MEDICAL SCHOOL A DEVELOPMENT OF SMALL BEGINNINGS

Assistant Dean of the Medical School. This is the tenth of a series of articles which is being published by the Crimson, written about the work of the various graduate schools by their respective Deans or leading professors.

The Harvard Medical School was started as a branch of the University in 1782, at which time three professorships were established: one in Anatomy and Surgery, one in the Theory and Practice of Physics, and one in Chemistry and Materia Mediea.

The first degrees in Medicine were conferred in 1788, but at that time the degree was that of Bachelor of Medicine. In 1811 the Degree of Doctor of Medicine was established. At this period the course of study was far from systematic and consisted of two short courses of lectures given by the three professors, the students gaining their practical experience essentially as apprentices either to their professors or to certain other physicians who were chosen for this purpose. At this time, also, the instruction in medicine was given in Cambridge. In 1815, however, the School was transferred to Boston in order to secure the much greater clinical advantages to be found there. After occupying several locations in what is now the down-town section of Boston, the Medical School was moved in 1906 to its present location on Longwood avenue.

Affiliation With Hospitals

In the present group of Medical School buildings there is one set apart for administrative purposes, which also contains the Medical School Library and the Warren Anatomical Museum. In addition to this there are four buildings, separated by corridors, in which are housed the various departments of the School having to do with teaching and research in the fundamental branches. These provide, in a general way, only for the first two years of work. The last two years are largely clinical and the greater part of this instruction is given at the various hospitals associated with the Medical School. The School is very closely affiliated with the Massachusetts General Hospital, the Boston City Hospital, the Peter Bent Brigham Hospital, and a group of other hospitals, making available exceptional clinical facilities. It is interesting to contrast the unusually excellent facilities which the School now has for teaching medicine with those which were available at the time the School was started. The buildings now occupy eleven acres of ground and the teaching staff numbers 220. When the School began, the first lectures were given in the basement of Harvard Hall, and afterwards in Holden Chapel, by three instructors.

In 1782 the knowledge of medical science was very primitive, as is illustrated by the fact that the whole course of systematic study occupied a less number of weeks then than it does months now. In the two courses required for a degree the work was the same, the second course merely giving the student an opportunity to repeat the instruction of the first together with the beginners in medical study. About 1870 the course of study was extended to three years, the classes were separated and the work was graded, so that preparatory subjects were taught first and subsequently the more advanced subjects were introduced. About 1890 a four-year graded course of study was adopted.

Develops With Science

The preparation for the study of medicine in the earlier history, not only of this School but also of all other medical schools was,--as perhaps befitted the type of medical instruction given, exceedingly elementary. The science of medicine was in a relatively undeveloped state and was not dependent upon the sciences in any such degree as it is today. With the development, however, of our knowledge of the sciences and of diseases, the study of medicine grew more difficult, new subjects were added to the curriculum, and it became more and more necessary for students applying for admission to have additional college training. In 1900 a bachelor's degree was first required of all students entering upon the study of medicine at Harvard, although the majority of the matriculants offered degrees prior to this. This standard has not been changed, except that since 1900 students who have had a least two years of work in an approved college and who at the same time have maintained a high scholastic standing may be admitted.

The science requirements have been gradually increased to keep pace with the advancement in medical sciences and to enable the student to approach the subjects of the medical curriculum with an elementary knowledge of scientific terminology and of scientific methods. Prior to this the Medical School found it necessary to include even in the second year of the two-year course, subjects which are now recognized as general scientific premedical subjects. Thus for the year 1864-1865 the course of study in the second year included the elements of botany and a course in zoology. At the present time all applicants for admission must present evidence that they have had a course in English such as is required of all candidates for the bachelor's degree, and a reading knowledge of French or German. The specific minimum science requirements are a year's college credit in general chemistry, physics and biology, and a half-year's credit in organic chemistry. Experience has clearly shown that it is impossible to teach medicine satisfactorily without this preliminary knowledge of the sciences. If this is not gained before beginning medical study it would be necessary to give instruction in these subjects as part of the medical school curriculum, as was the case in 1865. English medical schools, which do not require these subjects before admission but introduce them into the curriculum grant degrees only after six years of study.

Few Elective Studies Allowed

The course of study in the Medical School is almost completely restricted as to choice of subjects. In the thirty-two months' work necessary to secure a degree only one and a half months may be filled with elective subjects. This is so unlike the usual college curriculum that such a state of affairs may seem undesirable. However, the study of medicine is progressive: one cannot be expected to study anatomy efficiently without some knowledge of zoology; one does no better in physiology and pathology without anatomy; one can have little conception of the way drugs act in disease without physiology, pathology and bio-chemistry; and one can have no clear conception of clinical medicine and surgery without a previous knowledge of all of the foregoing subjects.

The medical student thus finds his time wholly occupied from nine until five or six o'clock with a fixed routine of lecture and laboratory, though chiefly laboratory, and this persists for two years,--, although in second half of the second year the laboratory exercise begins to yield to the hospital and the patient. But now the attention is merely turned from test-tube and laboratory tissue to another object of study, in which the student becomes an observer of living man rather than of the lower animals or of dissection and microscopic pathology. Students usually consider that their most difficult years are behind them when they more definitely enter upon the work of the third and fourth years. The hours during the whole day are still accounted for in the curriculum by some occupation; study periods exist only as a privilege of the evening hours, just as they did in the first two years; but in the clinical years the amount of subject matter to be recognized becomes less,--the work with patients has its fascinations and the studies of the laboratory years, involving laboratory technic, have their easily seen application and are on this account less arduous. The lecture persists in the third year in the afternoons,--the mornings are filled with hospital duties, examining patients,--but in the fourth year the lectures practically cease and the student finds himself assigned for varying periods of two to eight weeks to hospitals. This is the so-called "clinical clerk" system, comparatively recently introduced as a method of clinical instruction. It may be said to be an elaboration merely of the method which assigned the student to some practitioner for his experience; now he is assigned to a hospital and serves his apprenticeship under the direction of the hospital staff.

Introduces Harvard System

The plan of completing single or related subjects before taking up others was introduced by this School. This is sometimes spoken of as the "block system" and elsewhere as the "Harvard system" and has been used in other medical schools. It seems to be an effective method of study, with advantages for the student, who has only one or two subjects to carry at a time, and for the instructor, who has a part of each year free for research. There are some disadvantages, and certain modifications may be introduced.

In addition to the regular course which prepares for the practice of medicine, the Medical School offers excellent opportunities for graduate work along both fundamental and clinical lines. Higher academic degrees are offered, either through the Medical Faculty or through the Graduate School of Arts and Sciences for work in the fundamental medical sciences, as for example in anatomy, physiology and biochemistry. The preparation for the Doctor of Philosophy degree is the same as that required for this Degree as recommended by the Faculty of Arts and Sciences. The degree of Doctor of Medical Science is offered to regular matricu- lants in the medical School who have had an Arts or Science degree and who during their first two years in medicine maintain honor grades. The degree may be given on two additional years' work in some particular field in medical science. A doctorate in Public Health is offered to graduates in medicine for at least one year's work in addition to the four years in medicine.

Special opportunities are available in fourth-year students and to graduates in medicine in the special field of Industrial Medicine and Hygiene. This work gives excellent training in the medical problems which are inherent in industry but the work done does not lead to a special degree.

In the division of Courses for Graduates unusual opportunity is given to graduate physicians who may wish to specialize along either fundamental or clinical lines but without reference to a higher degree. In large measure the work is elected by physicians who wish to review medical progress usually in a clinical field. The work selected may occupy no more than two weeks or a month though it may less frequently be extended over a period of several months.

This, in brief, gives one a general idea of the development of the Medical School from very small beginnings to the present School with its exceptional advantages in preparing students for the practice of medicine and for research. There has also been outlined some of the conditions surrounding the study of medicine. It may be especially pointed out that the legal status of medical practice, as fixed by the several States, has kept pace with medical education and that the conditions upon which the medical degree is granted are also fixed by legal enactments. On this account they may not be waived even in the very exceptional case in which some minor defect in a student's preparation would probably not interfere with his ultimate success