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Medical Education: A Comparative Study. By ABRAHAM FLEXNER, New York, The Macmillan Company, 1925.
This is an invaluable work on a timely subject. It is timely because the more unconventionally-minded medical men are now asking whether, on the one hand, medical education is struggling under the burden of traditions evolved in the days when medicine was almost purely empiricism, or, on the other hand, whether we have not drifted into a system that attempts to make the poor neophyte into an anatomist, a physiologist, a chemist, a physicist, a pathologist, a physician and a surgeon instead of just a reasonably competent healer of the sick. Educators are criticizing both existing and projected policies; they are searching for some scheme whereby the student may learn how to profit by the advances achieved in the laboratory side of medicine and yet not have his poor head crammed with such a mass of data as no specialist nor general practitioner would ever try to retain. At such a time it is well to know just what schemes of teaching medicine there may be, what their history is and how they work out in practice. Flexner has provided just this information in regard to the systems of France, Germany, Great Britain, the United States, Canada, Holland, Belgium, Switzerland, Sweden and Denmark.
In general he distinguishes three main types. In France the student is an apprentice in a hospital designed primarily for treatment of the sick, adapted little or not at all for its teaching and neglecting the laboratory sciences fairly consistently. In Germany the teaching is done throughout in the University, whose clinics are as much a part of the University as are the laboratories for physics and chemistry and the clinicians whole time teachers rather than medical practitioners. In the English 'Hospital' system a certain compromise is reached and if the student attend one of the major Universities he gets a thorough training in the basic sciences and is then pitchforked into clinical work that may be inspired by quite different ideals and pursued by methods more empirical than 'scientific.' In the United States all kinds of mixtures exist from the disgraceful 'diploma mill' (now almost extinct) up to well organized schools of the University type. Further summary of the data presented would be out of place and futile. The book should be read. It suffices to say that the facts are presented with an extraordinary, even astounding, lack of bias. No trace of national prejudice is detectable.
Fitter material for a review is a discussion of the author's standpoint. No one, not suffering from a collecting mania, can work without having some programme, some Tendenz in mind. Flexner's ideals are manifest and avowed. The training of the medical student should be rational. First he should learn the 'normal' anatomy and physiology of the human body, being thoroughly grounded in physics and chemistry, and in the course of this instruction he should absorb the scientific attitude. 'Science for Flexner seems to be accurate observation, hypothesizing, experiment and the expression of data in quantitative form. That he so restricts the meaning of scientific method he would doubtless deny, yet it seems to be implicit in his viewpoint. Armed with knowledge of the normal the student should attack clinical problems, applying laboratory methods and resolved to be scientific. Every medical man should be an investigator. In order that disease should be studied and taught scientifically it is advisable or necessary that instructors should give all their time to the clinic undistracted by private practice. Flexner seems to adopt this programme as unquestionably the best.
At the present phase in the evolution of medicine it would be unsafe to dogmatize either in support or criticism of Flexner's ideals. But it may be allowable to question his assumptions. In the first place is not his conception of science too narrow? Fundamentally it means that the study of functions which cannot be expressed in physical or chemical terms is unprofitable. It is one exhibition of the materialistic philosophy which reached its climax about the turn of the century. With this inspiration laboratory methods have refined the diagnosis of many diseases and improved treatment in a few. On the other hand it has led to a deterioration in clinical acumen. The tendency is for the patient to become, in the mind of the laboratory clinician, a mere accumulation of organs and chemical reactions rather than an
improperly functioning individual. The Reviewer has frequently seen a clinician of the old school reach a correct diagnosis, using only eye, ear and hand, that was unattainable by distinguished 'scientific' physicians who had insensibly come to rely more on laboratory procedures than on direct and reasoned observation of disease. An enthusiastic member of a medical ‘unit' has given the Reviewer his opinion that 'whole time,' valuable as it may be for the investigation of certain aspects of pathology, is definitely inimical to the development of the highest degrees of clinical acumen. The tendency to lose sight of the individuality of the patient is an evil that will be recognized by the reader of this Journal without the emphasis of elaboration. There is no room for psychology in the laboratory concept of medicine.
Other objections may be raised against Flexner's ideal system. It is doubtful whether any but brilliant students are capable of the programme laid out for them. Who can learn all the mass of data presented in the basic sciences and have imagination to use them later? Again, it is questionable whether the normal form and function of the human body is ever truly learned except in comparison with other forms the huge subject of comparative anatomy-or in contrast with the abnormal. Before any subject is really learned it must have some meaning. Otherwise all that is gained is the capacity to reproduce dry bones of knowledge in examinations. Under Flexner's system the meanings guiding the correlation of data taught in introductory medical studies are those supplied by non-medical men. It matters not whether the anatomist or physiologist has a medical degree. Qua anatomist or physiologist his interests are not clinical. In consequence the student is apt to be taught as if his future were to lie in the laboratory rather than in the clinic. The brilliant student can escape suffocation in the flood of facts with which he is inundated, he can learn to think biologically and later begins to think medically. But it is doubtful whether more than a handful have this capacity. The average student studies medicine with the ambition of becoming a doctor. This means that he is interested in what he sees to have a bearing on the practice of medicine; other facts have for him a bearing only on examinations. Time spent in acquiring information for the placating of examiners is lost time and one wonders how much of the many years now demanded in preparation for a medical degree is consumed in such exercises.
Medicine is a study of human beings and can therefore never be reduced wholly to quantitative or material terms. If it could be, it could be largely learned in books and didactic lectures, the only practical experience being that necessary for acquisition of the technique of physical examination. Interestingly enough the tendency of the most 'scientific' medical education has been towards the elimination of personal experience. Flexner, while praising the German system for the solid foundation laid in the earlier years of training, deplores the preponderance given to demonstration by the professor of all the data about a patient, little opportunity being given to the student to learn about patients at close quarters. He does not realize that, psychologically, this is the corollary of the theory that the human body can be regarded as a machine. An engineer having learned his mechanics and become familiar with one machine can grasp completely the nature of another slightly different one without ever seeing it, being merely told about it by another engineer. If medicine and engineering were thus comparable the German system would certainly be the best.
J. T. MACCURDY.
Psychologie des Säuglings. VON DR SIEGFRIED BERNFELD. Vienna: Julius Springer. G.M. 12 unbound, 13.20 bound.
It is general knowledge that quite a large number of babies have been born since man began to chronicle his experiences; that the largest proportion of these babies have been carefully and tenderly observed by their mothers, fathers, nurses, uncles, aunts, midwives, doctors; baby's every and earliest pucker, every cry, the first wrinklings that can be manufactured into a smile, the differentiations between the call and the first efforts at speech, every gesture, the movements of the eyes, the hands, the fingers, toes, the crawl, the rise and fall from the ground leading to the earliest steps-all these and much more have been lovingly observed, made the subject of triumphant comment over and over again by the fond onlookers in every part of the earth, among the highly cultured or the most backward of savages, in ancient pile-dwellings or modern tenement houses.
Despite this concentrated and devoted interest on the infant, no one until Dr Bernfeld has attempted to present a comprehensive survey of the babe's psychology, though there are several fragmentary and more or less disconnected observations such as the well-known works of Sully or Miss Shinn in English, of Preyer or Stern in German. Bernfeld's work is something quite different. The facts are given, culled from a number of observers, including his personal observations, gathered not only from civilised man but from primitive man and the savages, and given in much greater detail than is usual in psychological text-books, but the facts are used not as so many bricks to be tumbled out of a cart but as bricks put together to form a structure-towards the understanding of the infant's mind. It is well to know, for instance, that after the third month the baby brings the hand under the control of the eyes, but this relationship is worked out by Dr Bernfeld as part of the growing infantile mind and is brought into connection with a host of other facts.
The life of the suckling is considered by Bernfeld under the following divisions:
1. Birth-whose structure-a term Bernfeld uses somewhat in Driesch's sense of the organism as a whole-is characterised by the tendency to revert, to seek an equilibrium-the conservative tendency, as Dr Bernfeld calls it. The new-born is under the sway of the R impulses, as Bernfeld terms them; the impulse to seek the position of rest, of non-stimulation and of regression. To speak of the ego impulses or instincts in the suckling is misleading for these are only gradually developing and are not formed out of earlier components as is the libidinal material.
2. The First Quarter-with its beginnings of the sexual instinct; by libidinal cathexis three well-marked erotogenic zones-eyes, mouth, ears have arisen. Biologically the child during the first quarter is still an ectoparasite but with more greed and energy than the new-born.
3. The 'Grasper Age'-the second and third quarters, when the instinct of possession begins to evolve; the hand comes to be used under the control of the eyes, the eyes drawn into the mouth-hand relationship. The instinct of possession is partly derived from the 'R impulses,' partly from libidinal impulses, but there is a considerable residue which cannot be so readily allotted to one or other, whilst the relationship of these constellations one to the other gives rise to the most difficult and as yet unsolved questions in the psychology of the infant. It is in this period that the development of the libido becomes well-marked, with clear manifestations of sexual desires. The external world can be libidinally taken hold of, but in the interest of the instinct of possession; the primary ambivalency consists in the sexual interest being subordinated to the mechanism of the 'R impulses.'
4. The Age of Weaning. If birth is to be regarded as the first great trauma in the life of the individual, weaning completes the second great trauma. With weaning comes the second great refusal and expulsion. First expelled from the womb, now from the breast.
It must not be thought that the book deals only with the affective side of the suckling; Dr Bernfeld points out that although psychology has given infinitely more consideration to cognition than to other mental conditions, even here it has dealt
scantily with the intellect of the suckling, so that the author has to content himself with a first sketch.
The questions of heredity, of the relationship of the infant to the external world, are discussed within the limits imposed by the nature of the book-a psychological study of the development of the child in reference to its impulses and instincts.
Within these limits Dr Bernfeld has, as I have said, written the first comprehensive account of the psychology of the suckling; he has been throughout careful to state the difficulties, the many lacunae which may make some of his tentative conclusions uncertain, but the main lines appear soundly constructed and in accordance with the derived knowledge of infancy obtained from the psychology of the adult.
M. D. EDER.