
thrived for a season, but their prosperity has been short-lived, 
first, because it arose from a shifty expediency, and secondly, 
because the sobei after-thought of the American people is right. 
1 he progressive schools have sometimes had poor classes during 
tile periods of transition, out the change nas, in almost every in- 
stance, been followed by a notable increase in the number of 
students. 
The requirements for graduation have undergone progressive 
changes not less important. The examinations have long since 
ceased to be perfunctory. They are now tests and, in most instances, 
severe tests of the knowledge of the applicant for the degree in 
the fundamental branches of medical science, and not rarely in 
the application of his knowledge at the bedside in the diagnosis 
of an actual case and in formulating a scheme of treatment. 
They are sometimes oral only, frequently written, and occasion- 
ally both written and oral. In the written examinations the use 
of improper aids is frequently, but not always prevented by ob- 
vious and unfortunately necessary measures. In the clinical 
branches, the possibility7 of extraneous help or collusion is re- 
duced to a minimum by the chaiacter of the questions. Twenty 
years ago the hope that the honor system would ever obtain in 
examinations for the doctorate in medicine would have seemed 
chimerical; to-day there are sane teachers who confidently ex- 
pect its arrival. Surely the standard of honor ought to be as 
high in medical as in military life. In many schools the final 
averages in particular branches are made up of the results of 
several examinations conducted by different teachers-the pro- 
fessor, a demonstrator, and the lecturer in the special depart- 
ment, each counting a prearranged percentage of the whole. 
The examinations no longer being a mere form and their subject- 
matter being purely technical, no student however clever, who 
has neglected Ins work or spent his time in riotous living ex- 
pects to pass by chance-to " skin through" in the words of an 
earlier time. Indeed, it not infrequently happens that students 
who have among their classmales the reputation of being fairly 
well prepared, absent themselves from the examination in one 
oi two blanches at the last moment, and defer graduation for 
another year rather than take the risk of being actually plucked. 
The development of medical education in the twenty-one 
years which measure the life of this Academy, in the scope of 
the knowledge to be acquired, in the character of the instruction, 
and in the requirements for graduation, constitutes a remarka- 
ble epoch in the history of medicine. Disregarding the post- 
graduate schools, the aim and scope of which are not immedi- 
ately7 considered in tnis argument, the changes have been so 
gieat as to have orought into full bloom a flower conspicuous in 
the brilliant intellectual development of the end of our century-■ 
the higher medical education. It is not assuming too 
much, Fellows of the Academy, to assert that this body has 
played an important, though inconspicuous part in bringing 
about these changes, fraught with so much importance to the 
well-being of the profession and to society at large. It would 
be strange, indeed, were this not the case. The very purpose 
of our organization was to promote such interests. The papers 
that have been read, the discussions that have followed, the en- 
thusiasm that nas been aroused, the force of association, the 
weight of opinion, developed and fostered by the contact of men 
interested in the promotion of the highest professional aims have, 
during these years, exerted a combined influence upon the pro- 
fession which has been potent for good. I congratulate you 
that during the existence of this body many of its highest aims 
have been achieved. 
A word in passing in regard to examining boards and the 
license to practise, it is a happy commentary upon the purity 
of piofessional aims that the most advanced medical educational 
institutions have been the most prompt to make sacrifices to the 
common good. One after another, in state after state, the col- 
leges have lelinquished a fundamental and most important char- 
ter light, namely'', that the diploma should confer upon its recip- 
ient the light to practise medicine. The movement for separate 
legal lequirements, first registration, then state examination, 
had its origin in those interested in the higher medical educa- 
tion, in many instances in the faculties themselves of the most 
advanced and wed-equipped schools. This movement, it is 
true, was aimed primarily7 against quacks of the itinerant kind 
and the diploma mills, but in its more recent development it has 
dealt serious blows at the inadequately equipped and officered 
second and third rate legally chartered colleges. It is certainly 
a lemarkable fact that educational institutions should, in the 
best interests of a common profession, voluntarily" relinquish the 
most impoitant franchise conferred upon them by charter. 
What the effect of the present tendency toward reciprocity 
among the states in the granting of licenses and the system of 
interstate indorsement may have upon certain of the schools re- 
mains to be seen. Greater uniformity of facilities for instruction 
will become necessary. Geographical situation and local con- 
ditions in some instances seriously hamper, in others render ab- 
solutely useless efforts to supply adequate clinical instruction. 3 Bulletin 
There are schools in which the elementary teaching is of the 
best character, that cannot secure the facilities for clinical work. 
The lengthening of the term from three to four years cannot, 
under these circumstances, meet the requirements of the case, 
but if a general comity in regard to the license to practise is to 
be established by the boards of different states, the law must 
regulate the length of the time of instruction and all boards 
must equally require that applicants for the license should have 
attended a four years' course. In that case studentswill natur- 
ally repaii' to those schools in which the fourth year is occupied 
in clinical work. This would constitute in many instances a 
serious misfortune, first, because of the unwieldiness of enor- 
mous classes, and secondly, because the non-clinical instruction 
in small college towns may be, and often is, of the highest char- 
acter. I would suggest that some of the difficulties may be over- 
come if students presenting certificates of having successfully 
passed their third year examinations should be admitted to the 
schools having large clinical facilities without examination for 
the fourth year, and be permitted to return to the college from 
which they came for graduation. This would, it is true, be a 
make-shift, but it would tend to equalize the opportunities of 
the students in different sections of the country and thus render 
feasible an interstate reciprocity among the licensing boards. 
Equally important is the movement toward uniformity of re- 
quirement for admission to the medical schools. It is at this 
point that the barrier must be set up by which men unfitted for 
professional life, either by lack of capacity or inadequate early 
education, are to be saved the waste of time and disappointment 
attending failure to successfully pass the examinations either in 
course of final. So important has this matter appeared to those 
interested in medical education that the degree of Bachelor of 
Arts or its equivalent has already been made a preliminary re- 
quirement in one medical school and is announced to go into 
effect in two others. The importance of this measure being 
granted, serious discussion has arisen as to how the prolonged 
course of four years in a collegiate department and four years in 
the medical school can be avoided. The President of one of our 
great universities has gone so far as to advocate the shortening 
of the collegiate course to three years. By another plan the 
student in the academic department is permitted to present him- 
self for the final examination at the end of the third or junior 
year. If successful, he then receives a certificate to that effect. 
This certificate entitles him to begin the course in medicine, the 
degree of Bachelor of Arts in the academic department being, 
conferred upon him with his class at the end of the ensuing year. 
Should such a degree as a preliminary requirement be generally 
adopted by the medical schools, some expedient by which the 
academic course can be shortened a year will be a necessity, 
since the technical medical course cannot be shortened even in 
the case of students who do biological work as electives, without 
detriment to their medical education. Eight years of study 
prior to obtaining the doctorate in medicine and the license to 
practise, constitutes a longer period of time and involves a 
greater expense than the majority of aspirants for honors in the 
medical profession can afford. This fact has added force when 
we consider the time, spent by many graduates in serving as hos- 
pital internes, and in other work for which they receive no pecu- 
niary recompense. 
We, as a working society, have seen not only the wonderful 
advance in medical education of which I have spoken, but we 
have also seen the organization of the College Association, one 
of the objects of which is to make that advance uniform and per- 
manent. We have witnessed not only the enactment of laws by 
which in many states the license to practise'can only be obtained 
by successful examination under rigorously defined regulations, 
but also the Confederation of the State Boards of Examiners for 
the purpose of securing the highest degree of efficiency. In 
short, in medical education our eyes have looked upon a burst 
of light like a new dawn, and it has been ours to have had some 
part in preparing for the day. But there is more to be done, and 
we may count ourselves happy that we are to do much of it. Eor 
what we do as an organization we feel sure will be done well. 
The educational problems are far from being yet solved; the re- 
lations of the profession to the state are not yet well-defined; 
questions as to expert testimony are still vexed ; the status of 
medical men in armies and navies is not satisfactory ; hospital 
and dispensary abuse is a crying evil; the growth of the com- 
mercial spirit is a dry rot within our ranks. Here are problems 
for us to work out-problems of great moment to us as members 
of the noblest of professions. ? Individuals may toil at them and 
do good, but if we as an association make them the objects of 
our united labors, we will make ourselves felt as no single man 
or many single men working apart can ever, no matter how 
great their individual gifts and energy, succeed in doing.