diplomas therefore immediately arose, and the supply was soon fully equal to the demand. Had it not been for the energetic efforts of the Illinois State board of health, to whom great credit should be given for exposing at least ten of these bogus colleges, there would no doubt have been many others in existence. But notwithstanding the efforts to weed out all diplomas of fraudulent schools they still find a ready market, for although it has been repeatedly shown how easily a diploma can be obtained from a "legally chartered school," yet the legislatures are slow to act, and it does not fall within the province of any particular one to have the law changed, and the medical profession especially can not well make the effort lest a charge of selfishness be brought against them. Even when the venders of bogus diplomas are brought into the courts and fined they only engage in the business more assiduously than ever in order to recover the amounts they have lost. "Carey has been twice arrested, convicted, and fined for practicing medicine illegally, nevertheless his diplomas are recognized in Washington, Idaho, and elsewhere as those of a legally chartered institution, and persons are practicing thereon." A hardware dealer in Buffalo, who had never spent an hour in the study of medicine, received by express his medical diploma, dated May 27, 1889, paying for it $60 on delivery. These bogus diplomas are found in all the States allowing practice on a diploma from a legally chartered medical school, and they are not even confined to this country, but find their way across the Atlantic. Complaint has more than once been made to the National Government by the European authorities of persons seeking practice on the strength of fraudulent American diplomas. It is probable that since the medical colleges are all lengthening their courses and adopting other restrictive measures, there will be a greater demand than ever for diplomas from "legally chartered medical schools."

SPRING COURSES OF LECTURES.

A few years ago the catalogues of nearly all medical schools spoke particularly of spring courses of lectures, and of the advantages students might derive from them. Now there is very little said on the subject. At that time the length of the annual session was only four or five months, and it was a common occurrence even then for first-year students to leave a month or two before the close of the session. Many institutions recognized the importance of longer sessions, and endeavored to remedy the matter by having a complementary session in the spring or fall, but notwithstanding the efforts made to get students to attend them, the number was always insignificant. A more effective method has therefore been instituted. Quite a number of institutions have lengthened the regular annual course to six or seven months, and some to eight or nine months, and the students not in the graduating class are required to remain till the close of the session before they can receive the certificate of a year's attendance. Consequently these colleges no longer have any complementary course, although the students have the privilege of remaining during the summer and attending the clinics if they so desire, but this is scarcely advisable after a long medical session. In answer to the question asking the number of weeks in the spring course, fifty-five medical schools state that they have no spring course, while only twenty-two answer affirmatively; the remaining schools do not answer at all, but very probably have no spring course.

STUDY UNDER A PRECEPTOR.

A few years ago, when nearly all medical colleges had a course of only two years of four or five months, it was generally stated in the catalogues that the student would be required to spend one year under a preceptor before he could matriculate; and this would have been of much value to him if it was spent under proper direction and attention; but unfortunately those physicians who were most competent to

Rep. Ill. Board of Health, p. 140.

direct his work were generally so engrossed with other duties that they had little time to devote to the medical student. The latter soon recognized the fact that his time was not being well spent, and that he must look after his own interests; consequently he usually spent only a few months, or perhaps weeks, in the study of anatomy, aided only by a few bones which had been hidden away in his preceptor's office. He then went to some medical college where he felt confident he could complete the course in a brief period, registered his name, age, and residence, and the name of his preceptor, paid his matriculation fee, and began to attend the same lectures as those who were soon to complete the course, He soon recognized, however, that he labored under difficulties, for he was nonplussed at the terms spondylolisthesis, symphyseotomy, colporraphy, oöphorectomy, sponge tents, etc., but when he spoke of it to his fellow-students they allayed all fears by telling him he would hear exactly the same thing the next year and would then understand it.

Now that the medical schools have adopted graded courses of three and four years, and the student is led along in his work in an orderly and systematic manner, he is no longer required to spend any time under a preceptor, for it is well known that his time could be far better employed at the institution; in fact, the time in a preceptor's office is wasted. "According to Dr. N. S. Davis it (reading medicine in a doctor's office) consisted in 1877 in little more than the registry of the student's name in the doctor's office, permission to read the books of his library, or not, as he chose, and the giving of a certificate of time of study for the student to take to the medical college when he expected to graduate."

CLINICAL INSTRUCTION.

Although the State governments and municipalities render very little assistance directly to medical education, yet indirectly very much is done by city governments and charitable citizens, an aid the lack of which would be serious indeed, but one which is not yet fully utilized. How difficult would be medical instruction without hospitals to furnish illustrations of the various diseases; and especially difficult would it be to give instruction in surgery. It would be the written description of a steamboat to a boy, instead of placing him on the wharf where he might see it with his eyes instead of having to build it up with his brain. The catalogues of medical institutions almost without exception call particular attention to the hospital advantages which they possess, indicating how important it is that the student enjoy full clinical opportunities. These hospitals have sometimes been established by the munificence of wealthy individuals, frequently as memorials of relatives or friends. Municipalities often establish them, and when their great usefulness is made apparent to the public, friends spring up to make known their claims, and they meet with the success so evidently merited. Every large city now has one or more of these institutions ready to receive and carefully attend the indigent sick and those suffering from accidental injuries. The advantages of treatment in a large hospital possessing all necessary appliances and accommodations arranged for constant use, and in furnishing well-trained nurses, are so great that many persons of ample means prefer to be treated there rather than at home. But to the poor, who can barely provide common food and shelter when in health, and whose domestic environment is frequently such as to induce disease instead of warding it off, the hospital comes as a great blessing, furnishing proper diet, the advice of skillful and experienced physicians, and attendance of trained nurses; and the only compensation asked of them is that young men and women whose work in life will be to ameliorate suffering and cure disease shall be permitted to observe the symptoms characteristic of different diseases, so that they may afterwards be able to recognize them at a glance and institute proper treatment at the outset of disease. No medical student can properly enter upon the practice of his profession until he has had this clinical teaching, for it is a knowledge which can not be obtained from books and lectures. All medical colleges make special efforts to provide for their students full instruction of this kind.

But since the courses in medical colleges have been raised to three and four years and the sessions lengthened to eight and nine months the schools need other assistance than that derived from clinical instruction in the hospitals; for, notwithstanding the great value of this instruction, it is not a source of revenue at all. The schools should not be left to depend upon tuition fees for support. This fact is becoming known to men of wealth, and some institutions are receiving substantial assistance from them.

Mr. William Deering, a wealthy Chicago, manufacturer, has given $50,000 to the trustees of the Northwestern University, to endow a chair in honor of Dr. N. S. Davis, in the medical department of the university-the old Chicago Medical College, of which Dr. Davis was the founder.

The Harvard medical school received a bequest in 1894 valued at $50,000, under the will of the late Rev. W. C. Moseley, of Newburyport.

The New York Homeopathic Medical College received from the estate of Mr. William Ogden $50,000.

The medical department of the University of Pennsylvania received $50,000 from Dr. William Pepper when resigning his position as provost of the university.

STUDENTS HAVING DEGREES.

It would be of interest to know how the percentage of medical students having degrees in arts or science at the present time compares with the number of such students some years ago, especially since we find the secondary schools constantly increasing the amount of work required of their students and consequently raising the age at which it can be completed; while, on the other hand, the medical schools are all adopting courses of three or four years and at the same time becoming much more rigid in the requirements for matriculation. To determine with any accuracy the number of medical students having degrees in arts or sciences is a difficult matter, for only a few medical schools keep an accurate record of this item. Harvard Medical College is one of the few institutions which keep this record. In it the decrease in the number of graduate students since 1884 has been remarkable. The figures are as follows:

Here we find that since the year 1884, with one exception, there has been a uniform decrease. The per cent of students holding degrees in Harvard medical school would no doubt compare quite favorably with the number in any other school, and since it is about to add a fourth year to its course the proportion of graduate students will probably be diminished still further.

Medical graduates would doubtless be well qualified for their work if they first completed the entire secondary school course, which President Eliot places at about the eighteenth or nineteenth year; then a college course at 23 and the medical at 26 years of age, or at 27 in those schools which require four years; and allowing them only three years for hospital experience and in which to get located and a practice started, such students might be expected to become self-supporting at 30 years of age. No allowance is made here for the loss of a year or two by failure to reach the required standard at any time, or on account of sickness, or other reason, but it is a steady, nonintermittent course, and one which needs to be sustained by a well-filled purse. At a recent congress of American physicians and surgeons a member claimed that the medical student should have the A. B. degree, requiring four years; then he

should spend four years in a medical school, one year in a hospital, and one year in a medical school in Europe-making ten years in all. Dr. P. S. Connor, of Cincinnati, argued that it would be unjust to insist upon all students that they should first be in possession of the A. B. degree, and then possibly have to practice at some country crossroads where the people around were unable to speak a single sentence correctly. However, to prescribe a course of training is one thing; to have it followed is another. To make it a requirement of all medical students that they should take the course mentioned above, requiring ten years for completion and only to be finished after 30 years of age, would be to demand what is impracticable. Not only would many students be prevented from taking such a course from financial reasons, and others claim that their prospective income in rural districts would not justify it, but there are also some educators who hold that there should be a better adjustment of the collegiate and professional courses-that the collegiate student should have better opportunities for electing studies preparatory to his professional work, or that his professional course should help constitute the requirements for an academic degree. The latter plan has been adopted by a few institutions. But in objection to this the question may be asked, What special reason is there why the practitioner of medicine should receive an academic degree at all if he can not obtain it in the regular way? If he is not to receive the training and knowledge which the collegiate course is designed to give, then the degree would be misleading and deceptive and therefore objectionable; although it may be said that his medical training develops his mental faculties in the same way as collegiate studies, it is answered that he receives the M. D. degree for the completion of the medical course and that it should not entitle him to double distinction. If so, why should not the medical student take an extended course in purely medical education and then receive the three degrees, A. B., Ph. D., and M. D.? There would be one advantage in this: he would not spend one-half his life preparing for the other half. He could complete his secondary course at 18 or 19 years of age, his medical course at 25 or 26, and still be able to enter upon the practice of his profession with honors heaped upon him. Another plan has also been adopted by some institutions to enable medical students to enter earlier upon the practice of their profession. In about one-fourth the medical schools of the United States students who are graduates in arts or science are allowed to enter upon the second year of the medical course, thus completing the course one year earlier than nongraduates.

"The average age of students who enter the Harvard academic department has been gradually rising during the whole of this century, until it has reached nearly 19 years. The student who enters the medical school, therefore, finds himself just beginning the preparation of the real work of his life at an age when many of his contemporaries are already engaged in the productive work of their professions. In Germany the best class of students begin their professional studies at a little earlier age than that at which our young men enter Harvard College. As the course of study leading to the degree of doctor of medicine lasts five years, it follows that the German physician is ready to begin practice before he is 234 years old.”1 Says President Eliot in his report of 1892-93:

"The professional schools are demanding longer and longer periods of study; and this demand, coupled with the improvement in the secondary schools, makes it more and more natural, and for young men of small me ans even necessary, to go direct from secondary schools to professional schools."

Here it seems that the young men, when they find it necessary to curtail the time required, have omitted or abbreviated the college course, holding that their early training should be full and accurate, a good foundation, but that as their professional attainment will form the basis of their lifework and determine its success, it should be the last to be abridged.

Dr. J. C. Warren.

In considering the subject of medical education it is well to remember that all students can not be expected to pursue the same stereotyped course of study; in some cases the limitations of age or of finances would compel the student to seek the nearest entrance to the practice of medicine, while in other cases the student would be able and desire to obtain first a full general education and then to spare neither time nor money in obtaining a thorough and accurate medical training, so that he would be able to practice his profession with that satisfaction to himself which only skillful training can furnish. There must of necessity be two standards of medical education; a minimum standard, to which all students are required to attain, and a maximum or ideal standard, to which all students should desire to attain if possible.

The first simply requires that the student shall have received a full secondary or high school education, then an attendance upon three full courses of lectures, and the passing of an examination in each branch of study. This course will be taken by those whose age or financial condition prevents the possibility of a more extended training.

The ideal course is the one mentioned on a preceding page, a full secondary education by 19 years of age, the completion of a regular four years' collegiate course by 23, then four years in a medical college and one or two years in a hospital, the student not beginning practice until 30 years of age. Of course many students can not take this ideal course, but there are many who will, and especially will those who expect to seek practice in the large cities endeavor to comply with it. Those schools whose graduates go mainly to rural districts and villages will probably receive the larger number of students taking a short course, while other schools possessing large endowment funds, and independent of tuition fees, especially those schools which constitute departments in the old and well-established universities where can be found every appliance for complete laboratory investigation, will be sought by those students desiring to receive the fullest medical training; while the large body of medical students will seek an intermediate plane between the two extremes, but each year approaching nearer to the highest standard. Of course the number of students pursuing the extensive course above mentioned is not large at present, but as the country becomes more densely populated and as the candidates for professional honors are increasing rapidly, only those who have received full preparation can long expect to compete successfully for medical practice.

WOMEN IN THE PRACTICE OF MEDICINE.

It is well known that in America woman has a wider, more independent, and more remunerative sphere of work than in any other part of the globe. In fact, there are but few callings here in which she has not at least a few representatives. Although there is a greater demand here for "woman's rights" and probably more conventions are held to secure them than in any other part of the world, still it is to America that they ever look for the nearest approach to the ideal condition of woman. The greater freedom has whetted the appetite for still wider fields. But when we consider that some of the most skillful and eminent authorities on medical subjects have been women, we need not be surprised that they are still engaged in the work. When a Lachapelle and a Boivin have gone before, their followers are sure to be coming after. During the year 1892-93 there were 1,302 women enrolled as students in the various medical schools of the United States, including 61 students not reported in time to be tabulated. Women were enrolled in 61 medical schools as follows: