branches. The student pursues these branches almost in what order he pleases. His freedom is even greater than the freedom he has enjoyed in the laboratories. The failure to work out his studies in more logical sequence

seems to me once more an unneces

sary dissipation of time, energy and interest. But the absolute responsibility of the mature student for his own course I regard as a highly important characteristic. The German procedure recognizes and emphasizes the vastness of the field, its essential and inherent lack of any one type of organization, and the abundance of loose ends and unsolved problems. No two students have pursued precisely the same course; their contact is therefore novel and stimulating. They know different things, reached by different routes; for the student wanders from place to place, seeking new teachers, whose diverse views stimulate thought and rebuke conformity. An air of adventure therefore permeates laboratory and lecture-room, and in such environment native power enjoys an incentive which the neatly dovetailed course of study is powerless to impart, though potent to destroy.

With the teaching methods commonly employed much fault can be fairly found. The German university was originally, and long remained, a lecturing institution. The laboratory and the clinic have been grafted on it. Meanwhile, the lecture remains the backbone of the general instruction in all departments. Its stubborn hold is due not only to tradition but to interest. The university attracts strong and able men partly because a successful university career is highly profitable, and the profits depend upon the large classes which can be assembled to hear the professors' lectures. Efforts to improve the lecture by joining with it occasional practical exercises either

in the laboratory or in the clinic have not, in my judgment, succeeded. But the training of the student is enormously better than one would judge from a casual glimpse into a crowded amphitheatre. It is enormously better, in the first place, because of the skill and intelligence of the teacher; in the second, because of the highly trained quality of the student; in the third, because every student who is worth his salt takes advantage in one form or another of the abundant opportunities for individual work as a volunteer or as an assistant in the laboratories and clinics.

This voluntary activity is indeed the very essence of the German system of medical education. It begins with the boy's entrance into the medical school and it does not stop for years after his graduation from the university. Aside from the variety of opportunity offered by varied and abundant courses, in term time as in vacation you will find famuli, or student-assistants, working in the laboratories of anatomy, physiology, and pathology at every spare moment from the very outset of their medical studies. Six, eight, or a dozen boys will be engaged in working up extra or superfluous material, watching carefully for every scrap that is not consumed in the daily demonstration. The same practice holds in the clinic. The elasticity of the time-table permits and encourages this valuable custom. Student volunteers are found in every hospital service, during the semester as well as between semesters. And the habit of working overtime a natural consequence of consistent opportunity and stimulus throughout the medical course

does not of course disappear with the attainment of the degree. No serious person regards his educational career as finished until, as assistant, he has served under one or more dis

tinguished masters. A year's hospital service is indeed required; but it has thus far proved of little worth on account of lack of supervision and oversight. But of the high value of the assistantship, whether it be volunteer or appointed, there is no doubt whatsoever. No praise is too great for the patience and devotion with which the German student of medicine, who has passed nine years in the Gymnasium and at least five years in the university, devotes himself on small or no pay to the service of assistant for periods ranging from one to ten years, without which service he does not regard himself as equal to the full responsibilities of his calling.

In connection with clinical teaching, I have one more point to make, a point in respect to which we Americans make a particularly bad showing. The German medical profession respects-as the American medical profession does not respect the teacher of medicine. The German doctors do not think- as Americans doctors usually do think that the practicing profession of a town is quite capable of taking up without forethought or preparation the responsibilities of clinical teaching. Very properly, I think, the Germans hold that medical teaching is a profession, a career,—not identical with medical practice. They therefore allow the universities to select their teachers of medicine and surgery where and as they please; and they do not dream of contesting hospital privileges with men thus chosen. I can imagine no more instructive contrast than could be drawn between the great Allgemeines Krankenhaus of Vienna and Bellevue Hospital, New York, or the Cook County Hospital of Chicago. At Vienna the hospital has university and non-university divisions; as a matter of course, the university is free to appoint whom it

pleases, and the men appointed are free to conduct their wards as their judgment approves. At Bellevue there are also university and non-university divisions; but no university is really free in its own division, and, if one division desires to do a particular thing, the others can automatically come together to prevent.

The German hospitals that are affiliated with medical faculties are in earnest about medical education and medical research. They permit universities without question to summon their clinical professors whence they please; and the universities scour all Germanspeaking Europe for competent leaders. The professor, once installed in the clinic, is eager to distinguish his tenancy by the productive work of himself, his assistants and his students. America makes a sad contrast in this very important respect. With few exceptions the relations between medical schools and hospitals leave the schools no initiative in the choice of clinical teachers. In some instances a proper understanding has indeed been arrived at, but even in these, the school is rarely strong enough to utilize its nominal privileges. To no small extent, the improvement is as yet mainly on paper. More serious still, our clinical heads mainly unproductive men - are far from hospitable to young workers. Where the chief is not himself a productive scientist, obvious considerations make it inexpedient for him to open the doors wide to ambitious and original advanced students.

The truth is that the clinical teacher in the German sense hardly exists as yet in America at all. As contrasted with Germany, American teaching of medicine, surgery, and obstetrics, and so on, cannot properly be called professional teaching. Our professors of the clinical subjects, with exceptions so few as to be numerically negligible

are practitioners who make no effort to create the scientific or academic atmosphere and environment characteristic of the German clinic. The university spirit is missing in the clinical half of the American medical school. Let us not deceive ourselves on this score. We are paying the price of long-continued and still-continuing exploitation of clinical teaching. A race of practitioners willing to sacrifice personal advantage for scientific progress is just beginning to be bred. In consequence, the few young men who have renounced practice have received quick and large rewards in the shape of promotion and opportunity. But the movement is in its incipiency. The general situation has not been transformed, even though it has been improved. The spirit of a medical school cannot be wholly renewed even if one or two clinical posts are tenanted by devoted and ambitious men.

An amusing example of total incapacity to appreciate the ridiculous has recently been furnished by a New York institution. In order to avoid being lowered in classification by the Council on Education of the American Medical Association, certain influential members of its medical faculty undertook to introduce certain improvements, itself a situation which could not arise in Germany. The university authorities refused to carry out the bargain, whereupon the members in question resigned. Did this affect the school? Not a bit! The vacant places were at once filled with practicing doctors. I venture to say that the incident could be repeated indefinitely, and the faculty kept full none the less.

The essential features which have contributed to the greatness of German medicine may then be concisely formulated as follows: first, the high minimum level of organization and

equipment, below which the government will permit no medical school to live; second, the prolonged and serious secondary-school training which is absolutely, without exception, exacted of every student in the medical faculty; third, the freedom of the German university, which gives the professor the strength and leisure to work and encourages the capable student to do more than the minimum requirements of the curriculum for graduation; finally, the high respect in which the practicing profession holds the teaching profession, and the custom of calling teachers freely from university to university. Reformers of American conditions will do well to bear these four criteria in mind. Those schools which cannot now meet them, or soon hope to meet them, ought not to be allowed to go on contributing their quota of immature and ill-trained practitioners to a medical profession whose general average is already probably below the lowest to be found in any other great modern nation.

My praise of German medical education, though high, has not been unmixed. But to one important defect in their situation, a defect which the native German critic hardly suspects,

particular attention may be called. In the creation and development of the medical faculties in Germany government has done everything. Practically nothing has come from private initiative. For this reason there is even now very little to be hoped for from private sources. The demands on government for the support of the army, the navy, the schools, and so forth, are so great that the universities unquestionably suffer for lack of the funds needed for expansion. The German medical scientist, therefore, looks with envy and wonder upon the munificence of the great American benefactors of medical education. Johns

Hopkins is an old story; but it may be repeated any day, as can readily be illustrated. Three years ago, for example, there was hardly a single auspicious opening for medical education west of the Mississippi River. Within that time, however, preliminary steps have been taken to establish in St. Louis an institution whose ideals and equipment place it on the same level with the Johns Hopkins Medical School. Through the wisdom and generosity of a small group of men, Washington University, St. Louis, has constituted a medical faculty composed of able scientists brought together from different quarters of the continent. It has built an admirable set of modern laboratories, to be opened the coming autumn, and it has established a working connection with a newly endowed hospital answering every necessary purpose in respect to treatment, science, and education. The difficulties in the way of launching this undertaking were very great. An old type of medical school had to be slowly wound up, even while the new school was ushered into being. Abundant building and endowment funds had also to be provided. The arduous and delicate steps have been successfully carried through, thanks to the confidence, imagination, and generosity of local benefactors.

Farseeing, public-spirited, and generous citizens of this type are found only, or mainly, in America. Whatever be the advantages enjoyed by the teachers across the waters, men of this type are not 'made in Germany.'

The large scope allowed in America to private initiative is, however, not without countervailing disadvantages. It produced the excellent medical schools I have named in Baltimore and St. Louis, and is doubtless destined to produce others in the near future. But it produces other things, too. For example: the rapid decrease in medical schools during recent years might be interpreted by an ordinarily intelligent person to mean that the day of the unsupported medical school, with ill-taught students and with incompetent local practitioners as faculty, has gone by. But in this free country it is dangerous to look upon anything as finally and utterly dead. Nothing prevents the resuscitation of a departed medical school or the creation of a new one without adequate

resources.

Our real problem lies here. Private initiative in education—in originating as well as in furthering educational movements has amply approved itself in America. Its scope is likely to increase rather than decrease, as conscience and intelligence suggest further fields of endeavor. The Germans have thus far denied themselves expansion thus secured; and they give little indication of ever embracing it. The excesses and absurdities to which private initiative in America has led appear partly to justify their policy. It is therefore for us to decide whether we can retain the full benefits of large individual initiative without laying ourselves open to its abuse.