Popular Science Monthly/Volume 75/July 1909/The Preparation for the Study of Medicine

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THE PREPARATION FOR THE STUDY OF MEDICINE
By FREDERIC T. LEWIS, M.D.

HARVARD MEDICAL SCHOOL

Those who intend to study medicine are advised by the Medical Faculty to pay special attention to the study of Natural History, Chemistry, Physics, and the French and German languages, while in College.

This sentence of advice is contained in the catalogue of Harvard University issued in 1874. Thirty-two years later, at the dedication of the new buildings, it found more vigorous expression in the address of President Eliot.

Medical students should therefore have studied zoology and botany before beginning the study of medicine, and should have acquired some skill in the use of the scalpel and the microscope. It is absurd that anybody should begin with the human body the practise of dissection or of surgery; and, furthermore, it is wholly irrational that any young man who means to be a physician should not have mastered the elements of biology, chemistry and physics years before he enters a medical school. The mental constitution of the physician is essentially that of the naturalist; and the tastes and capacities of the naturalist reveal themselves, and, indeed, demand satisfaction long before twenty-one years of age, which is a good age for entering a medical school.

It is here assumed that these special studies form a part of the work for a bachelor's degree in arts or science, which the student has obtained before beginning his medical studies. Two groups of competent teachers of medicine dissent from this advice—those who believe that the bachelor's degree is unnecessary, since two years of special college work are sufficient; and those who consider that the degree should be required, but as a result of studies in literature, art, history and philosophy, rather than in biological science. Some physicians, therefore, send their sons to college with the advice, "Study nothing which bears upon medicine: you will have enough of that later"; and of those who have followed these directions, some have succeeded notably, both as practitioners and scientists. Because of this difference of opinion, an explanation of the relation of certain college courses to the study of medicine may be helpful to students.[1]

Zoology.—It has long been recognized by the public that zoology is not medicine. When Harvey studied the circulation of the blood, "he fell mightily in his practice." "Had anatomists only been as conversant with the dissection of the lower animals as they are with that of the human body," he wrote in 1628, "the matters that have hitherto kept them in a perplexity of doubt would, in my opinion, have met them freed from every kind of difficulty." However, the public was unwilling to admit that this was a proper occupation for a physician, and in 1711 Addison wrote:

There are innumerable retainers to physic who, for want of other patients, amuse themselves with the stifling of cats in an air-pump, cutting up dogs alive, or impaling of insects on the point of a needle for microscopical observations; besides those that are employed in the gathering of weeds, and the chase of butterflies; not to mention the cockle-shell-merchants and spider-catchers.

Huxley admits that he really has never been able to learn exactly why a physician is expected to know zoology, and writes:

If I had to choose between two physicians—one who did not know whether a whale is a fish or not, and could not tell gentian from ginger, but did understand the applications of the institutes of medicine to his art; while the other, like Talleyrand's doctor, "knew everything, even a little physic"—with all my love for breadth of culture, I should assuredly consult the former.

This is a part of Huxley's argument for excluding comparative anatomy and botany from the curriculum of medical schools. As a preliminary training for the physician he approved of them, for later he wrote:

There can be no doubt that the future of pathology and of therapeutics, and, therefore, of practical medicine, depends upon the extent to which those who occupy themselves with these subjects are trained in the methods and impregnated with the fundamental truths of biology.

These fundamental truths are taught in college. In a general course in zoology the student should learn what an animal is, and into what great classes animals are divided. Representatives of these classes should be studied in the laboratory, and the probable relationship of one class to another, and of man to other mammals, should be considered.

The biological methods which the student should have learned in college include dissection and microscopic technic. It requires but little imagination to compare the work of two students beginning human dissection—one producing a set of instruments which he has already used, and proceeding to follow in minute detail structures similar to those which he has previously studied in the cat or rabbit; the other attempting to learn the general plan of the body and how to dissect, while he is supposed to be mastering the minutiae of human anatomy. Practise in the dissection of vertebrates and a general knowledge of their bones, muscles, nerves, vessels and organs are essential for good work in human anatomy.

Similarly in microscopic anatomy no student can afford to try to learn how to handle a microscope while his companions, by its use, are making rapid progress in the study of human tissues. The student who has learned how to cut and stain sections for microscopic examination will be at considerable advantage. Some medical schools give courses in this "microscopic technic," but the time is better spent in studying sections than in preparing them. It has been found by Professor Waite that the better medical schools afford less time for this subject than inferior schools. A college course in which the chief tissues are prepared and studied is therefore recommended.

Embryology, which deals with the development of the body from the egg-cell to the adult organism, is divisible into two parts. That which deals with the early stages and chiefly with lower vertebrates and the invertebrates, has grown up in zoological laboratories. That which deals with the formation of the organs and the nervous, vascular and muscular systems in mammals, and with the development of the membranes in man, has been studied especially in medical schools. It is this portion of the subject which is an invaluable aid in understanding anatomy, histology and pathology, and its study should precede the medical school work in these subjects. Unless this is possible in the medical school which the student is to attend, college work in embryology should be considered. Thus in the Medical Department of Johns Hopkins University, where the teachers of anatomy are distinguished for their researches in embryology, no medical school work in this subject is required; a college course is recommended.

Special courses in the anatomy of the nervous system are given both in college and in the medical school, though generally from different standpoints. The subject is so intricate that the college work will be found of considerable assistance.

Occasionally a college announces a course on some one group of animals, such as the protozoa, insects, or worms, as desirable in preparation for medicine. The knowledge of these groups obtained from the general course should be sufficient for a practitioner. The theoretical and statistical study of variation and heredity has only a general interest for medical students, and courses in systematic zoology are of still less importance.

The value of zoological courses as a preparation for anatomy and histology is shown in the following table, based upon the marks of the class which entered the Harvard Medical School in 1907. The table shows the number of men obtaining the grades A to E, A being the highest (90-100 per cent.), and E failure to pass (less than 50 per cent.).

Anatomy Histology
Students who have taken in zoology— a b c d e av.% a b c d e av.%
More than two courses 0 4 7 2 1 69 5 6 3 0 0 85
Two courses 0 1 9 7 3 53 3 6 9 2 0 77
From one half to two courses 0 0 8 8 10 49 3 4 12 5 2 68
No courses 0 0 4 4 7 45 0 2 5 2 6 52

From this table it is seen that the more zoology the student has taken the better his grade in anatomy and histology. As already stated, however, the practitioner must not specialize in anatomy, and the only college courses which it seems wise to recommend to all candidates for the medical school are as follows: General zoology, dissection of vertebrates, practise in the use of the microscope and in microscopic technic, elementary embryology.

Botany.—The study of plants is clearly less intimately related to medicine than the study of animals. The peculiar importance of the bacteria, however, makes a laboratory half-course in the morphology of plants, with special reference to the fungi, very desirable. This will give the student a more comprehensive idea of these organisms than can be obtained in a medical school; it will show their relation to yeasts, moulds and other low plants, some of which are of medical importance. At the same time the student will be trained in making accurate observations of natural phenomena and in reasoning on the basis of what he has himself observed. This ability, which may be cultivated both in botanical and zoological courses, is of the utmost value to the physician.

The study of the flowering plants was once intimately associated with medicine; and the array of drugs still used, which are derived from plants, would seem to make it important. The teacher of pharmacology, however, is not seeking students familiar with medicinal foxgloves and white poppies, but desires those well trained in chemistry. The botany of flowering plants is, therefore, not recommended.

Geology.—Geology appeals irresistibly to a "naturalist," but has little value for the physician. The air, soil and water are discussed in courses on hygiene, and in connection with drainage problems and water supplies geological knowledge is important. This, however, is not a sufficient reason for recommending geology.

Chemistry.—The study of chemistry in preparation for the work of a medical school is of great importance. Accordingly both a considerable amount of theoretical chemistry and not a little laboratory work are desirable.

General descriptive inorganic chemistry and qualitative analysis are a necessary introduction to all chemical study, and must come first in any plan of chemical training; they serve to familiarize the student with the characteristics of simple chemical processes and substances, and with the more elementary chemical theories. These courses must be followed by at least a brief course in organic chemistry, because that subject, with its unique and highly important theoretical development, is absolutely essential to an understanding of certain physiological processes; and it is of such a nature that it can be assimiliated, even in its most simple form, only after a considerable period of time has been devoted to its study.

Quantitative analysis is important in another way. It gives valuable training to the hand and eye, and develops a particular form of accuracy which is required in biochemical work, and which enables the student to interpret justly the work of others.

Physical chemistry to-day contains a mass of material of the highest importance in all branches of biological science. An elementary acquaintance with it is essential for understanding such subjects as the physiology of the blood and the functional activity of the kidney and lung, since it explains the nature of solutions and the conditions governing the passage of substances through membranes.

Many medical schools require for entrance, work in general chemistry and qualitative analysis, and a few call for organic chemistry. These are essential. A half course in quantitative analysis and a half course in physical chemistry are desirable.

Physics.—Many students who are careful to take courses in biology and chemistry in preparation for medicine neglect physics entirely, or think that the elementary work done for admission to college is sufficient. A thorough college course, with laboratory work consisting of accurate measurements, is necessary for certain branches of medical practise and for the fundamental study, physiology. Physics is related to physiology in many ways. In studying muscular contraction the elements that constitute mechanical work and the action of levers should be known. For the study of the circulation it is necessary to understand the principles of hydraulics and the transmission of pressure in fluids; the laws of osmosis (studied in physical chemistry) aid in interpreting the diffusion of fluids between vessels and tissues. In considering the constructive and destructive changes in the body, the principle of the conservation of energy should be kept constantly in mind. To understand the maintenance of normal temperature and the changes in fever, some knowledge of the physics of heat is needed. An understanding of electricity is necessary for explaining the electrical changes produced in living tissues, and in order to stimulate tissues experimentally so that their activities may be studied. Electrical stimulation is used in treating certain diseases, and the physiological laboratory contains many pieces of electrical apparatus. The importance of the X-ray in medicine is sufficiently well known. In order to understand vision and the application of lenses to the eye, the principles of reflection and refraction must be understood. The nature of sound and its transmission through various media is similarly related to the physiology of hearing. It is a serious mistake to begin work in a modern laboratory of physiology before taking a thorough college course in general physics.

Mathematics.—The value of mathematics for medicine is indirect, since it is required chiefly in preparation for physics. The student taking such a course in physics as has been recommended, should have had algebra, plane geometry and plane trigonometry. These courses come normally within the province of any good high school program. For advanced work in physics, solid geometry and higher mathematics are needed. For the benefit of medical students the mathematical requirement in certain special courses in physics is made as light as possible. It may be noted, however, that in the college course for future medical students outlined by Johns Hopkins University, the study of mathematics extends through two years.

Psychology.—Although psychology is a college study directly related to medicine, it appears that no medical school has yet required it for admission. A course in psychology often begins with a summary account of the nervous system and sense organs, and proceeds with the study of the states of consciousness. It discusses sensations and the nature of pain, and deals with instincts, memory, habits and the will. It gives the student a good understanding of "treatment by suggestion" and is a foundation for the study of abnormal minds, especially of hallucinations, illusions and delusions. Some knowledge of child development and an insight into sexual instincts, neurasthenia and psychasthenia are afforded by such a course. It is important for parts of physiology, pediatrics and internal medicine, and particularly for neurology and psychiatry. A half-course in psychology is therefore recommended.

French and German.—Since much of the progress of medicine is recorded in French and German publications, it is desirable, and in several schools it is required, that students should be able to read both of these languages. A beginning should be made before entering college. Courses in general literature, with practise in writing and speaking, will be found more profitable than those which are restricted to reading scientific prose. The importance of French and German in medicine is indicated by the number of periodicals in these languages for which medical libraries subscribe. The figures for the scientific libraries at the Harvard Medical School and for the Boston Medical Library, which is used largely by practitioners, are as follows:

Subscriptions for Periodicals

English French German
Harvard Medical Libraries 110 35 109
Boston Medical Library 88 67 161
198 102 270

Since this medical literature should be at the command of students and practitioners, and is indispensable for investigators, it is necessary to be able to read both French and German.

Other Foreign Languages.—Although important medical articles are published in Italian, and to a less extent in Spanish and other modern European languages, they are not so numerous as to justify a study of these languages. Latin is required for admission to certain medical schools, "in order to enable the student the more rapidly to master scientific and medical nomenclature." The international anatomical nomenclature is now entirely Latin and many of its terms are employed as English words. It is, therefore, very desirable that a student of medicine should have studied Latin as a part of his preparation for college. Greek is of much less importance, although it has supplied many barbarous medical terms.

English.—Although some students believe that in an examination in anatomy they should be marked upon anatomy alone, and not upon English, this is impossible. Every examiner, as well as every intelligent patient, will judge of the physician, in part at least, by his manner of expression. In a lot of examination books which had been marked in the usual way, there were a few with the grade A, and in none of these was there an example of strikingly bad English. The first book of low grade (60 per cent.) which was taken up, contained the following statement:

Voluntary striated muscle, developed differently, than smooth and cardiac, that coming from mesenchyma, this from somite or segments, has a definite cell membrane sarcolemma, which gives off fibers, its nucleus is found at the periphery.

It is useless to assert that clear and well-ordered anatomical knowledge exists in a mind which can not express it.

The study of English literature in college is to be recommended not only for its utilitarian value, but as a source of recreation and diversion from specialized scientific studies. There may be a few medical students who need the advice which Holmes gave to the young practitioner: "Do not linger by the enchanted streams of literature," but many more should heed the warning—"Do not let your literary life become a memory—a reminiscence." Unfortunately there are those who enter medicine with nothing on which to found a literary reminiscence.

Drawing.—The principles of drawing are taught in connection with courses in the fine arts or in architecture. Accuracy of observation may be developed in such courses, for no sooner does one begin to draw or model an object than attention is called to many details otherwise overlooked. For this reason drawing is required in studying anatomy, especially microscopic anatomy, in certain medical schools; and inability to draw seems to many students a justification for deficiencies in these subjects. To be sure, their professors are often in a similar predicament: Ruskin says:

That Professor Tyndall is unable to draw anything as seen from anywhere, I observe to be a matter of much self-congratulation to him; such inability serving farther to establish the sense of his proud position as a man of science, above us poor artists who labor under the disadvantage of being able with some accuracy to see, and with some fidelity to represent, what we wish to talk about.

If a course in art can develop this ability, it should be considered by medical students. To perceive accurately is not only a source of great enjoyment in itself, but to a certain extent it is an aid to the practising physician. One medical school in the United States recommends drawing for admission, and another provides instruction in anatomical drawing as an elective course.[2]

College Physiology and Hygiene.—Some colleges offer courses in physiology which are dilute presentations of medical school work. Thus, in one course, the student may be taught something of human anatomy, physiology, hygiene and medical bacteriology, all of which may be useful for those who are not intending to study medicine. It is wholly undesirable for the medical student to take time from other college work for the sake of such courses.

The Value of Research.—Some teachers believe that the original investigation of a subject in science, since it compels the student to think for himself and to depend upon his own observations, is worth several regular courses as a preparation for medical study. Certain researches, moreover, are not difficult. A study of the variation in the number of rays in the daisy, or of spinal anomalies in the salamander, might be made by an undergraduate if specially taught for this purpose. Such researches, however, are generally at the expense of fundamental education, and "researchlings" are not good students of elementary subjects.

Summary of Recommendations.—In the preceding pages it has been recommended that the medical student should have studied Latin, French, German, mathematics, physics and drawing in preparation for college; and that in college he should elect courses in zoology, botany, chemistry, physics, psychology, English, French and German, since these studies will be of direct value in connection with his work in the medical school. Between two and three years will be required for the recommended studies, but some time will be free for philosophy, history and political economy. These subjects are named since they are the ones not already discussed which were formerly required for the bachelor's degree, and which are now considered by some to be an essential part of a good education. Three full years of college work which have included such courses as have been recommended, and which have led to the bachelor's degree, will be accepted as a good preparation by any medical school in the United States.

The Value of the Bachelor's Degree.—The value of the bachelor's degree for students of medicine is now generally recognized. A few medical schools require it and many recommend it. Students should, however, be warned against believing that the degree may be earned by two years of college work. This low standard, thinly disguised by the fact that the degree is not given the student until he has spent two years in the medical school, has been adopted by many colleges and is sometimes announced with considerable satisfaction, as follows:

The incalculable advantages of such a combination course must commend themselves at a glance, alike to would-be medical students who realize the value of an academic degree to the physician, and to candidates for an academic degree who contemplate a medical career and hesitate before the length of time demanded by its preparatory work.

Not only should protest be made against reducing the college work to two years, but much might be said in favor of four years, leading to the master's degree. In the Harvard Faculty of Medicine there are fifteen men who graduated from college since 1890. Two of these are doctors of philosophy; of the remaining thirteen doctors of medicine, six are masters of arts. The positions held by the six masters of arts and the seven bachelors of arts, respectively, are as follows:

a.m. a.b.
Professors 2
Assistant Professors 4 2
Demonstrators and Instructors 5

Since this list happens to include few practitioners, it may be noted that the college classes of '88-'90 supplied the faculty with six members, all practitioners; five of the six are masters of arts.

Not long ago, American medical schools received freely students with no college training. Scattered through the classes there were some who, without being required to do so, had obtained a college degree. The success of these men has been so notable that the requirements for admission are rapidly becoming more stringent. At Columbia University the effect of demanding one year of college work has been to eliminate that stratum of medical students described by Professor Wood as the submerged tenth.[3] Most of the good schools now require two years of college work, and the student is tempted to regard this as ample preparation.[4] The community meanwhile is seeking not younger but abler physicians. A shorter preparation than that which was obtained by many leading practitioners of the present generation is not likely to make their successors more efficient.

The Value of Scientific Preparation.—There are some physicians who believe that the preparation which has here been recommended produces scientists and not practitioners. It is clear, however, that a single course in physiology, even a very thorough one, does not make a physiologist. The professor of embryology who addressed the students who had just finished his course as "fellow embryologists" was greeted with a roar of laughter. Some of those who know that scientists are not produced by the medical school course still assert that it develops an undesirable type of scientific practitioner. A graduating class has recently been told that "At the bedside science is sometimes a hindrance." Scientific knowledge is often contrasted with common sense and sympathetic humanity, as if they were incompatible and the patient must choose between them. The medicinal effect of a merry heart, known since the time of Solomon, has been rediscovered with great eclat, and the physician whom Holmes described as having a smile "commonly reckoned as being worth five thousand dollars a year to him" has his successors. The character of a physician is unquestionably of great importance, yet medicine is not an art of which "haply we know somewhat more than we know." No condemnation is too severe for a physician who, without adequate knowledge of the medical sciences, attends his patient with self-confidence and a genial smile.

The college student may well be assured that the way to financial and professional success in medicine is through long and careful preparation. In this great pursuit he will not become narrow. He will develop what Dr. James Jackson long ago described as "a mind liberalized by scientific studies," If he loses a certain breadth of culture because of specialization, still, as Cardinal Newman has said, "the advantage of the community is nearly in inverse ratio with his own."

  1. In preparing this account, assistance has been received from Drs. W. B. Cannon, L. J. Henderson, W. C. Sabine, E. E. Southard and L. W. Williams.
  2. Since this was written, President Eliot has referred to the advantages of studying drawing in the preparatory schools, as follows: "A university student who enters on the subject of botany or zoology is really crippled unless he can draw. He will make much slower progress; and will not have the best means of recording what he sees. And yet it is only a small percentage of the young men who now come to Harvard College that have any capacity for drawing. They have never had any opportunity to acquire any artistic skill."—Address to Graduates of the Massachusetts Normal Art School, April, 1909.
  3. Professor Wood advocates a low entrance requirement in the following remarkable statement. "The poor man, who has neither time nor money for long preparation, can enter and compete on an equal footing with the children of the rich. . . . If he does not survive the first year, well and good, no great harm has been done. . . ."
  4. A caution against this has recently been published by the dean of the medical courses at the University of Chicago. He says: "No device for curtailing the amount of his preparation should be sought or advised for students who can go 'the whole road' (that is, obtain a regular course and medical degree) within the age limit of twenty-seven or twenty-eight." The announcement of the University of Chicago contains the italicized statement: "Every student should complete a four-years' college course before entering the Medical School if his age and other circumstances make it possible for him to do so."