Page:Carnegie Flexner Report.djvu/163

Rh the number of the London schools. Amalgamation has already taken place in certain American towns: the several schools of Cincinnati, of Indianapolis, and of Louisville have all recently "merged." This step is easy enough in towns where there is either no university or only one university. Where there are several, as in Chicago, Boston, and New York, the problem is more difficult. Approached in a broad spirit it may, however, prove not insoluble; coöperation may be arranged where several institutions all possess substantial resources; universities of limited means can retire without loss of prestige,—on the contrary, the respect in which they are held must be heightened by any action dictated by conscientious refusal to continue a work that they are in no position to do well.

(4) A reconstruction of medical education cannot ignore the patent fact that students tend to study medicine in their own states, certainly in their own sections. In general, therefore, arrangements ought to be made, as far as conditions heretofore mentioned permit, to provide the requisite facilities within each of the characteristic state groups. There is the added advantage that local conditions are thus heeded and that the general profession is at a variety of points penetrated by educative influences. New Orleans, for example, would cultivate tropical medicine; Pittsburgh, the occupational diseases common in its environment. In respect to output, we may once more fairly take existing conditions into account. We are not called on to provide schools enough to keep up the present ratio. As we should in any case hardly be embarrassed for almost a generation in the matter of supply, we shall do well to produce no doctors who do not represent an improvement upon the present average.

The principles above stated have been entirely disregarded in America. Medical schools have been established regardless of need, regardless of the proximity of competent universities, regardless of favoring local conditions. An expression of surprise at finding an irrelevant and superfluous school usually elicits the reply that the town, being a "gateway" or a "center," must of course harbor a "medical college." It is not always easy to distinguish "gateway" and "center:" a center appears to be a town possessing, or within easy reach of, say 50,000 persons; a gateway is a town with at least two railway stations. The same place may be both,—in which event the argument is presumably irrefragable. Augusta, Georgia, Charlotte, North Carolina, and Topeka, Kansas, are "centers," and as such are logical abodes of medical instruction. Little Rock, St. Joseph, Memphis, Toledo, Buffalo, are "gateway The argument, so dear to local pride, can best be refuted by Ring pursued to its logical conclusion. For there are still forty-eight towns in the United States with over 50,000 population each, and no medical schools:we are 'threatened with forty-eight new schools at once, if the contention is correct. The truth is that the fundamental, though of course not sole, consideration is the university, provided its resources are adequate; and we have fortunately enough strong universities, properly distributed, to satisfy every present need without serious sacrifice of!sound principle. The