The English Side of Medical Education
I
THE virtues and defects of the English scheme of medical education are primarily of professional importance; but, altogether apart from its peculiar value in medical instruction, its most characteristic feature is of profound general educational significance. A knowledge of the English side of medical education is therefore of general as well as special educational interest.
The English medical school is an outgrowth of the English hospital, for it began when the English medical student attached himself to a master whom he followed through the wards. Such additional instruction as the student required — instruction, for example, in anatomy and pharmacy — he obtained in schools that grew up outside the hospital, but in close relation to it. In course of time, the separate masters, coming together, formed a ‘faculty,’ and their apprentices, being pooled, formed a student body. Thereupon the socalled ‘anatomical schools’ became part of the hospital schools. But these developments did not affect the character of medical training: in its first stage it was essentially and simply a hospital apprenticeship.
A second phase belonged to the latter part of the nineteenth century. A group of fundamental sciences had developed out of medicine or in close proximity to it, — pathology, physiology, biology, chemistry, etc.; they became parts of the hospital medical school, with such limitations as the organization, resources and spirit of the school enforced. The organization in question consisted of practicing hospital physicians; the resources were merely student fees; the spirit was intensely and immediately practical, as is necessarily the way with an apprenticeship. Under these circumstances, the so-called laboratory subjects gradually edged their way into busy hospital schools. Their teaching was in the first place entrusted to certain members of the hospital staff, — usually the younger members, who still had a certain amount of leisure time. This arrangement soon proved unsatisfactory, for it became evident that, even though the laboratory sciences in a medical school are in the first instance important because they have a bearing on clinical problems, nevertheless, so long as they are taught in a grudging instrumental spirit, they largely fail of even their practical purpose. They cannot, in a word, be effectively taught, except in so far as they are freely cultivated. For this reason, much of the teaching of the underlying sciences was in time differentiated and committed to a group of full-time teachers. Meanwhile, the clinical branches continued to be taught as before. The more intelligent clinicians absorbed and utilized the current scientific learning, assimilating it the more rapidly as its clinical value was demonstrated by successive triumphs; the apprentice in the wards thus enjoyed the opportunity of witnessing increasingly intelligent clinical methods.
From the preceding account it is obvious that the English medical school is to-day in essence a hospital apprentice school modified by the addition of the underlying sciences, independently taught and cultivated. Legally, many of them have some sort of university relationship: in London, for example, the schools are affiliated with London University, that is, they are known as ‘schools’ of the university. Each of the schools, however, is practically independent in the management of its internal affairs. The university connection is a mere matter of form. In the provinces the schools appear to be departments of the developing provincial universities; but only the laboratory subjects form properly organized university departments conducted by the university authorities, as are the departments of mathematics, Greek, and Latin. Of the clinical work, the universities have only nominal control. The schools are therefore nowhere of full-fledged university character.
In a recent discussion of the German side of medical education in the pages of the Atlantic Monthly,1 I called attention to what seemed to me its characteristic features — the high minimum level of organization and equipment of the medical schools; the admirable secondary school training exacted of every medical student; and the genuinely university quality of the entire faculty. A word as to each of these points. Despite the fact that German medical departments vary in extensiveness and completeness, all without exception possess adequate facilities — laboratory and clinical. The preliminary education of an overwhelming majority of the student body has been along classical rather than modern lines, and this without any especial adaptation to the demands of medical training; yet it has at least been a serious educat ion, of uniformly high quality and calculated to develop the student’s ability to put forth severe effort and to endure hard work.
Finally, the medical faculty of every university has been assembled on the basis of scientific eminence. The Germans are not without certain prejudices which now and then lead them to pass over the most highly deserving individual in favor of one somewhat less able or distinguished. But even in these instances, the appointment when made will prove to be a creditable one, while, as a rule, the competit ion of universities insures appointments on the basis of sheer scientific performance and promise. The practicing profession and the teaching profession are sharply distinguished from each other; and members of the latter are called from one university to another, as vacancies occur. In t hese respects laboratory and clinical teachers are on the same footing. They represent precisely the same university type of activity and ideal. If the professor of physiology is a productive scientist who has fought his way up from one university to another on the basis of achievement, so has the professor of medicine, so has the professor of surgery. To the points just touched on — the excellent facilities, a trained student body, a genuine university professoriat — the German medical school owes its character and its eminence.
In all these respects, English medical education fares badly in comparison. In the first place, the English facilities are inferior. The English medical school possesses a hospital, to be sure; as we have seen, the medical school grew out of the hospital. And as a rule, the hospital and its outpatient departments contain material enough for the purposes of instruction. But in other respects the hospital is far from satisfying modern standards. The material has as yet been only crudely different iated. Medicine, surgery, and obstetrics are recognized as separate divisions; but there has been little intensive specialization within these broad fields. In consequence, research suffers from the lack of concentrated and specialized material.
Moreover, while the English hospital is a comfortable and attractive place in which to lodge the sick, it lacks the laboratory equipment and staff needed for the critical study of disease. Practical appliances — usually devised and tried elsewhere — are, indeed, in process of introduction: X-ray machines, electric baths, and similar contrivances are now fairly common. But research laboratories with competent assistants and regular support are well-nigh unknown.
Of the underlying sciences, — anatomy, physiology, pathology, and the like — all excellently well developed in Germany and particularly from the standpoint of research, only physiology is as a rule creditably represented in the English hospital school. The arrangements for the teaching of anatomy suffice in general only for the elementary instruction actually required. Pathology is taught from the gross and descriptive points of view; its material comes mainly from the operating room and museum; on the experimental side there has been, in the medical school, no activity. Modern pharmacology is almost unrecognized. Physiology alone has been more liberally cultivated. A vigorous, though comparatively recent development requires practical instruction in which t he student actively participates, and independent activity on the part of the teaching force. With this exception, the somewhat meagre facilities and barren outlook of the medical sciences result in a mechanical, stereotyped, disciplinary type of teaching, scientifically uninspiring to both student and instructor. II
For these unsatisfactory conditions, the brief historical sketch above given furnishes an adequate explanation. The medical school has been a hospital apprenticeship. Whatever has been added to that has had to justify itself on practical grounds. Anatomy, physiology, chemistry, and pathology have been utilized because they bear on clinical problems and just so far as they bear on clinical problems. There has been — for the most part — no time, money, or inclination for their free and more or less irresponsible cultivation. Their development — always excepting physiology — has been stunted on this account, since science does not flourish where it is compelled at every step to justify itself by an immediately instrumental utility.
Again, the English student body is at once heterogeneous and not highly trained. Secondary education is in Great Britain still in an undeveloped condition. It is only within the last decade that local authorities have been constituted for the express purpose of establishing secondary schools in England, and that a special division of the Board of Education has been created to assist in giving financial support. While the secondary school situation is therefore now fairly on the road to effective organization, medical schools have up to this time, for the most part, made on their students only a slight educational demand. The English boy is still usually admitted to a medical school if he can produce a certificate showing successful examination in four subjects, three of them being languages: English, elementary Latin, and either French, German, Italian, or Greek. The fourth subject is mathematics, including arithmetic, elementary algebra, and a small amount of plane geometry. Of the Oxford or Cambridge medical student much more is, of course, demanded for entrance; but even he goes to London for his clinical training, entering one of the hospital schools and sharing in the instruction designed to suit the undertrained boys just characterized. In preliminary training the English students are therefore much less homogeneous and much less competent than the German.
Finally, the school and hospital staff is from the educational standpoint inferior. The historic evolution must again be considered. The hospital staff is the school staff. The conditions of hospital service have therefore limited the possibilities of scientific and educational development. Now the hospitals were in the first instance charities, to which the practicing medical profession willingly rendered such voluntary service as the current conduct of the institution required. While gifted individuals from time to time utilized their hospital opportunities in order to prosecute scientific inquiry, such inquiry was incidental and individual. It was never the purpose of the voluntary hospital to promote medical science; its sole object was to relieve distress. A tradition actually unfavorable to scientific endeavor has in the end been created. Promotion by seniority generally prevails. Young men who can afford to wait — and, therefore, as a rule those only — attach themselves to the hospital service, fairly certain that by assiduous attention to routine they will ultimately succeed to the principal posts. Step by step, as they rise in rank, their association with the prominent physicians holding the chief appointments leads to an increase in private practice which is apt to be increasingly fatal to scientific ideals. Moreover, the hospitals all inbreed. The lower posts are filled with recent graduates, who succeed almost automatically to the leading positions. Men are rarely called from one hospital to another, even in the same town. The incentive which ‘calling’ offers to the German scientist is therefore almost entirely lacking. The worldly, as well as the professional and scientific, future of the German clinician depends in t he first instance on his scientific productivity, for he will rise either in the service of his own university or in the service of some other university only if he has successful performance to his credit. The English medical man has no such spur. Once started on the hospital ladder, he is destined to rise if he is assiduous in following his chief and reasonably faithful in the performance of his routine duties. Scientific renown will not of course hurt him, but it is rare and therefore by no means indispensable. Do what he will, only consummate ability will ever be summoned from one hospital service to the other, and then only under highly exceptional circumstances.
Between the practicing and teaching clinical profession there is in England no distinction at all, except in so far as the men attached to English hospitals are for the most part consultants rather than general family practitioners. It follows, therefore, that the atmosphere of the English medical school is the atmosphere of English medical and surgical practice. It is not an atmosphere distinguished by the presence of ideas. A certain contempt for pure science or scientific medicine is even observable. One is told that the English are practical people; that it is the business of the doctor to prescribe for his patients; that the practical bearings of scientific inquiry are too often remote from the current needs of the busy practitioner. Demonstrated, tangible improvements are indeed taken up, but these have usually been demonstrated somewhere else. Facilities are not furnished for the purpose of scientific investigation. There is lack of cordiality in the relationship between the staff physicians and the chemists and physiologists who have latterly been added to the medical school staff. Whereas the German university clinic is alive with ideas and with the spirit of inquiry, the English hospital is on this side casual and incidental, precisely as is the practicing profession of the country.
III
Thus far the contrast is sufficiently to the disadvantage of the English system. Nevertheless, a highly important counter-consideration has now to be taken into account. The German medical faculty began in a university that had been for centuries a lecturing faculty devoted to theoret ical exposition. The lecture method, the method of philosophical presentation and elaboration, prevailed in the medical faculty as in other faculties — law, for example, or theology. In consequence, during this entire period, medical thought was completely dominated by metaphysics, and medical education in the university had no contact with disease in the concrete. As recently as 1805, the medical students at Tübingen preferred theoretical instruction to interrogation in the presence of patients, and it is apologetically recommended that at least in the matter of obstetrics the young doctor should have seen one birth before undertaking a case where two lives are at stake. Almost half a century later Helmholtz, despite his inborn experimental turn, publicly expounded, upon the occasion of his graduation as military surgeon, the operation of tumors, although he had never seen a tumor operated on.
With the development of the laboratory sciences in the university, German medicine shook off the metaphysical incubus, and in the laboratories and hospital came into close and immediately fruitful contact with disease and its manifestations in the concrete. Medicine had previously been damaged by its university character, because the university connection had meant lack of contact with reality; now it was enormously and very rapidly benefited, because that connection meant inspiring ideals, ample facilities, and the stimulus of allied sciences, many of which bore upon clinical problems. The transformation of the lecturing and expounding mediæval university into the modern critical, investigating university, with its seminars, institutes, laboratories, and clinics, is indeed an astounding phenomenon. No other faculty has profited so much by the evolution as the medical faculty. No other faculty had so far to go; no other faculty ramifies so widely and so intricately. It is hardly too much to say that almost every advance in physical, chemical, and biological science may have consequences for medicine. The complete inclusion of medicine in the university throughout the modern scientific period made certain that the ideals with which science was working and the results obtained would immediately affect medicine and the medical sciences. All this is just as true of the clinical as of the laboratory branches. The hospital is a university institute, as favorable as the laboratory branches to the inception and cultivation of new ideas; for the clinical professor in Germany is a university professor in the full sense of the term, enjoying all the dignities attached to a university professorship and subject to precisely the same standards of scientific and medical achievement.
In one crucially important respect, however, medical teaching in Germany has failed to modernize. The German undergraduate student of medicine is still taught largely by lectures, mitigated though they are by demonstrations and exhibits at which he gazes from his seat in the amphitheatre. Special courses more concrete and individual in character are indeed offered; but the lecture course, the traditional exercise of the mediæval university, is still the backbone, and furnishes largely the bulk of the instruction. Even in the hospital, the student is a mere onlooker. He is not freely admitted to the bedside of the patient. A few devices have been tried by way of remedying the difficulty, but they have entirely failed. Not until the graduated doctor becomes a hospital assistant does he obtain the close and constant opportunity to observe disease in its entire course which should have been his throughout his clinical education.
It is precisely here that the counter consideration to which I called attention enters; precisely at this point — and it is a point of priceless value — the comparison is all in favor of the English method. I have said that the English medical school began when staff physicians were accompanied on their hospital rounds by the few students who had personally attached themselves to them. The student, therefore, from t he first, saw the pat ient at the bedside. He observed his master at work; he was permitted to examine the patient, to confirm or to disprove his master’s observations, and, subject to his master’s control, to go through all the motions involved in the practice of medicine. His training was vivid, real, and concrete from the start. Disease was not to him merely a verbal account of disordered function. He observed the disordered function as he watched and touched the patient before him. From the standpoint of training, the English medical schools have, from the start, thus been in full possession of the one absolutely and really indispensable thing.
Attendance upon a preceptor changed in time, as we have remarked, to membership in a more or less organized hospital school. Laboratories were added for teaching the underlying sciences. But these developments have in no wise altered the character of English medical education. The privileges and opportunities of the students have been in no wise abridged. The medical student has remained thoroughly at home in the wards of the hospital. His education has cont inued to be an apprenticeship—an apprenticeship which has lost none of its advantages even though it has been more and more systematized in recent years.
In this matter the English hospital authorities have shown the greatest wisdom and liberality. They have never displayed any inclination to meddle with educational matters, nor have they attempted, by fussy regulations, to interfere with sound educational procedure. Privileges are heartily, not grudgingly, extended. Indeed, the hospitals have largely profited by their connection with medical education. The student body, serving as clinical clerks, are utilized as important aids in the care of the sick. The hospital does not feel that it is conferring a favor, for it is getting a valuable quid pro quo, and thus, through a fortunate arrangement, all parties are equally benefited — the patient, the hospital administration, the medical staff, and the medical student.
The clinical clerkship, above mentioned, is worthy of more extended notice, not only because it is the backbone of English clinical education, but because it is the only effective method of clinical education ever devised. After approximately a year’s preliminary training in anatomy, chemistry, and physiology, the student enters the hospital, where he is first taught to notice and interpret the ordinary physical signs, and to make case records. Even before this course in diagnosis is completed, ‘clerking’ begins. Small groups of students — six, for example, at the London Hospital — are assigned to a visiting physician and his assistant, who have — at this same hospital — a service of sixty beds. Cases are assigned to the students or clerks in rotation. Each clerk is required to make a complete history and description of each of his cases, including the requisite microscopical examinations. For t hese purposes he has free entry to the bedside. The students’ notes, criticized and revised by a member of the staff, form permanent and essential parts of the case records. Ward rounds are made daily. The chief, his assistants, and his clerks, move almost noiselessly from cot to cot, conversing in low tones over the patient. At each bed the clerk in charge steps forward, reads his notes, proposes his diagnosis and suggests a line of procedure. The chief questions, criticizes, offers alternatives, and stimulates a discussion in which presently the entire group is involved. The method fulfills every requirement of sound teaching: the student is at first hand familiar with the patient; he is compelled to observe and to think; he notes and reports progress from day to day; he sees his master on trial, as the procedure followed is either vindicated or discredited by developments. Meanwhile, the clerk can do no harm, for, free as he is to suggest, only the chief or his assistant can prescribe. The student has therefore every inducement to the active and responsible exercise of his faculties under conditions which t horoughly protect the patient against amateur medication.
Educationally speaking, nothing could be better. Modern medicine is indeed on these terms an ideal educational discipline. Society seeks intellects trained to observe, to frame tentative hypotheses on the basis of observed phenomena, to try procedures suggested thereby, and to persist or to modify procedure, in the light of results thus obtained. This is the very essence of the scientific attack on any situation. Men trained to pursue this method — representing a combination or interplay of deductive and inductive logic — bring to bear upon a difficulty the most powerful known intellectual solvent. And this is precisely the method of scientific medicine. The modern physician must be an accurate and cautious observer; he must on this basis construct his tentative hypothesis or diagnosis, which suggests a definite therapeutic procedure; and the results vindicate his observation and judgment or send him back to the facts for fresh observation and reflection. The English clerkship furnishes an opportunity for a prolonged training along these lines; for the clerk systematically and persistently carries on his activities in this fashion. The only limitation lies here — that if his observation is inadequate or incorrect, or his proposed line of action injudicious, the criticism of his teacher rather than the suffering of the patient shows him his error.
On general educational grounds, the English method of teaching medicine, as was intimated at the outset, is notable from still another point of view. In two important respects clerking is thus pedagogically suggestive. Professor Dewey has wisely remarked that in education ‘the initiative lies’ — or should lie — ‘with the learner.’ If training is to develop the pupil’s ability to deal with situations, — if, in other words, education means not merely knowledge of, but capacity to deal with, — then the student’s reactions must constitute the raw stuff out of which the teacher must develop orderly and effective mental processes. That is, the learner must act before the teacher can react upon him. How much of education — modern as well as ancient — is discredited by this simple but significant criterion! ‘Clerking’ however, passes muster. In his studies of anatomy, physiology, pathology, and physical diagnosis, — themselves concretely pursued, — the student has presumably become familiar with normal conditions. Asked now to describe a patient, he takes the initiative in noting divergencies, and, again, in propounding his diagnosis and in suggesting a course of treatment. The teacher attacks; he defends. To begin by telling him, by pointing out, by interpreting, as the lect ure or demonstration does, would be to deprive him of that initiative which is so highly educative. Learning is a game in which, whenever possible, the learner must move first. English medical education complies with t his fundamental and general educational principle.
Again, educational processes gain enormously in their capacity to elicit and to direct energy by being real or quasi-real. Once more, if education aims to become a formative, stimulating and coördinating power in the individual’s experience, — if it aims, not to communicate information or to imitate an approved model, but to provoke intelligent activities,—the genuineness of its appeal is a powerful factor. Artificial problems may leave the beginner cold, while a real difficulty may put him at once upon his mettle. Obviously, however, in the absence of acquired information or approved models, a genuine experience may be of little educational use. Hence, the other side — call it historical, theoretic, or what you will — cannot be neglected; we shall indeed in a moment see that neglect of pure and irresponsible intellectual pursuits deprives practical training of a large part of its inspirational value. But, waiving this point, we may affirm that the reality of the means employed is of the highest educative value, and that, viewed from this standpoint, ‘clerking’ is an excellent example of sound method. The clinical clerk deals with genuinely sick people in real hospitals; and he deals with them in the same methodical way as the staff physician. Small wonder then that the English physician is ready, businesslike, and practically master of the accepted technique of his profession.
Why then does so admirable a method produce, on the whole, unsatisfactory results? I have just intimated the answer to this question. The clinical teachers are practical men, rarely men of scientific vision or enthusiasm. They move contentedly within the area of the known; as the boundaries of knowledge are pushed further, their sphere of operations gradually widens; but they are not themselves, as a class, pioneers. The students possess certain excellent qualities; they are steady, earnest, reliable. But they lack — once more, of course, taken as a whole — intellectual discipline,maturity,and interest. When teachers of the type characterized undertake to train students of this kind, the instruction, while conscientious and thorough, is likely to be uniform, mechanical, cut and dried, uninspiring. Professor Ostwald has pointed out the educational significance of doing more than is required. Science cannot prosper on required courses; education in the higher sense lies always beyond the stipulated letter. The German university is fully impregnated with this spirit. Its pride is its appeal to voluntary activity; it has no use for men who do not seek opportunities to do what no one requires of them. The English medical school, however, offers little or no inducement or opportunity for that free, liberal, irresponsible exercise of the faculties without which neither ideas nor faculties can sprout. Every school offers substantially the same courses; every student does substantially the same things, and spends no small amount of time and energy doing them over and over, so as to be examination-proof. Despite an excellent method the clinical atmosphere is depressing. An apprenticeship can, in a word, rise no higher than its source. Reality of environment, of appeal, of responsibility is not alone for most students educative in a high sense. The real appeal must take place in an atmosphere of ideas, of large interests, if anything more than humdrum efficiency at present levels is to result. At a time when practical coöperative training is coming into vogue, the importance of this point must not be overlooked.
IV
A scheme usually has the defects of its virtues. But in the case of German and English medical education this is not necessarily the case. The defects of both may be cured without sacrificing the peculiar virtues of either; nay more, the full value of both will be realized only when their present defects have been remedied. And, curiously enough, such remedy requires that the two methods be combined. It would be hard to find another instance in which different methods of pursuing an object really supplement each other as effectually as do German and English medical training: if the characteristic virtues of both are merged in a single method the result, as method, will be fairly beyond criticism.
Very explicit admission of the capital defect just pointed out has been made in the admirable report of the Royal Commission which, with Viscount Haldane as Chairman, has been planning a complete reorganization of university education in London. The Commission attacked the entire problem from the standpoint that ‘ university teaching can be given only by men who are actively and systematically engaged in the advancement of knowledge in the subject they teach’; and it decided that, from this point of view, the clinical teaching of the London medical schools is not of university grade. It held that in a university ‘the standard of the teachers in these [i.e. the clinical] subjects ought not to be different from that of university professors in other subjects, and it is therefore necessary to appoint and pay professors of the various branches of clinical medicine and surgery who will devote the greater part of their time to teaching and research.’ This recommendation is frankly intended to introduce the German university conception into English medical education. But the Commission appreciates fully the value of clinical clerking and does not intend either to surrender or curtail it. ‘All the evidence we have received points to the necessity of continuing the distinctly English method of clinical teaching. Under the German system this kind of instruction is not provided for, but this defect has no essential connection with the merits of that system, and could be corrected without interfering with the organization or spirit of the clinic. There is no inherent difficulty in combining the two systems of teaching.’ 2
In conclusion, a word may be added in reference to American conditions. Of medical education in America, it is difficult to speak in general terms, for it lacks the homogeneity characteristic of other countries. Whatever the respective merits or defects, medical education in Germany, France, or England is at any rate always the same sort of thing. This is not true of the United States, where medical education includes something of what is best and all of what is worst to be found among civilized nations. In respect to the really essential and characteristic excellences above pointed out, the American medical school is on the whole inferior to both German and English types: it has in general not yet attained the homogeneous university constitution characteristic of the German medical faculty; it too frequently lacks the clinical opportunity characteristic of the English hospital school. Exceptions are indeed beginning to be more frequent on both counts: something approaching university homogeneity may be occasionally affirmed; the clinical clerkship is becoming more frequent under more and more favorable conditions. The one point of real superiority in American conditions is, however, their greater plasticity. The Germans can hardly be imagined as deliberately and resolutely altering their scheme to meet criticism; the English will but slowly come to love and value university ideals in medical teaching. In America, however, a few well-managed schools have already contrived to unite what is best in German with what is best in English medical education. They have taken from Germany the productive ideal; they have taken from England the clinical clerkship. And convincing proof of their compatibility is already at hand.
Despite a heterogeneous and generally unsatisfactory situation, progress in other directions, indicative of the capacity for growth, can also be recorded. A very rapid reduction in the number of schools — a process that must, however, be carried much further — shows that general conditions tend to respond to intelligent and wellinformed criticism. Interesting efforts are making in a few of the good schools to devise more efficient teaching methods and to correlate more effectively laboratory and clinical work. These efforts are bound to tell in developing a more intelligent medical pedagogy. Moreover, the question has been raised as to what sort of preliminary education most naturally leads to the study of medicine, and an interesting and helpful experience is being well utilized to economize time and effort in the medical school.
Perhaps the most interesting innovation, however, undertakes to deal with the problem of the clinical teacher. In Germany, the clinical professor has long been of precisely the same type as the laboratory professor, a man devoted to teaching and research. Latterly, however, professional prosperity in large centres has tended to make him too worldly a figure, both education and research suffering in consequence. In England, the hospital consultant has rarely been anything else; and his educational and scientific importance have accordingly been limited. America, like England, has employed practicing physicians and surgeons as professors of medicine and surgery, with results generally unsatisfactory both to science and to education.
Three university schools of medicine — the Johns Hopkins at. Baltimore, Washington University at St. Louis, and Yale — have now undertaken to reorganize the main clinical departments on the full-time or university basis. It is proposed that the incumbents of the posts in question and their necessary assistants — laboratory and clinical — become salaried members of the university staff, — like the teachers of anatomy and physiology; that they devote themselves wholly to the service of the hospital, education, and research; and that they withdraw altogether from paid private practice. In order that their experience may be in no wise restricted, it is stipulated that absolutely no limitation is to be placed upon them: they remain entirely free to see any case that interests them, be the patient a pauper or a millionaire. The well-to-do and the wealthy cease, however, to be able to command the academic clinician’s time and attention. He may and will see them, not because he is to be paid, but because it is worth while in the service of science, education, and humanity. Fees paid for such service are to go, not to the university clinician personally, but to the fund which supports the new system. It is gratifying — and perhaps not surprising — to find that academic posts on this basis have been already accepted by men in the prime of life at immense pecuniary sacrifices. The reasons are not far to seek: the scientific prosecution of medicine and surgery in America — as in England — has been backward for the lack, first, of adequate facilities; secondly, of conditions favorable to single-minded devotion. Latterly, the facilities have been provided in a few places; but the men have been distracted by the routine and the entanglements inseparably connected with practice. Meanwhile, the clinical branches make a powerful appeal from both scientific and humanitarian sides; and the full-time scheme just outlined represents an endeavor to pitch their cultivation on a high plane. The schools which are undertaking to introduce the full-time principle in clinical teaching are university departments which have appropriated from Germany the productive ideal, and from England the clinical clerkship. They work therefore under the most favorable conditions, and ought to train a generation of physicians who are at once skillful practitioners, competent investigators, and devoted humanitarians.