SOME THOUGHTS ON HIGHER MEDICAL EDUCATION AND MEDICAL ETHICS. BY DAVID CERNA. Ph.D-, Demonstrator in Physiology in the Medical Depaitment of the University of Texas, etc. REPRINT FROM American Medico-Surgical Bulletin, December, 1893, and January I, 1894. TO CONTRIBUTORS. 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BY DAVID CERNA, M.D., Ph .J)., Demonstrator in Physiology in the Medical Department of the University of Texas, etc. REPRINT FROM American Medico-Surgical Bulletin, December, 1893, and January I, 1894. SOME THOUGHTS ON HIGHER MEDICAL EDUCATION AND MEDICAL ETHICS.* Demonstrator of Physiology in the Medical Department of the University of Texas, etc. By DAVID CERNA, M.D.,Ph.D., NO more important general topics could properly be brought up again for discussion in this body, it seems to me, than those of higher medi- cal education and medical ethics. A good deal has been said and written upon the subjects, it is true, but so far com- paratively little has been accomplished in the right direction, and the fault, it may be said, with Cassius, "is not in our stars, but in ourselves that we are underlings ! " The task of struggling for truth and justice is formidable, but none the less inviting and appropriate at all times, and under all cir- cumstances. The question of medical edu- cation, so ably treated by a former president of the Texas State Medical Association, Dr. J. F. V. Paine, and that of medical ethics also touched upon by the same writer in an official address, are always, and especially at present, it seems to me, of exceeding interest. 1 ask, therefore, for no excuse in bringing up anew those questions for further ventilation. The spirit of the times, the cause of higher medical education, the in- solent attitude of charlatanism and quackery, 1. Medical Education. * Read by t'tle befo- e the Texas State Medical Association, at Galveston, Texas, Mav. :8qi. 3 the utter disregard of medical ethics even by prominent members of the regular pro- fession, all, all demand further consideration of the topics proposed in this paper. Quackery and patent-medicine traffic arc too dangerously on the increase to allow the sad order of events to take its own course. The same- may be said in regard to professional misconduct. All these sub- jects, intimately linked the one with the other, are of vital importance and worthy of the most serious consideration. How can we effectively deal with the growing evils? I would propose the fol- lowing measures : (i) Raise the standard of medical education. (2) Teach medical ethics in all the medical and pharmaceuti- cal colleges. (3) Do away with, at least, two-thirds of the so-called medical journals published in this country. (4) Let the govern- ment interfere with quackery and the pat- ent-medicine traffic. RAISE THE STANDARD OE MEDICAL EDUCATION. How? By a firm resolution to stop teaching- medicine from a commercial point of view. It cannot be gainsaid that many of the medical institutions of this country are mainly business concerns, and the rivalry existing among some of these consists often, not in which of them shall be able to im- part a better education, but in which of' them shall boast of a larger number of stu- dents. Quantity, not quality, is the chief object in view. This is, and it goes with- out saying, the very beginning of demoral- ization. But it seems that it must be so. since the majority of these colleges depend almost wholly for their existence upon the income from students. Abolish the fees in 4 such cases and the colleges are sure to perish. I'he method just pointed-out is the first great error, for the obtaining of a medical degree under such circumstances becomes comparatively an easy one. All examina- tions must be, and generally are. of a low standard, otherwise students, not properly qualified for the ordeal, are perforce driven away to other institutions not so strict. Hence the endeavor to retain students at the price (not generally known by the public) of " sham " examinations ; for, in point of fact, the loss of one single student in many a medical college in this country, is detri- mental to the financial health of the institu- tion. The same may be said in regard to the students' qualifications for admission. I'he examinations alleged to be required in such cases are often not carried into effect. Medical institutions there are at present whose constant endeavor is to make it ap- pear that their standard of education is of a high order, and in their catalogues are printed certain requirements for the admis- sion of students. But the truth of the mat- ter is that such requirements are a delusion and a snare, and they are actually dead- tetter. For instance, when a student pre- sents himself to one of these colleges, as a candidate for admission, all he has to do is to inscribe his name on the marticulation- book, pay the fee therefor, receive his en- trance ticket from the clerk, and all is done ! No questions asked. He (the student) sees the secretary or dean of the faculty for the first time when he is to deliver the corres- ponding fee for the scholastic year ; and sometimes not even then, for an understand- ing in the case can often be had with the 5 clerk. And it does not matter whether such a student is really an A. B., an A.M., a B S., or a graduate in Farmacy ! The require- ments, I say, may as well (and more pro- perly, perhaps) be left out of the catalogue, and thus cease to give the lie direct to an unsuspecting public ! Once admitted, the student goes through his course with comparative ease, passing from one year to another, for the most part, after an oral examination of short duration. Practical or bed-side instruction he gets little or none, except what he can obtain at a general clinic-if he happens or chooses to attend. I trust I am not being misunderstood. I am criticizing methods only. So far as medi- cal teachers and laboratory and clinical facilities are concerned, I do not believe superior ones can be found, even in Europe. And a propos of this, it seems to me that going across the ocean (after a thorough instruction has been received at any of our leading medical colleges here), for the al- leged purpose of acquiring a more complete medical training, is more or less following an aristocratic fad, for fads we have even in professional life ! For this country to have produced such eminent medical and surgical lights as Leidy, Stille, Hayes Agnew, Da Cos- ta, Weir Mitchell, McDowell, G. B. Wood, H. C. Wood, Pepper, Marion Sims, Emmet, Thomas, Wormley, S. D. Gross, the Flints, Ashhurst, Hunter, McGuire, and a host of others just as brilliant, a course in Europe would not have been, I believe, absolutely necessary. But to return to our subject of medical training. Sometimes, even under the pecu- liar! v favorable circumstances mentioned 6 in connection with medical studies, students fail (and alas ! for the rarity) to pass the examinations. And what is the result? A trial is made at a rival institution with, generally, the desired success. 1 know, for example, the case of a student who. having failed to pass his final examinations at a medical college, tried a second institu- tion, and, having again failed in this latter one, tried a third faculty (he was bound to get, as he said, a sheepskin), and at last succeeded in obtaining from his third Alma Mater his coveted diploma, graduating even with high honors !!! ; and yet that young man was then not more qualified to practice medicine than a "Christian scientist," a " mental healer," or what not, not to say than the man in the moon. This happened in a city famous as a medical center. In speaking of the reputation of certain medi- cal schools, I may be allowed to parody Madame Roland by exclaiming : " Reputa- tion, oh ! reputation, how many crimes are committed in thy name." The indiscriminate and highly censur- able custom of self-styled medical colleges in this country, of sending out yearly an enormous quantity of steam-manufactured, and, in many instances, grossly ignorant, graduates, explains the evil and its terrible consequences. It has truthfully been said by some one (*) that medicine and pharmacy have advanced considerably in the last decade ; but the advance in evil far more than counter- balances that in good ; for while the multi- plicity of colleges of medicine and phar- macy have facilitated the acquisition of medical and pharmaceutical knowledge, the * Lucas : in this journal, March, 1893. 7 method of bidding for students has placed the standard for qualification so shamefully low, that some diplomas are hardly worth their paper. To show to what extent this evil has grown, we need only cite the fact that the German Empire, with nearly the same population, graduates about seven hundred, and the United States nearly four thousand, physicians annually." It may be added that the figures given by the author apply to several years ago ; but it is believed with some foundation that the proportion has not materially changed since then Now, seventy-five per cent., at least, of these young men thus supplied with a medi- cal degree never make a mark, scientifi- cally or otherwise, chiefly owing to an al- most absolute ignorance of diseased condi- tions and of the proper therapeutic indica- tions and means to combat the same. Under such a sad alternative, these practi- tioners, as a last resort, fall on quackery as a more lucrative means of obtaining a livelihood. And how can it be otherwise ? " It has often seemed to us," bewails a recent writer (*), ''that the 30 per cent, of graduates of American medical colleges, who are rejected by the several State ex- amining boards, have a real grievance against the teachers of their several medical colleges, and would be warranted in return- ing to said teachers and kicking them for the scurvy trick of taking their money and tailing to teach them modern medicine in regular doses." So long, it seems to me, as the study, the teaching, and the practice of medicine are * The American Lancet, February, 1893. 8 carried wholly on a commercial basis, with- out a proper regard for the main object in each case, so long, do I hold, will the no- blest of all professions fail of its high and legitimate purposes, and so long will quackery live and continue to thrive upon " the fat of the land;" that is, upon credulity on the one hand, and disappointment on the other, of a suffering humanity. It is satisfactory to note that considerable attention has of late been given to higher medical education and that the profession as well as the public in general are begin- ning to realize the necessity and importance of progress and reform in this direction. The practical and firm attitude taken by a few of our leading medical schools is a most wise one, and has undoubtedly met with the approval of every right-thinking person inside and outside of the profession. An examination of the terms for medical instruction, instituted by even the best equipped medical schools in this country, and of the various methods of teaching em- ployed, reveals the fact that the average course of study is less than three years, owing to an antiquated custom of such schools keeping their doors closed half the year. On the other hand, these institu- tions, by permitting uneducated men to matriculate and graduate, are degrad- ing the profession continually, thus making the study of medicine not only repulsive but uncongenial to the average cultured man. We learn from a critical examination of the thousands of medical matriculants in the different schools, that although the number of such students having a college degree in letters or science has apparently increased, the relative number has actually 9 decreased considerably. It is true that the education of the average medical student is superior to-day to what it was several years ago, but this does not disprove the un- pleasant fact that the number of ignorant, uncultured students pursuing a course in medicine has increased. It is similarly a sad fact that the medical department is neglected by most of the uni- versities of this country; " it is farmed out or left to shift for itself on half rations, or, in the best instances, treated from an educational standpoint in an exceptional manner." In- deed, the State neglects medical institutions, and the same may be said in regard to the behavior of benevolent persons or associa- tions, as remarked by a critical observer. Most attention is lavished, as a general rule, on technological schools, "and in spite of the fact that the state and all benevolent institutions have put a heavy task of gratui- tous, and often compulsory, service on the medical profession. " A review of the "United States Educa- tional Report for 1889-90" by Holmes(*), bearing upon the above statements, is ex- ceedingly interesting and instructive. It is shown that there has been an increase of the different medical sects in this country ; that the attendance at regular medical schools has increased 26 percent.; at eclectic schools, 2 percent., while a falling off of about 3 per cent, has been noticed at homoeopathic schools. For the year 1890, the actual figures are these : Regular, 13,044 ", eclec- tic, 600; homoeopathic, 1,128. Compared with other professions, not much change has been effected. "Among 100,000 inhab- itants there are twenty-four students of * Medical Record y March 25, 1893. 10 medicine, seven of law, eleven of theology. In Germany, the number of medical students per 100,000 inhabitants is about 18; in France 17. Dr. Holmes's figures show very plainly that the average time of study for American medical students is less than three years : that, practically, the great majority of medi- cal students graduate after an actual period ot study of eighteen months." We need not be startled by this almost accurate statement: "The laws which allow the diploma to become a license to practice, put the short-term, no-require- ment schools in a position to dictate to the schools that offer a medical education in place of a degree." Now, in view of these facts, are we to remain in statu quo? Are we to allow the order of things to go on without protesting and an endeavor to reform ? Shall we con- sent in the establishment of a competition that would only lower the high standing of reputable, honest, and cultured physicians to the level of the ignorant, the imposter, and the quack ? Apostles of truth and justice, have we lost all energy, all man- hood, all self-respect ? Again, as a general rule, people do not know how to protect themselves from the ignorance of the ten months' medical graduate on the one hand, nor from the imposition of the unprincipled charlatan on the other. It becomes, then, the duty of those who are better qualified to understand and denounce abuses, to protect, in every possible manner, those unable to protect themselves. It is reasonably held (*) that, "in the first instance, physicians must educate their personal friends individually ; * The American Lancet, February, 1893. 11 if collectively, they also do this so much the better. Boards of health, general or local, have done much in this sort of teach- ing. This process must be extended until a sufficient amount of public instruction has been accomplished, when it will be possible to induce the State Legislatures to pass the needful law and provide for the protection of the people from the ignorance and vic- iousness of those who would prey upon the sick. This condition has been reached in many States, especially in the West, but in the South and East relatively slow pro- gress has been made." Wherever the subject has been considered seriously in this country, and given a practical test by proper legislation, the re- sults have been most gratifying; beneficial alike to the profession and the public in general. Thus, I may state from a reliable source (*) that, " as the result of several thou- sand examinations the last few years, they have revealed the character of the work being done by the low grade colleges. Fully 25 per cent, of their students have failed to receive a license, while the students hailing from higher grade colleges have very rarely failed. About 98.5 per cent, of their number being licensed. There are at the present time fifteen States with practice acts that require an examination of all per- sons desiring to practice medicine in the respective commonwealths. These States include nearly 50 per cent, of the entire population. From present indications all the States will be equipped against the pro- ducts of the 'Commercial Medical College- in the near future. The results of these changes is quite obvious. The intelligent * The Joum-of the Amer. Med. Association,yw.Yixaxx' -j, 1893. 12 young man realizes that he can only obtain a scientific medical education in those schools having the facilities to teach, and that have a thorough curriculum. In conse- quence of these changed conditions, the high grade school of the future will reap the harvest at the expense of their weaker com- petitors. Let the work continue. Il -Teach Medical Ethics in all the Med- ical and Pharmaceutical Colleges. Il is the disregard of medical ethics that, like a vampire, is at present bent on im- bibing the very sap of professional dig- nity. threatening an overthrow of all medical morals. And yet I have heard reputable physicians express themselves against laws governing professional conduct and practice: physicians who have advocated, and con- tinue to advocate, the idea of letting every doctor alone, of letting him practice medi- cine according to the dictates of his own conscience and his honor ! But such an idea is absolutely impracticable; the method would be, as it has been heretofore, open to the grossest abuses. We must just as well abolish law, order, and government, and let all of us live and do as we think fit; this would be the destruction of society, the an- nihilation of all distinction between right and wrong, the advent of anarchy. Let every one act according to his idea of a gentleman ! Now, I ask what constitutes a "gentleman" so called? I am sure all of us have different ideas about the matter. Everything under the sun is relative. Experience teaches us this at all times, in all conditions, under all circumstances. What I consider right you believe wrong. 13 We generally hold, for instance, as highly immoral th? idea of polygamy, and yet amongst us. in this civilized country, we have citizens, and good citizens at that, who honestly believe in the plurality of wives as the highest moral principle; and so do many of the human species in other parts of the world. It is a matter of education to a large extent, you will say; and so it is. And what is education in all its bearings? Nothing but the framing of the mind and heart to the adoption of certain laws,-laws which must conform with the mutual interests of a few individuals or of a community. All ideas of right and wrong, in the abstract as well as in the concrete, are rela- tive. I deny the existence of innate moral principles. Did these exist, there would be no need of moral instruction, so termed. From time immemorial religion, in this or that form, has been thought to contain the elements of morality and to exercise a check on the evil tendencies of mankind; and yet to-day moral laws so-called are constantly violated, crimes committed, not only by members of the different flocks, but also by the very pastors themselves, by the so-styled ministers of the Gospel. This alone would seem to show the non-existence of innate moral principles in the individual or in the community, and the absolute necessity, therefore, for the creation of laws to govern conduct in all the conditions and ranks of life, without which laws, order, peace, and dignity would be impossible. Let every one alone, and rely solely on "'gentlemanly'' conduct, and the conse- quences would soon show that no discrimin- ation can be made between the worthy ami 14 the unworthy,-the honest heart and mind, and the scamp. Honor and dignity would be merely pass-words without meaning, an order of things by which the sanctity of the home would be confounded with the unholi- ness of the house of prostitution. Do away with law and government; throw wide open all prison doors, and let the maggots of society feed upon the bounty of sacred individual life and private property. Let the liberty of civil morality be converted into one of libertinism and debauchery. Yes. let all and each one of us embrace the cause of the envious Cassius and exclaim with utter contempt for the honest man, "Upon what meat doth this our Caesar feed that he is grown so great? " And when we shall have satiated our morbid desires, and, with remorse in our consciences and weight in our hearts, come to contemplate the ignoble work of our wild endeavors and doings, surely we shall then say in retaliation : "Age art thou shamed; thou hast lost the breed of noble bloods 1 " Do to others as you would like to be done by is certainly a very good principle,- but with a lav' attached to it. The question before us, however, is not one of sentiment- ality. but of practical advisability, of ex- pediency. The tendency of humanity is to do wrong, and if wrong is done in spite of law ami government, imagine what the result would be in all human affairs if no check were put to such a tendency. No ; in medical affairs, as in all others, of equal, of more, or of less delicate nature, we must have a supreme law to be governed by. Our so-called moral principles are not sufficient for the purpose at issue. Let us trust no one; let us not rely alone on so- 15 called "gentlemanly" conduct. It is loose- ness of principle, the lack ot a sense of honor, the want, or the violation, of an existing ethical law. that begets discord, anarchy, dissolution itself, in the best or- ganized bodies. Order is life, chaos death ! Let us begin at the beginning: let us teach medical ethics in all our medical and pharmaceutical colleges ; let us imbue our students with a sense of professional honor: let us, then, first make them promise to ob- serve in the future a conduct worthy of a physician and a pharmacist, and afterward, when they shall have been invested with these titles, emblems of honor itself, remind them of, and oblige them to adhere to, their pledges, lest they be condemned to the oppro- brium of the laity as well as that of the regular profession. How oblige them ? By the adoption and strict observance of a code of ethics. hi regard to physicians, let it be to the credit of the medical profession in this country that such a code has been created and generally adopted. Unfortunately, this supreme medical law has been, and is being, the subject of contempt and ridicule with those very ones, indeed, whose medico-eth- ical education has been sadly neglected. And 1 may here repeat what has been cour- ageously stated by a writer on the subject (*): "In many sections of Europe, medical men disdain the idea of medical ethics, and we are frequently reminded of the fact by foreigners who come to live among us. This feeling is readily understood when it is re- membered that in those countries the govern- ments protect the profession by rigid laws * Paine: President's Annual Message, 7/ unsiictions of the Ve.vtis State Medical Association, 1889. 16 regulating the qualifications of physicians. It is difficult to comprehend the motives which actuated certain prominent doctors in some of the Northern States of this country a few years ago, in trampling upon the national code, and openly declaring their contempt for it. They were probably im- bued with European notions. However that may be. by their action they draggled in the dust the standard of professional dig- nity, and they degraded themselves in the eyes of American physicians. In the United States,-with the exception of a few states,- there are no laws protecting the medical profession from the encroaching of charla- tans and impostors; the only safe-guards against them are the barriers which the pro- fession has thrown up around itself, and they should remain like a Chinese wall to all adventurers. The abolition of the code of ethics would level all distinctions between scientific medicine and the various sectarian 'pathies', and the shadowy and delusive systems. " Bearing upon this very question, it has been said (*) that "the dissatisfaction with certain provisions of the code expressed itself in the State of New York, especially, to such an extent that one of the most import- ant sections of the code,-one, indeed, which has done more than any other to maintain the dignity of the profession,-has been re- pudiated : " to which it has properly been replied (f) that "a dissatisfaction is ex- pressed, but no reason is offered in explan- ation, no argument is made to give it form, and no just cause for it is assigned. A few ♦Editorial in Medical News; Sept. 17, 1892. t A Conservative Member in the Journal of the American Medical Association, February ir, 1893. 17 persons are dissatisfied, therefore the worl ! must and shall satisfy them at any costd This is substantially the kind of reasoning that appears with their demand, and the author of the News editorial seems to think that something must be done to appease the wrath of individuals who cannot say why or whence their choler and general discomfort. A few dissatisfied physicians repudiate just and time honored laws, and gather around themselves others who know little or nothing of these laws, blindly follow their misguided leaders, and adopt new laws which tend to lower professional dignity. Not content with this, they are now striving to disorgan- ize the national body that made the laws, which they seem to consider too strict. " In regard to the serious division in the profession, alleged to have been apparently created for a time, by this act of repudiation on the part of the Medical Society of the State of New York, the last writer goes on to say that "until the year 1882, the profession in the City and State of New York was har- monious. A few years before that time, ten or twelve physicians formed a cabal which they extended to the State Society and which resulted in the repudiation of the American Code, and the adoption of the ' new code.' Had the dissenters stopped at this point, a simple protest would have been made, but they insisted that the whole profession in the state should adopt their ' new code, bitterly denounced all those who differed from them, and spoke in the most disrespect- ful terms of the National Association in pub- lic medical gatherings, in medical journals, and even in newspapers. This was naturally resented by the defenders of the Association in the City and State of New York. The 18 extent of the division of which the editorial speaks was ascertained at the time, for in 1883 the state was canvassed with the fol- lowingresult: 5002 physicians received each a communication asking certain categorical questions; of this number, 3,826 sent corres- ponding answers ; 34 sent indefinite replies, and 1,142 did not reply. This leaves for 'no code' and the 'new code' together 1,279, and for the National Code 2,547, or within a small fraction of two to one, in favor of sustaining the Nation's code. In the year 1883 this was the extent of the division of the profession in the State of New York. Since then many of the uncommitted and of the ' new code ' adherents, have declared them- selves in favor of the National code, and many more will doubtless do so when they have studied critically the American code." For those who desire the Code of Ethics abolished, believing that " no code is neces- sary other than that every doctor should be an honorable gentleman," permit me to trans- cribe the following expressions from an ed- itorial in a recent number of a reputable journal (*): "The Code of Ethics of the American Medical Association was intended to give the characteristics of a ' medical gentleman.' It is claimed that this descrip- tion has become obsolete. Granted; but will the persons desiring its abolition kindly give us their own definition of a medical gentleman ? Understand, we call for a scientific description of this person, so that he can be recognized on the streets of New York or among the Indians of the Rocky Mountains, in the wretched hovel and the palace, among his equals and his inferiors, with the ignorant and the learned, among his * 1'ke American Lancet. February, 1893. 19 fellow-practitioners, in the medical society, at the bedside, in the social circle, alone with a patient who is calumniating some of his fellow-practitioners. We want to know what course he will take in all matters per- taining to the interest of the community in which he lives. We desire to know how this gentlemanly doctor will treat rumors against brother practitioners in general, or the profession as a whole. Give us a clean- cut description that shall enable any person to pick him out at all times, in all places, under all circumstances, and then we shall have something to consider. "At present, it is the veriest rot and un- scientific nonsense to talk of the 'gentle- manly doctor,' because he is a simple myth, concerning which there is no general agree- ment, or understanding by individual mem- bers of the profession. The only attempt to define him in this country has been the Code of Ethics. We submit that those who desire this code abolished should give us something better in its place. If the profes- sion is to act in unison at all. it must agree upon some general principle of action in each of its several relations. If the old principles are obsolete, by all means let us have the new ones, and let us have them quick, so that we may be able to settle the lines of future association and work." But, even here, we must go slowly even in view of the alleged pressing need of re- form. The revision or abolition of a code that contains so many excellent precepts, so many merits,-merits and precepts which have been recognized by the medical profes- sion even outside this country, should, if at all, be made with the greatest caution. The cry of dissatisfaction must be heard with 20 patience and due consideration. We must not be seduced by impulsive entreaties, or stricken down by imaginary ills. The as- sertions of the enemies of medical morals must be taken for what they arc worth, and nothing more. It has been maintained on good authority (*) that ' the majority of those who repudiated it, knew very little of this code, and many confessed that they bad never read it, while others boasted they would never do so." Are such people, who misunderstand the question, who confess ignorance, or who boast of not wishing to become acquainted with the matter at issue, entitled to a hearing? " There are few men." says a writer (f), "competent to form an opinion on the literary merits of a paper, who, after careful and impartial reading of the code, would not admit that as a specimen of English 'pure and unde- tiled ' it does honor to the scholarship of its authors. Its style is perspicuous without dogmatism, copious without redundancy, and elegant without pedantry. Its tenets have no flavor of magisterial assumption, but are formulated in reason and justice, so plainly set that the 'wayfaring man, though a fool, need not err therein'." Properly, in- deed, it may be said that (£) "it now be- comes necessary for the Association to sup- press the rising disaffection in its ranks, re- membering that reformation is too often undertaken only when abuses have become extreme, and that then it is generally futile. Lt is when an evil is in embryo that it should be stamped out forever, or its eradication is ♦ A conservative member in Journal of the American Midical Association: February n, 1893. t A. N. Talley, Journ. Amer. Med. Asso. February 25, 1893. t A conservative member, Ibid, February ir, 1893. 21 no longer possible. Let the American As- sociation, then, beware of the hydra of dis- affection that unceasingly rises from the depth ot distorted minds ; that has already shed its venom of discord over one state; and that may spread it throughout this broad land, unless the reptile is speedily destroyed. The demon of the code heresy will surely renew its onslaught in some form or another after it is believed to have been exorcised. Again and anon will the same or similar turbulent and evil spirits assert themselves with nefarious intent. Therefore, let the judicial council-the guardian of good order-be ever on the alert, ready for exorcism, and let the Association raise its mighty voice, and annihilate the monstrosity with truth and justice." HI.-Do Away With at Least Two-thirds oi the So-Called Medical Journals Pub- lished in This Country. I do not exaggerate when I say that two- thirds at least of the so-called medical jour- nals published in this country, are not worth the paper they are printed on. And not only that, but such sheets are a dis- grace to the profession, an open insult to medical literature. Such periodicals, in point of fact, are nothing more nor less than advertising mediums containing "mysteri- ous quasi-scientific 'formulas' and other jargon, which sounds very learned and orthodox, and clinched, as they often are, by quotations from honored authors, and some- times by direct testimonials of those who are regarded as ' authorities.' " And whois to blame for all this ? Why, of course. " the physician most largely and his medi- cal journal next ' '' 22 It is true, the same advertisements ap- pear in the daily non-professional press: this is bad enough, but we cannot do any- thing here toward suppressing this part of an injurious illegitimate business. Our at- tacks must be directed where they can be felt most effectively, and good results may yet follow. "Every doctor in the land,' says one writer with much truth (*), "is daily deluged with the most impudent advertis- ing-matter, under the title of ' medical jour- nals; ' so well have these proprietary houses learned that the easiest way to humbug the doctor is under the guise of 'Clinical re- ports'and 'Therapeutic hints.' The legiti- mate and usually reliable medical journals, on the other hand, are of necessity forced to be almost silent on this subject; because, almost without exception, a most important part of their income is from these very advertisers." There is but one alternative. We must do away with at least two-thirds of these so-called medical journals. How? By dis- couraging such publications in every possi- ble way. Let us turn a deaf ear to their de- lusive bidding for subscriptions, and if they are sent to us gratis, place them in our waste-baskets and prevent thus their cir- culation ! IV.-Let the Government Interfere with Quackery and the '•Patent-Medicine" Traffic. Yes, let the government intertere with such procedures, which are nothing more than open robbery, and, therefore, illegal, punishable. In fact, the government that openly allows, or even by keeping silence consents, in the carrying on of frauds like the * Melvin: in th i~ journal, March, 1893. 23 ones under consideration, is largely respon- sible for the evil consequences accruing therefrom. If laws are enacted to prevent quackery, legislation should also be created to suppress the manufacture and sale of quack- ent-medicines. Quackery and "patent medi- cine" traffic come under the same category: both are crimes and both should be dealt with in the same manner. Should not the cir- culation of the advertisements of both be discountenanced by even existing law? A physician (*) has properly suggested that "as the whole tenor of this business is im- moral and repugnant to the spirit of divine and human law, why permit the advertise- ments of these self-constituted illegitimate doctors to go through the mads, any more than lottery tickets or obscene prints ?' Is it not a source of mortification to na- tional pride, when a foreigner (f), judging from practical observation, makes the fol- lowing accusation ?: " the title of Doctor is a very cheap one in this country * * and is applied to common farriers, patent-medi- cine peddlers, and a host of druggists. The ratio of legitimate practitioners to the population in the states is i to 500, and this does not include the great number of hum- bugs that flood the country. Counter pre- scribing by druggists is very extensively practised, and there is a great deal of •self- doctoring' carried on by the average Ameri- can. I seldom see a patient who has not been administering this or that nostrum to himself before sending for me. To give an idea of the enormous sale of patent-medi- cine in this country, I may state that one- third of the space of the average chemist's * Carrol : in this journal, March, 1893 tA correspondent in the l.ancel (London) March it. 1893 24 shop is allotted to these remedies, and that they are for sale at every grocery." Is it not, I repeat, a mortification to national pride, even to listen to such expressions, es- pecially when no honest denial can be given? In the meantime, what is to be done? A writer asks (*): ''Is there, then, no hope? Not for the speedy suppression of the busi- ness; but for its ultimate downfall, I trust there is; if but physicians and pharmacists will zealously join hands in common battle against the enemy; and with a better knowl- edge of disease and remedies to combat it, --with purer drugs and more skilful hands to compound them,-march onto inevitable victory over deceit and robbery. " I am delighted to observe that part of the subject at least has recently been brought up for discussion by a medical journal, and that independent physicians and pharma- cists have beg' n to express their opinions in the matter "without fear or favor." From such opinions I have quoted here and there. As regards my own attitude in the ques- tions which I have brought before this As- sociation, sufficient can be gleaned from what I have already stated. But 1 may be permitted to repeat that the study, the teaching, and the practice of medicine, merely on a private gain I asis, are all, in my humble estimation, entirely wrong; while the illegitimate methods portrayed in the pre- ceding paragraphs, and carried on not only in this country but almost in every corner of the civilized world, are, I believe, wrong, and criminal as well, and should be dealt with accordingly. 1'his is the true sense of my private opinion, the very esssence of my honest convictions. * Page; in this journal, March, 1893. 25 Let us, then, at least reform our methods of teaching,-but in practice, not in theory. Let us follow the laudable examples set forth by the University of Pennsylvania, Harvard University, the University of Michigan, and one or two more of our lead- ing medical schools. by establishing a four years' course and prolonging each scholastic year to at least nine months. And let the requirements for admission of students and for graduation be of as high a standard as the subject of medical instruc- tion really demands. It will not be very long, 1 trust, before the University of Texas (destined, on account of its thorough organi- zation and encouraging support, to become the medical college of the South), shall follow the footsteps of its sister institutions of the North, and establish the four-yearcurriculum. In this connection I wonder whether the agreement subscribed to recently at Louis- ville by the Association of Southern Medi- cal Colleges, will hold good in the future ? On the other hand, let us wage war merci- lessly. not only upon the quack-nostrum, but also upon the enemies of medical ethics. Let us not cease in our work for honesty, right, and truth. Let us not yield to profes- sional anarchy and "patent-medicine" traf- fic. Let not dismay enter our individual hearts or invade our ranks. We must labor, we must tight to the bitter end. and victory shall surely triumph over an unjust cause, truth over error, science over ignorance and charlatanism, principle over dishonesty. A writer, whose name I cannot report just now. has well said that "there is no quack- ery in medicine, religion, or politics which may not impose, even on a powerful mind, when such a mind is disordered by pain or 26 fear.'- Let us not, then, even falter in the struggle until these quacks, these ene- mies of health, these professional syco- phants and apostates (and to follow the brilliant thought of a recent medical writer [*] referring to theory and science), shall lie powerless before the standard of honest physicians "like strangled snakes around the cradle of Hercules !" Galveston, Tex.; 1320 Ave. E * Clopton, Daniel's Texas Medical Journal, March, 1893. 27 SEVENTH YEAR. $2.00 per year. American Medieo=Surgical Bulletin A SEMI-MONTHLY JOURNAL OF PRACTICE AND SCIENCE. Issued on the 1st and 15th of each month. THE BULLETIN PUBLISHING COMPANY, 73 William Street, N. Y. EDITORIAL STAFF. WILLIAM HENRY PORTER, M.D., Chief Editor. SAMUEL LLOYD, M.D., Department of Surgery. WILLIAM FANKHAUSER, M.D., Department of Materia Medica and Therapeutics. ADOLPH ZEH, M.D., Pathology and General Medicine. WILLIAM C. GUTH, M.D., Pathology and General Medicine. GEORGE G. VAN SCHAICK, M.D., Pathology and Clinical Medicine. W. TRAVIS GIBB, M.D., Gynecology. GUSTAV A KLETZSCH, M.D., Gynecology. J. CLIFTON EDGAR, M.D., Obstetrical Surgery. 1. S. SOUTHWORTH, M.D., Pediatrics. WILLIAM OLIVER MOORE, M.D. Ophthalmology and Otology. FREDERICK PETERSON, M.D., Associate Editor. J. RIDDLE GOFFE, M.D., Department of Obstetrics, Gynecology and Pediatrics. ADOLPH BARON, M.D., Diseases of Children. HENRY F. QUACKENBOS, M.D., General Medicine. T. HALSTED MYERS, M.D., Orthopedic Surgery. GEORGE THOMAS JACKSON, M.D., Dermatology. WILLIAM B. COLEY, M.D., General Surgery. JAMES E. NEWCOMB, M.D., Laryngi >logy. GEORGE K. SWINBURNE, M.D., Genito-Urinary Surgery. HENRY T. BROOKS. M.D., Bacteriology.